欧洲肠外肠内营养学会肠内营养指南

欧洲肠外肠内营养学会肠内营养指南欧洲肠外肠内营养学会（ESPEN）肠内营养指南于2006年刊登在《临床营养》（ClinicalNutrition）杂志上，为临床营养支持的应用提供了科学依据。

该指南采用苏格兰学院间指南协作网（SIGN）分级标准，A级推荐的内容为荟萃分析或随机对照研究的结果，B级推荐为描述研究、比较研究的结果，C级推荐为专家意见。

适当的营养支持可以帮助重症患者度过严重疾病导致的高分解状态，通过管饲的肠内营养（EN）是目前重症患者摄入营养物质的主要途径。

ESPEN指南对营养支持的应用、途径、和营养制剂配方做出了循证推荐。

Clin Nutr. 2006 Apr;25(2):210-23.ESPEN Guidelines on Enteral Nutrition: Intensive care.Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J; DGEM (German Society for Nutritional Medicine), Ebner C, Hartl W, Heymann C, Spies C; ESPEN (European Society for Parenteral and Enteral Nutrition). Department of Intensive Care Medicine, University Hospital Eppendorf, Hamburg, Germany.Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool andshould be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma. 营养支持的应用所有3天内无法通过经口进食满足营养需求的重症患者需要接受肠内营养（C级推荐）。

没有证据显示重症患者接受早期肠内营养可以改善相关转归参数。

但是专家推荐血流动力学稳定的重症患者，若胃肠道功能健全，应该早期（24小时之内）接受适量喂养。

（C级推荐）肠内营养喂养量应该根据疾病进展和肠道耐受的情况作出适当调节，因此不作总体推荐。

在重症疾病的急性期和开始阶段，外源性能量补充不应超过20～25k cal/kg/d，否则可能会对患者转归造成不良影响。

在重症疾病处于分解恢复期时，外源性能量摄入应提供25～30kcal/kg/d的能量。

（C级推荐）严重营养不良的患者应接受25～30kcal/kg/d的肠内营养。

对于无法耐受肠内喂养的患者（如胃残留较高的患者），可以考虑静脉输注甲氧氯普胺和血红蛋白。

（C级推荐） 营养支持途径对于能够耐受肠内喂养的患者，肠内营养是营养支持的主要途径。

在重症患者的肠内营养中，采用空肠管与采用鼻胃管的效果没有显著差异。

对于那些能够耐受肠内营养，且能够通过肠内营养达到或接近喂养目标的患者，应避免增加肠外营养（A级推荐）。

若通过单纯肠内营养无法满足患者的营养需求，那么不足的部分应通过肠外营养补充。

对于不能耐受肠内营养的患者，肠外营养支持应小心进行，营养补充的量应该相当于其营养需求的水平，要避免过度喂养。

（C级推荐） 营养制剂配方大多数重症患者适宜用整蛋白制剂，并没有证据显示多肽制剂可以改善患者的临床症状。

（C级推荐） 在以下这些患者中，应用免疫营养制剂（添加了精氨酸、核苷酸和ω-3脂肪酸的制剂）比标准肠内营养制剂更有优越性。

这些患者包括，上胃肠道择期手术患者（A级推荐）、急性生理及慢性健康状况评分（APACHEⅡ）低于15分的轻度脓毒症患者（B级推荐）、创伤患者（A级推荐）、成人呼吸窘迫综合征（ARDS）患者（B级推荐）。

其中，ARDS患者应接受富含ω-3脂肪酸和抗氧化剂的制剂。

对于严重脓毒症的患者，免疫营养制剂可能有害，因此不推荐对重症患者应用（B级推荐）。

对于患有严重疾病的ICU患者，若其不能耐受每天700ml以上的肠内制剂，那么不应添加精氨酸、核苷酸和ω-3脂肪酸（B级推荐）。

在烧伤患者中，微量元素（铜、硒、锌）的补充量应该高于标准制剂（A级推荐）。

在烧伤和创伤患者中，应该在标准肠内制剂基础上添加谷氨酰胺（A级推荐）。

老年患者的营养支持因为疾病和身体肌肉组织减少，老年患者发生营养不足的风险增加。

因此，保证老年患者营养充足是有重要意义的。

对于老年患者，肠内营养支持可以提供充足的能量、蛋白质和微量营养素，保持或改善其营养状态、活动功能、康复能力以及生活质量，减少死亡率。

ESPEN指南认为，虽然老年患者接受经口进食的营养补充比较困难，也耗费时间，但是此种方式对老年患者生理和心理康复均有益处。

因此，不推荐仅为了方便操作和节省人力而对老年患者开展管饲（T F）。

ESPEN指南还对此类患者的适应证、营养支持方式、制剂选择等做出了循证推荐。

Clin Nutr. 2006 Apr;25(2):330-60.ESPEN Guidelines on Enteral Nutrition: Geriatrics.Volkert D, Berner YN, Berry E, Cederholm T, Coti Bertrand P, Milne A, Palmblad J, Schneider S, Sobotka L, Stanga Z; DGEM (German Society for Nutritional Medicine), Lenzen-Grossimlinghaus R, Krys U, Pirlich M, Herbst B, Schütz T, Schroer W, Weinrebe W, Ockenga J, Lochs H; ESPEN (European Society for Parenteral and Enteral Nutrition).Head Medical Science Division, Pfrimmer-Nutricia, Erlangen, Germany.Nutritional intake is often compromised in elderly, multimorbid patients. Enteral nutrition (EN) by means of oral nutritionalsupplements (ONS) and tube feeding (TF) offers the possibility to increase or to insure nutrient intake in case of insufficient oral food intake. The present guideline is intended to give evidence-based recommendations for the use of ONS and TF in geriatric patients. It was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was discussed and accepted in a consensus conference. EN by means of ONS is recommended for geriatric patients at nutritional risk, in case of multimorbidity and frailty, and following orthopaedic-surgical procedures. In elderly people at risk of undernutrition ONS improve nutritional status and reduce mortality. After orthopaedic-surgery ONS reduce unfavourable outcome. TF is clearly indicated in patients with neurologic dysphagia. In contrast, TF is not indicated in final disease states, including final dementia, and in order to facilitate patient care. Altogether, it is strongly recommended not to wait until severe undernutrition has developed, but to start EN therapy early, as soon as a nutritional risk becomes apparent. 适应证对于营养不足或存在营养不足危险的患者，应使用口服营养补充（ONS）增加能量、蛋白质及微量营养素的摄入，维持或改善营养状况，提高生存率（A级推荐）。