PPT-肿瘤患者营养风险筛查与评估(于康)

营养风险筛查评分与临床结局
Nutritional status
Kondrup J, Rasmussen H, Hamberg O,et al. Nutritional Risk Screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr ,2003,22（3）:321-336
(ESPEN Guideline)
Phase 2: Indication and Prescription related Assessment Phase 3: Indication related Nutrition support Phase 4: Monitoring Phase 1 Phase 2 Phase 3 Phase 4
无营养不良TPN
组：感染并发症发生率
明显高于对照组
saline )
有营养不良TPN组：非感染性并发症减少 提示：无营养不良患者
接受TPN无益
How were the patients actually selected? Conclusion: The use of nutritional support should be
General Surg Undernutrition(%)
285 (10.1) 254 (11.9) 278 (10.8) 313 (12.4) 209 (9.0) 95 (3.5)
哈尔滨
NRS>3(%)
秦皇岛 北京 乌鲁木齐 天津 青岛 石家庄 西安 南京 上海 武汉 成都 杭州 贵阳 东部 昆明 西部 广州 南宁 西部 岳阳
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10.3 (189/1844)
29.7 (548/1844) 22.0 (87/395) 21.5 (93/433)
41.0 (525/1281) 34.0 (247/727) 34.7 (102/294)
营养筛查及评定是营养诊疗前提

3
Nutrition care algorithm
(ASPEN 2011)
营养筛查、营养评定与营养干预 是营养诊疗三个“关键步骤”
Scheme of nutritional management 4 Phases
Phase 1: Screening (Using NRS 2002)
Thoracic Surg Respiratory G-I Nephrology Neurology Overall
955 (33.9) 751 (35.2) 937 (36.4) 590 (25.5)
1130 (44.7)
1434 (9.5)
5367 (35.5)
1004 (36.6)
营养风险筛查≥3分 PN & EN 应用情况（15 098 例）
Stratton RJ, Green CJ, Elia M. Disease-related malnutrition. CABI Publishing 2003
28% vs. 46% 24% vs. 44% 17 % vs. 24%
1
Subjects: n=395, G-I, Lung Cancer pts Design: RCT Study group: TPN Control: No NS (5% glucose normal
Components of NRS-2002 (ESPEN guideline)
（成年住院患者）
Nutritional Assessment （老年患者，社区）
ASPEN Clinical Guidelines. JPEN 2011, 35: 16-24
Recent dietary intake ( future tendency)
Kondrup et al. Clin Nutr 2003; 22: 321-336 ASPEN Clinical Guidelines. JPEN 2011, 35: 16-24
2002-2003，ESPEN提出。2004 引入中国
概念分析
ASPEN Clinical Guideline (2011)
www.espen.org education; Kondrup et al. Clin Nutr 2003; 22: 321-336 + 415-421
5
Disease severity(Metabolic need)
Plus age, to get the final nutritional risk score
Respiratory Cases (%)
G-I Cases (%)
Nephrology Cases (%)
Neurology (%)
营养不足(%)
营养风险(%)
44.8 (321/716)
呼吸内科
505 (27.1) 519 (54.3)
4.4 (945:214)
268 (19.4) 281 (37.4)
related complications (=nutritional risk)
(注：1991年尚无“营养风险”概念)
To implement the evidence: develop a screening tool based on evidence that outcome will change, i.e. the available RCTs
Neurology, GI disease, liver disease, malignant disease, elderly, abdominal surgery, orthopaedic surgery, critical illness/injury, burns. Hospital or community Oral supplements or tube feeding
27 RCTs with 1710 patients (complications) and 30 RCTs 3250 patients (mortality).
Meta-analysis of
营养支持是否让全部患者受益?
NEJM (1991) Study
问题-1：
P <0.001
Complications Infections Mortality
24
6
“营养风险、不良、支持与结局” 协作组各研究中心分布
大城市大医院 (2004-2006) 大中城市中小医院 (2007-2010) 营养风险、不良、支持与结局 (2008-2012)
Malnutrition rate in China based on 15 098 cases study
营养不良(营养不足)发生率 (15 098 例)
Do the patients selected for these studies have a common denominator for risk of nutrition-
问题-2：
如何确定需要营养的患者？
limited to patients who are “malnourished”
Nutritional
Prognostic Inflammatory and Nutritional Index Prognostic Nutritional Index Simple Screening Tool Short Nutrition Assessment Questionnaire
Assessment-对要营养支持患者制定个体化处方 （Kondrup，2007）
4
评价筛查工具的核心标准： 被该工具筛查阳性的患者，可从营 养支持中获益---“真实预测效度” 典型的“伪预测效度”： “Maastricht Nutritional Index”

Nutritional Screening tools
3.4 (484:144)
127 (7.8) 187 (20.0)
17.0 (306:18)
456 (32.7) 562 (49.8)
23.9 (1004:42)
55 (3.2) 57 (9.7)
8.6 (103:12)
80 (4.6) 150 (14.9)
2.3 (175:76)
基本外科 神经内科 肾内科
(%) (100) NRS<3 with NS
15098
Cases
Surgery Cases (%)
Thoracic surg Cases (%)
营养不良（营养不足）和营养风险发生率 （n=5690）
19.8 (142/716) 6.5 (83/1281) 12.7 (50/395) 10.3 (75/727) 9.7 (42/433) 4.1 (12/294)
Kondrup et al. Clin Nutr 2003; 22: 321-336
2
Screening
需要“Screening”工具
营养支持不可能使所有患者受益 营养支持能使什么患者受益？？
leads to nutritional care
The purpose of screening
…is to predict the probability of a better or worse outcome due to nutritional factors, and whether nutritional treatment is likely to influence this.
Risk Screening 2002
ASPEN Clinical Guidelines. JPEN 2011, 35: 16-24
根据ASPEN Guideline 2011
Subjective Global Mini
Nutrition assessment tools
Assessment
Impaired nutritional status (Score 0-3) BMI ( present condition) Recent weight loss ( past tendency) Severity of disease(Score 0-3) Age score (Score 0 or 1)
Birmingham Nutrition Risk Score Malnutrition Screening Tool Malnutrition Universal Screening Tool Nutrition Risk Classification Nutritional Risk Index
ASPEN Clinical Guidelines. JPEN 2011, 35: 16-24
Kondrup et al. Clin Nutr 2003; 22: 321-336
Screening & Assessment
问题-4：
Screening-确定患者是/否有营养支持适应证
是否所有”Screening”工具 都能“真实反映结局”？
Outline：
以“营养筛查”为基础 营养支持改善结局
于康
北京协和医院 临床营养科
1. 2. 3. 4. 5.
营养能否让所有患者受益？ 如何确认能营养受益的患者？ 为什么要引入“营养风险”概念？ 如何筛查营养风险？ 用营养筛查为基础，营养支持改善结局
Evidence: nutrition support improves outcome
两点启示: 营养支持需要判断适应证 营养支持的效果是相对的
中华临床营养杂志-国际编委评论 Editorial for CJCN Kondrup J & Meier R
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用NRS-2002筛查可改善临床结局 CJCN, 2013, June
Screening by NRS-2002 improves clinical outcome
Guidelines
recommend performing a screening at admission
问题-3：“营养风险”

两个不同概念：“营养风险” ≠ “营养不良风险”
Nutritional risk = Risk of nutrition related complications (outcome) if untreated “the risk of malnutrition ” 与outcome无直 接关联