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1、SCCM/ASPEN 成年危重病患者营养支持治疗实施与评估指南 (5/6)2016 年 02 月 29 日 指南导读, 进展交流 暂无评论Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)成年危重病患者营养支
2、持治疗的实施与评估指南：美国危重病医学会(SCCM)与美国肠外肠内营养学会(ASPEN)Taylor BE, McClave SA, Martindale RG, et al. Crit Care Med 2016; 44: 390-438翻译：清华大学长庚医院 张振宇 许媛M. SURGICAL SUBSETS 外科部分TRAUMA 创伤Question: Does the nutrition therapy approach for the trauma patient differ from that for other critically ill patients?问题：创伤患者的营
3、养治疗方案与其他危重病患者有何不同？M1a. We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate post-trauma period (within 24 to 48 hours of injury) once the patient is hemodynamically stable.Quality of Evidence: Very Low与其他危重病
4、患者相似，我们建议一旦创伤患者血流动力学稳定，应尽早（创伤后 24-48 小时）开始高蛋白配方肠内营养。【证据质量：非常低】 Question: Should immune-modulation formulas be used routinely to improve outcomes in a patient with severe trauma?问题：严重创伤患者是否应常规使用免疫调节配方以改善预后？M1b. We suggest that immune-modulating formulations containing arginine and FO be considered in
5、 patients with severe trauma.Quality of Evidence: Very Low我们建议严重创伤患者给予富含精氨酸与鱼油的免疫调节配方肠内营养。【证据质量：非常低】TRAUMATIC BRAIN INJURY 颅脑创伤Question: Does the approach for nutrition therapy for the TBI patient differ from that of other critically ill patients or trauma patients without head injury?问题：TBI 患者的营养治疗
6、方案与其他危重病患者或没有颅脑损伤的其他创伤患者有何不同？M2a. We recommend that, similar to other critically ill patients, early enteral feeding be initiated in the immediate post-trauma period (within 24 to 48 hours of injury) once the patient is hemodynamically stable.Quality of Evidence: Very Low与其他危重病患者相似，我们建议一旦患者血流动力学稳定，在
7、创伤后（损伤 24-48 小时内）立即开始早期肠内营养。【证据质量：非常低】Question: Should immune-modulating formulas be used in a patient with TBI?问题：TBI 患者是否应当使用免疫调节配方吗？M2b: Based on expert consensus, we suggest the use of either arginine-containing immune-modulating formulations or EPA/DHA supplement with standard enteral formula i
8、n patients with TBI.基于专家共识，我们建议 TBI 患者使用含有精氨酸的免疫调节配方，或使用添加 EPA/DHA 的标准配方。OPEN ABDOMEN 开放腹腔Question: Is it safe to provide EN to patients with an OA?问题：开放腹腔患者应用 EN 是否安全？M3a. Based on expert consensus, we suggest early EN (2448 hours post-injury) in patients treated with an OA in the absence of a bowe
9、l injury.根据专家共识，我们建议没有肠道损伤的开放腹腔患者应尽早（伤后 24-48 小时）开始 EN。Question: Do patients with OA have increased protein or energy needs?问题：开放腹腔患者的蛋白质或能量需求是否增加？M3b. Based on expert consensus, we suggest providing an additional 15 to 30 grams protein per liter of exudate lost for patients with OA. Energy needs sh
10、ould be determined as for other ICU patients (see section a).基于专家共识，我们建议开放腹腔患者按照 15-30 g每升渗液丢失量额外增加蛋白质补充。能量需求与其他 ICU 患者相同（见 a 部分）。BURNS 烧伤Question: What mode of nutrition support should be used to feed burn patients?问题：烧伤患者应用何种营养支持方式？M4a. Based on expert consensus, EN should be provided to burn pati
11、ents whose GI tracts are functional and for whom volitional intake is inadequate to meet estimated energy needs. PN should be reserved for those burn patients for whom EN is not feasible or not tolerated.根据专家共识，对于保留胃肠道功能且口服饮食不能达到预计能量需求的烧伤患者，应当给予EN。不能实施 EN 或 EN 不能耐受时考虑给予 PN。Question: How should energ
12、y requirements be determined in burn patients?问题：如何确定烧伤患者的能量需求？M4b. Based on expert consensus, we suggest that IC be used when available to assess energy needs in burn patients with weekly repeated measures.基于专家共识，我们建议可能时使用 IC 每周重复测定以评估烧伤患者的能量需要。Question: What is the optimal quantity of protein to d
13、eliver to patients with large burns requiring ICU care?问题：需要 ICU 治疗的大面积烧伤患者，理想的蛋白质补充量是多少？M4c. Based on expert consensus, we suggest that patients with burn injury should receive protein in the range of 1.52g/kg/day.根据专家共识，我们建议烧伤患者蛋白质补充量为 1.5-2.0g/kg/天。Question: When should nutrition support be initi
14、ated?问题：何时开始营养支持？M4d. Based on expert consensus, we suggest very early initiation of EN (if possible, within 46 hours of injury) in a patient with burn injury.根据专家共识，我们建议烧伤患者尽早开始 EN（如果可能，应在损伤后 4-6 小时内开始）N. SEPSIS 全身性感染（脓毒症）Question: Are patients with severe sepsis candidates for early EN therapy?问题：
15、严重全身性患者是否适宜进行早期 EN 治疗？N1. Based on expert consensus, we suggest that critically ill patients receive EN therapy within 2448 hours of making the diagnosis of severe sepsis/septic shock as soon as resuscitation is complete and the patient is hemodynamically stable.根据专家共识，一旦复苏完成且血流动力学稳定，我们建议应当在诊断严重全身性感
16、染或感染性休克后 24-48 小时内给予 EN 治疗。Question: Should exclusive or supplemental PN added to EN providing 80% of target energy goal over the first week. We suggest delivery of 1.22 g protein/kg/day.根据专家共识，我们建议在全身性感染早期给予滋养型喂养策略（定义为 10-20 kcal/h 或不超过500 kcal/day），如果耐受良好，则 24-48 小时后开始增加喂养量，第一周内达到 80%目标量。我们建议蛋白质供给量为 1.2-2.0 g/kg/天。 Question: Is there any advantage to providing immune or metabolic-modulating enteral formulations (arginine with other agents, including EP
