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1、如何合理实施临床营养支持 How to Implement Rational Clinical Nutrition Therapy,吴国豪 复旦大学附属中山医院普外科 复旦大学普通外科研究所,为什么需要营养支持?那些病人需要营养支持?,如何进行合理的营养支持？,第一部分,Prevalence of malnutrition The German hospital malnutrition study,Matthias Pirlich，Clinical Nutrition (2006) 25, 563572,癌性恶病质的发生率,N A Stephens; MEDICINE 2007;36:(2)
2、:78-81,Malnutrition is common in cancer patients,Malnutrition occurs in 30-87% of cancer patients Shills ME;et al: Cancer Res 1977; 37: 2366 Nixon DW et al: Am J Med1980; 68: 683 Tchekmedyian NS et al: Oncology 1995; 9: 79Andreyev et al:Eur J Cancer 1998;34:503 Monitto CL et al: Am J Physiol 2001; 2
3、81: E289 Stephens NA et al: Medicine 2007;36:(2):78-81,营养不良的危害,免疫机能下降,脏器功能异常,预后不良,Cumulative Mortality: Protein-Energy Malnutrition,Cederholm et al, Am J Med 1995.,Mortality %,Months after admission,P0.01,Malnutrition Is Associated with Increased Complications,Numerous studies have demonstrated comp
4、lications of malnourished patients to be 2-20 times greater than those of well nourished patients.,Buzby et al, Am J Surgical 1980. Hickman et al, JPEN 1980. Klidjian et al, JPEN 1982.,Malnutrition Is Associated with Increased Complications,42% of patients with severe malnutrition experience major c
5、omplications 9% of patients with moderate malnutrition experience major complications Severely malnourished patients are four times as likely to have post-operative complications as well-nourished patients,Detsky et al, JPEN 1987. Detsky et al, JAMA 1994.,Clinical Outcomes of malnutrition,Tewari N，e
6、t al:Lung Cancer (2007) 57, 389394,Clinical Outcomes of malnutrition,Pirlich M，Clinical Nutrition (2006) 25, 563572,Clinical Outcomes of malnutrition,p 0.001;,Schiesser M et al:Clinical Nutrition 2008;27:565-570,608 patients admitted for elective gastrointestinal surgery. Nutritional risk was define
7、d by NRS 2002 and correlated to the incidence of postoperative complications,Clinical Outcomes of malnutrition,NRS 2002,p 0.001;,Schiesser M et al:Clinical Nutrition 2008;27:565-570,P0.001,PJ Ross；British Journal of Cancer (2004) 90, 1905 1911,Clinical Outcomes of malnutrition,Bachmann J，J Gastroint
8、est Surg (2008) 12:11931201,作用与目标:调整病人的代谢改变及内稳态失衡, 改善营养状态与免疫机能降低医院获得性感染发生率 缩短住ICU时间 最终改善病死率,营养支持在疾病治疗中的作用,营养支持对营养状态的影响,*P=0.04,Klein S, JPEN 1997,21:133,Nutritional Therapy Affects Outcomes,Bragan Arch Surg 2002;137:174,* P=0.02,Nutritional Therapy Affects Outcomes,Bragan Arch Surg 2002;137:174,* P=
9、0.001,Nutritional Therapy Affects Outcomes,Neumayer LA J Surg Res 2001;95:757,Nutritional Therapy Affects Outcomes,Neumayer LA J Surg Res 2001;95:757,* P=0.0001,Nutritional Therapy Affects Outcomes,Bozzetti F JPEN 2000;24:4-14,* P=0.03,* P=0.02,Nutritional Therapy Affects Outcomes,Fan ST et al: N En
10、gl J Med 1994;331:1547,* P=0.02,Nutritional Therapy Affects Outcomes,Fan ST et al: N Engl J Med 1994;331:1547,* P=0.01,Nutritional Therapy Affects Outcomes,Fan ST et al: N Engl J Med 1994;331:1547,* P=0.004,问题二:那些病人需要营养支持?,Which patients should we feed?,which patients can safely be left to resume fe
11、eding themselves? 14 days starvation - dangerous depletion of lean body mass mortality rises in ICU patients with a second week of severe under-feeding 5 days without feed increases infections but not mortality one view is therefore that 5-7 days is the limit,Which patients should we feed?,all malno
12、urished patients all patients who are unlikely to regain normal oral intake within either 2 or 5-7 days depending on your view one meta-analysis suggests reduced infections if patients are fed within 48 hours one meta-analysis of early TPN versus delayed EN found reduced mortality with early feeding
13、,外科病人的营养支持,围手术期营养支持 短肠综合征 炎性肠道疾病 肠外瘘 重症胰腺炎 危重病人 器官移植,围手术期营养支持指征,目前认为:营养状况良好病人可耐受一般手术创伤,10天内无营养支持不会产生副作用 严重营养不良患者;中等程度营养不良而需接受重大手术患者;手术后一周以上禁食者;手术前营养支持者;严重营养不良而手术前未进行营养支持者;术后出现严重并发症者,临床上普遍存在营养不良 营养不良影响患者预后,结 论,临床上许多疾病治疗过程中需要进行营养支持,通过合理营养支持改善患者预后,问题三:如何选择营养支持途径?,Parenteral nutrition,One of the most si
14、gnificant therapeutical advances of the past 50 yearsIndications: the ability to ingest necessary nutrients for a time during increased metabolic demands in clinical situations in which enteral (oral) nutrition is not or only partially feasible,Who Needs Parenteral Nutrition?,Any patient requiring n
15、utrition support who has a non-functioning or possible inadequately functioning gastrointestinal tract Start as soon as possible if there is pre-existing malnutrition or metabolic stress and oral/enteral feeding is unlikely to be achieved within 7 days,改善肠道功能,完整性 防止饥饿或创伤所致的肠道结构异常 增加内脏血流 刺激肠道免疫功能,维护机
16、体防御水平,Enteral or Parenteral ?,过去1015的年研究发现EN的作用要优于PN,危重病人胃肠功能的损害,肠黏膜萎缩 细胞受损,坏死,EN作用: 肠通透性、肠动力、分泌功能、屏障功能、免疫功能,Levy B et al. CCM 1998; 26:199194 Kentigern Thorburn et al. CM; 2004,32:24649,EN vs PN in critically ill patients meta-analysis (13RCT Infectious complications),Gramlich L et al., Nutrition 2004;20:843-848,EN vs PN in critically ill patients meta-analysis (13RCT Mortality),Gramlich L et al., Nutrition 2004;20:843-848,第二部分,如何合理提供营养支持,
