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1、卒中患者肠内营养的实施卒中患者肠内营养的实施北京天坛医院北京天坛医院卒中单元卒中单元NICUNICU杨中华杨中华卒中后营养的重要性卒中后营养的重要性卒中患者营养不良的发生率卒中患者营养不良的发生率N N(%)1week1week31(35)31(35)5weeks5weeks29(33)29(33)3months3months18(20)18(20)6months6months20(22)20(22)the Journal of Nutrition,Health & Aging 2007;11:75-793低热卡摄入与血液感染低热卡摄入与血液感染Crit Care Med 2004; 32:3
2、50357Days Since MICU AdmissionP50%75%75%=25%50%1.000.750.500.250.0002040Proportion Without First ICU BSI4FoodFood试验的基线特征试验的基线特征NormalOverweightUndernourishedProportion aliveTime since randomisation (months)123456780.00.10.20.30.40.50.60.70.80.91.0Stroke. 2003;34:1450-1456.5营养不良是急性缺血性卒中并发症的独立危险因素营养不良
3、是急性缺血性卒中并发症的独立危险因素Arch Neurol. 2008;65(1):39-436急性卒中后营养不良对临床结局的影响急性卒中后营养不良对临床结局的影响Stroke. 1996;27:1028-1032 Score at 1 moScore at 1 moMalnourishedMalnourishedNonmalnourishedNonmalnourishedNo.No.%No.No.%P PCSSCSS5 5161666.766.7151522.422.40.00010.0001BIBI0.0120.01295954 416.716.7282841.841.855-9055-9
4、03 312.512.5151522.422.45050171770.870.8242435.835.87吞咽困难是卒中后营养不良吞咽困难是卒中后营养不良的最重要的机制的最重要的机制卒中后吞咽障碍的发生率(筛查)卒中后吞咽障碍的发生率(筛查)Stroke. 2005;36:2756-27639卒中相关性肺炎的发生频率卒中相关性肺炎的发生频率- -吞咽困难吞咽困难 vs vs 无吞咽困难无吞咽困难10卒中相关性肺炎的发生频率卒中相关性肺炎的发生频率- -误吸误吸 vs vs 无误吸无误吸Review: ArticleComparison: 01 Incidence of PneumoniaRev
5、iew: 02 Figure 2-Incidence of Pneumonia in Stroke Patients-Aspirators vs Non-AspiratorsStudy Aspirators Non-Aspirators RR(Random) Weight RR(Random)Or sub-category n/N n/N 95%CL % 95%CLHolas et al,1994 8/61 1/53 7.36 6.950.90 , 53.78Schmidt et al,1994 5/26 1/33 7.18 6.350.79 , 51.03Kidd et al,1995 17
6、/25 2/35 11.54 11.903.02 , 46.94Smithard et al,1996 7/20 12/74 16.74 2.160.98 , 4.76Teasell et al,1996 10/84 2/357 10.58 21.254.74 , 95.18Reynolds et al,1998 12/34 9/68 17.03 2.671.25 , 5.70Ding & Logeman,2000 60/185 40/193 20.44 1.561.11 , 2.21Meng et al,2000 3/7 0/13 4.59 12.250.72 , 208.21Lim et
7、al,2001 5/26 0/24 4.56 10.190.59 , 174.94Total(95%CL) 468 850 100 4.452.25 , 8.81Total events:127(Aspirators),67(Non-Aspirators)Test for heterogeneity:Chi2 =24.70,df=8(P=0.002),I2=67.6%Test for Overall effect:Z=4.28(P0.0001)0.1 0.2 0.5 1 2 5 10 Non-Aspirators Aspirators11A SPIRATION PNEUMONITIS AND
8、ASPIRATION PNEUMONIA右肺下叶局部形成空洞(箭头所指)右肺下叶局部形成空洞(箭头所指)N Engl J Med, 2001,344(9):665-671N Engl J Med, 2001,344(9):665-67112吞咽筛选试验吞咽筛选试验任意程度的意识水平下降;任意程度的意识水平下降;饮水之后声音变化;饮水之后声音变化;自主咳嗽减弱;自主咳嗽减弱;饮一定量的水时发生咳嗽;饮一定量的水时发生咳嗽;限时饮水实验有阳性表现。限时饮水实验有阳性表现。有一种异常即认为有吞咽困难存在。有一种异常即认为有吞咽困难存在。 13正规吞咽筛查对肺炎的影响正规吞咽筛查对肺炎的影响Strok
9、e 2005;36:1972-197614正规吞咽筛查对肺炎的影响正规吞咽筛查对肺炎的影响- -卒中严重程度卒中严重程度Stroke 2005;36:1972-197615选择肠内还是肠外营养选择肠内还是肠外营养国内肠内营养的现状国内肠内营养的现状18k18k1.8k1.8k2002200235k35k6k6k20072007PN:EN=10:1PN:EN=10:1PN:EN=6:1PN:EN=6:117国外肠内营养概况国外肠内营养概况Intensive Care Med. 2003 Jun;29(6):867-918EN vs PN-EN vs PN-死亡率死亡率Nutrition 2004
10、;20:843 848.19EN vs PN-EN vs PN-感染并发症感染并发症Nutrition 2004;20:843 848.20肠外营养是院内感染的危险因素肠外营养是院内感染的危险因素Variable Variable P P Odds ratio Odds ratio 95% CI 95% CI Age Age 0.05 0.05 2.172.171.06 -4.441.06 -4.44Presence of infection on admission Presence of infection on admission 0.001 0.001 0.20.20.09 -0.47
11、0.09 -0.47Parenteral nutritionParenteral nutrition 0.020.023.223.221.53 -6.81.53 -6.8Presence of central venous catheterPresence of central venous catheter 0.0040.0047.937.931.92 -32.711.92 -32.71Jpn. J. Infect. Dis., 60, 87-91, 200721肠内营养应用之科室分布肠内营养应用之科室分布北京和广州药剂科数据北京和广州药剂科数据22早期喂养与延迟喂养早期喂养与延迟喂养早期肠
12、内营养早期肠内营养 vs vs 延迟营养延迟营养- -感染并发症感染并发症Crit Care Med 2001; 29:2264 227024早期肠内营养早期肠内营养 vs vs 延迟营养延迟营养- -非感染并发非感染并发症症Crit Care Med 2001; 29:2264 227025早期肠内营养早期肠内营养 vs vs 延迟营养延迟营养- -住院时间住院时间Crit Care Med 2001; 29:2264 227026早期肠内营养早期肠内营养 vs vs 延迟营养延迟营养- -死亡死亡Crit Care Med 2001; 29:2264 227027Food trial 2-
13、MRS at follow-upFood trial 2-MRS at follow-up859 patients were enrolled by 83 hospitals in 15 countries into the early versus avoid trialreduction in risk of death of 5.8% (95% CI -0.8 to 12.5, p=0.09) reduction in death or poor outcome of 1.2% (-4.2 to 6.6, p=0.7).Lancet 2005; 365: 7647228早期喂养面临的问题
14、早期喂养面临的问题胃排空延迟胃排空延迟经胃喂养经胃喂养 vs vs 经空肠喂养经空肠喂养创伤患者胃排空创伤患者胃排空- -1313C C标记苯丙氨酸试验标记苯丙氨酸试验Dig Surg 1999;16:192196normal historic controls was 4. 57 +/- 1.48 mmol/l30创伤患者胃排空创伤患者胃排空normal historic controls was 7.08 +/- 0.33.Dig Surg 1999;16:19219631克服胃排空延迟克服胃排空延迟监测胃内容物残留监测胃内容物残留量量Crit Care Med 2001; 29:1955
15、196132胃排空延迟胃排空延迟选择经空肠喂养选择经空肠喂养使用胃肠动力药物使用胃肠动力药物合理的胃内容物监测合理的胃内容物监测33肠内营养途径的选择肠内营养途径的选择肠内营养管饲的途径肠内营养管饲的途径管饲管饲-鼻胃管鼻胃管-鼻空肠管鼻空肠管-PEGPEG-PEJPEJ35鼻胃管鼻胃管36PEG372005 ESPEN guidelines for PEGClinical Nutrition (2005) 24, 84886138非急性老年病房非急性老年病房:NGT vs PEG-:NGT vs PEG-生存率生存率PEG减少老年非急性患者的死亡率(hazard ratio (HR)=0.4
16、1; 95% confidence interval (CI) 0.22-0.76; P=0.01). PEG减少误吸的风险(HR=0.48; 95% CI 0.26-0.89) PEG减少自拔管率(HR=0.17; 95% CI 0.05-0.58) Clinical Nutrition (2001) 20(6): 53554039CONCLUSIONCONCLUSION非急性期,长期肠内营养的患者使用非急性期,长期肠内营养的患者使用PEGPEG可以提高存活率可以提高存活率PEGPEG具有更好的耐受性具有更好的耐受性降低误吸的风险降低误吸的风险Clinical Nutrition (2001
17、) 20(6): 53554040Food3-Food3-早期早期PEG vs NGTPEG vs NGT对对mRSmRS的影的影响响321 patients were enrolled by 47 hospitals in 11 countries早期PEG绝对增加1% (-10.0 to 11.9, p=0.9)的死亡风险早期PEG增加死亡或者不良预后,7.8% (0.0 to 15.5, p=0.05)Lancet 2005; 365: 7647241FOOD trial 3:Effect of feeding via PEG FOOD trial 3:Effect of feeding
18、 via PEG versus nasogastric tubeversus nasogastric tubeLancet 2005; 365: 7647242FOOD Trial 3FOOD Trial 3 结论结论卒中早期卒中早期PEGPEG没有能够提高患者的生存率,并且会增加患者的致残率,没有能够提高患者的生存率,并且会增加患者的致残率,2-2-3 3周内应该选择鼻胃管喂养周内应该选择鼻胃管喂养对于存在吞咽障碍的卒中患者,不支持早期使用对于存在吞咽障碍的卒中患者,不支持早期使用PEGPEG喂养喂养432008 ESO 缺血性卒中指南缺血性卒中指南Cerebrovasc Dis 2008;
19、25:45750744喂养流程喂养流程Intensive care unit (ICU) feeding algorithmJAMA. 2008 ;300(23):2731-41. 46管饲管饲腹泻的肠内营养流程腹泻的肠内营养流程JAMA. 2008 ;300(23):2731-41. 47高营养高营养 vs vs 普通饮食普通饮食FOOD-1FOOD-1: :经口强化营养对住院卒中患者的影响经口强化营养对住院卒中患者的影响Lancet 2005; 365: 75563Modified Rankin scale grade Modified Rankin scale grade No supp
20、lements No supplements Supplements Supplements (n=2007) (n=2007) (n=2016) (n=2016) 0 0159 (8%) 159 (8%) 164 (8%) 164 (8%) 1 1313 (16%) 313 (16%) 308 (15%) 308 (15%) 2 2352 (18%) 352 (18%) 343 (17%) 343 (17%) 3 3456 (23%) 456 (23%) 507 (25%) 507 (25%) 4 4242 (12%) 242 (12%) 228 (11%) 228 (11%) 5 5220
21、 (11%) 220 (11%) 218 (11%) 218 (11%) Dead Dead 253 (13%) 253 (13%) 241 (12%) 241 (12%) Alive but MRS not known Alive but MRS not known 5 (0%) 5 (0%) 3 (0%) 3 (0%) Outcome not known Outcome not known 7 (0%) 7 (0%) 4 (0%) 4 (0%) MRS 35 (poor outcome) MRS 35 (poor outcome) 918 (46%) 918 (46%) 953 (47%)
22、 953 (47%) Death or poor outcome Death or poor outcome 1171 (58%) 1171 (58%) 1194 (59%) 1194 (59%) 537大卡热量大卡热量 22.5g蛋白蛋白4023 patients were enrolled by 125 hospitals in 15 countries49FOOD trial 1FOOD trial 1 经口强化营养对卒经口强化营养对卒中患者死亡的影响中患者死亡的影响Lancet 2005; 365: 7556350FOOD-1FOOD-1 经口强化营养对卒中患者死亡和经口强化营养对卒中
23、患者死亡和不良结局的影响不良结局的影响Lancet 2005; 365: 7556351FOOD Trial 1FOOD Trial 1:结论结论卒中后经口强化营养有卒中后经口强化营养有1-2%1-2%的获益的获益但是我们不主张对不经选择的卒中患者比如营养状但是我们不主张对不经选择的卒中患者比如营养状态良好的患者常规强化营养治疗态良好的患者常规强化营养治疗52强化营养有助于中风康复强化营养有助于中风康复-随机,前瞻性,双盲,单中心研究-116例营养不良的患者-Significant weight loss as indicated by unintentional weight loss of
24、 at least 2.5% within 2 weeks following stroke onset-随机分组,强化营养组(240 calories, 11 g of proteins)和常规营养组(127 calories, 5 g of protein)-主要结果评价方式:功能独立自主量表得分(FIM)-次要结果包括FIM motor,cognitive subscores, length of stay (taken from day of admission), 2-minute and 6-minute timed walk tests measured at admission and on discharge, and discharge disposition (home/not home)Neurology 2008;71:1856186153强化营养有助于中风康复强化营养有助于中风康复Neurology 2008;71:1856186154老年(平均老年(平均6565岁)的患者经口强化营养的作用岁)的患者经口强化营养的作用5556营养不良的老年人营养不良的老年人营养支持营养支持-死亡率死亡率57营养正常老年人营养支持营养正常老年人营养支持-死亡率死亡率58肠内营养肠内营养“小事情小事情” 大问题大问题谢谢谢谢 个人观点供参考,欢迎讨论