2016重症营养2.doc

sccm/aspen成年危重病患者营养支持治疗实施与评估指南(2/6)2016年02月17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：清华大学长庚医院周华 许媛d. monitoring tolerance and adequacy of en en耐受性与充分性的监测question: how should tolerance of en be monitored in the adult critically ill population?问题：如何监测成年危重病患者en耐受性？d1. based on expert consensus, we suggest that patients should be monitored daily for tolerance of en. we suggest that inappropriate cessation of en should be avoided. we suggest that ordering a feeding status of nil per os (npo) for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery.根据专家共识，我们建议应每日监测en耐受性。我们建议应当避免不恰当的中止en。我们建议，患者在接受诊断性检查或操作期间，应当尽可能缩短禁食状态(npo)的医嘱，以免肠梗阻加重，并防止营养供给不足。question: should grvs be used as a marker for aspiration to monitor icu patients on en?问题：grv是否应当作为接受en的icu患者监测误吸的指标？d2a. we suggest that grvs not be used as part of routine care to monitor icu patients on en.我们建议不应当把grv作为接受en的icu患者常规监测的指标。d2b. we suggest that, for those icus where grvs are still utilized, holding en for grvs 500 ml in the absence of other signs of intolerance (see section d1) should be avoided.quality of evidence: low我们建议，对于仍然监测grv的icu，应当避免在grv 500 ml且无其他不耐受表现（见d1部分）时中止en。证据质量：低question: should en feeding protocols be used in the adult icu setting?问题：成人icu是否需要制定en喂养方案？d3a. we recommend that enteral feeding protocols be designed and implemented to increase the overall percentage of goal calories provided.quality of evidence: moderate to high我们推荐制定并实施肠内营养喂养方案，以提高实现目标喂养的比例。证据质量：中至高d3b. based on expert consensus, we suggest that use of a volume-based feeding protocol or a top-down multi-strategy protocol be considered.d3b. 根据专家共识，我们建议考虑采用容量目标为指导的喂养方案或多重措施并举的喂养方案(top-down multi-strategy protocol)。question: how can risk of aspiration be assessed in critically ill adults patients receiving en, and what measures may be taken to reduce the likelihood of aspiration pneumonia?问题：对于接受en的危重病患者，如何评估误吸的风险？哪些措施可减少吸入性肺炎的风险？d4. based on expert consensus, we suggest that patients placed on en should be assessed for risk of aspiration, and that steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed.根据专家共识，我们建议对接受en的患者，应当评估其误吸风险，并主动采取措施以减少误吸与吸入性肺炎的风险。d4a. we recommend diverting the level of feeding by post-pyloric enteral access device placement in patients deemed to be at high risk for aspiration (see also section b5)quality of evidence: moderate to high对于误吸风险高的患者（见b5部分），我们推荐改变喂养层级，放置幽门后喂养通路。证据质量：中至高d4b. based on expert consensus, we suggest that for high-risk patients or those shown to be intolerant to bolus gastric en, delivery of en should be switched to continuous infusion.根据专家共识，对于高危患者或不能耐受经胃单次输注en的患者，我们建议采用持续输注的方式给予en。d4c. we suggest that, in patients at high risk of aspiration, agents to promote motility, such as prokinetic medications (metoclopramide or erythromycin), be initiated where clinically feasible.quality of evidence: low对于存在误吸高风险的患者，我们建议一旦临床情况允许，即给予药物促进胃肠蠕动，如促动力药物（甲氧氯普胺或红霉素）。证据质量：低d4d. based on expert consensus, we suggest that nursing directives to reduce risk of aspiration and vap be employed. in all intubated icu patients receiving en, the head of the bed should be elevated 3045 and use of chlorhexidine mouthwash twice a day should be considered.依据专家共识，我们建议采取相应护理措施降低误吸与vap的风险。对于接受en且有气管插管的所有icu患者，床头应抬高3045，每日2次使用氯已定进行口腔护理。question: are surrogate markers useful in determining aspiration in the critical care setting?问题：在icu中，替代指标能否判断是否发生误吸？d5. based on expert consensus, we suggest that neither blue food coloring nor any coloring agent be used as a marker for aspiration of en. based on expert consensus, we also suggest that glucose oxidase strips not be used as surrogate markers for aspiration in the critical care setting.根据专家共识，我们建议，无论食物蓝染抑或其他染色剂，均不能作为判断en误吸的标记物。根据专家共识，我们也不建议在icu使用葡萄糖氧化酶试纸检测误吸。question: how should diarrhea associated with en be assessed in the adult critically ill population?问题：如何评估成年危重病患者en相关性腹泻？d6. based on expert consensus, we suggest that en not be automatically interrupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an icu patient to determine appropriate treatment.根据专家共识，我们建议不要因icu患者发生腹泻而自动中止en，而应继续喂养，同时查找腹泻的病因以确定适当的治疗。e. selection of appropriate enteral formulation 选择适合的肠内营养制剂question: which formula should be used when initiating en in the critically ill patient?问题：危重病患者的早期en应使用哪种配方？e1. based on expert consensus, we suggest using a standard polymeric formula when initiating en in the icu setting. we suggest avoiding the routine use of all specialty formulas in critically ill patients in a micu and disease-specific formulas in the sicu.根据专家共识，我们建议icu患者开始en时选择标准多聚体配方肠内营养制剂。我们建议micu的危重病患者应避免常规使用各种特殊配方制剂，sicu患者应避免常规应用疾病专属配方肠内营养制剂。question: do immune-modulating enteral formulations have an impact on clinical outcomes for the critically ill patient regardless of the icu setting?问题：免疫调节型肠内营养制剂能否影响icu危重病患者的临床结局？e2. we suggest immune-modulating enteral formulations (arginine with other agents, including eicosapentaenoic acid epa, docosahexaenoic acid dha, glutamine, and nucleic acid) should not be used routinely in the micu. consideration for these formulations should be reserved for patients with tbi and perioperative patients in the sicu (see sections o and m).quality of evidence: very low我们建议在micu不应常规使用免疫调节型肠内营养制剂（精氨酸及其他药物，包括二十碳五烯酸epa、二十二碳六烯酸dha、谷氨酰胺与核苷酸）。上述制剂可用于颅脑创伤与sicu的围术期患者。证据质量：非常低question: should en formulas with fish oils (fos), borage oil and antioxidants be used in patients with ali or ards?问题：ali或ards患者是否需要使用含鱼油(fos)、琉璃苣油与抗氧化剂的肠内营养配方？e3. we cannot make a recommendation at this time regarding the routine use of an enteral formulation characterized by an antiinflammatory lipid profile (e.g., omega-3 fos, borage oil) and antioxidants, in patients with ards and severe ali, given conflicting data.quality of evidence: low to very low有关ards与严重ali患者使用含有抗炎作用的脂肪（例如-3 fos，琉璃苣油）及抗氧化剂的肠内营养制剂，目前临床资料相互矛盾，因此我们不做任何推荐。证据质量：低至非常低question: in adult critically ill patients, what are the indications, if any, for enteral formulations containing soluble fiber or small peptides?问题：成年危重病患者应用含可溶性纤维或短肽配方的肠内营养制剂的指征是什么？e4a. we suggest that a commercial mixed fiber formula not be used routinely in the adult criticall