肠外营养全合一配置的重要性

肠外营养全合一配制的重要性,现状：“单瓶输注”仍在广泛使用,Pan H, Cai S, Ji J, et al. The impact of nutritional status, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center, prospective cohort study in Chinese teaching hospitals. Nutr Cancer. 2013;65(1):62-70.Maisonneuve N, Raguso C A, Paoloni-Giacobino A, et al. Parenteral nutrition practices in hospital pharmacies in Switzerland, France, and BelgiumJ. Nutrition, 2004, 20(6): 528-535.,单瓶输注，是将各种营养物质（葡萄糖、脂肪、氨基酸）以一个个单瓶分别输入患者外周静脉的肠外营养方式。2013年中国一项含2000余例患者的前瞻性、多中心、队列研究发现：单瓶输注仍占到营养治疗患者的46%！,难以快速供能,缺少葡萄糖,导致单糖供能时耗氧量大、呼吸负担重,缺少脂肪乳,无法有效增加蛋白质合成,缺少氨基酸,单营养素输注不全,Hamilton-Farrell MR, Hanson GC. Assisted ventilation. 3. General care of the ventilated patient in the intensive care unit. Thorax. 1990 Dec;45(12):962-9.,序贯输注或串输不平衡,黎介寿. 临床营养支持策略的变迁. 中国普外基础与临床杂志. 2009;16(12):953-5.Abunnaja S, Cuviello A, Sanchez JA. Enteral and parenteral nutrition in the perioperative period: state of the art. Nutrients. 2013 Feb 21;5(2):608-23.Menne R, Adolph M, Brock E, et al. Cost analysis of parenteral nutrition regimens in the intensive care unit: three-compartment bag system vs multibottle system. JPEN J Parenter Enteral Nutr. 2008 Nov-Dec;32(6):606-12.Puntis J. Safe parenteral nutrition and the role of standardised feeds. Signa Vitae. 2010; 5(1):8-12.,不能使营养素同时进入人体起作用,未按比例混合,高血糖或低血糖、氮质血症、高甘油三酯血症,代谢并发症,多个容器和导管带来的感染风险,感染并发症,营养输入不平衡的后果,因营养素比例不合而导致的代谢并发症高血糖或低血糖氮质血症高甘油三酯血症导管相关感染并发症发生率高,Menne R, Adolph M, Brock E, et al. Cost analysis of parenteral nutrition regimens in the intensive care unit: three-compartment bag system vs multibottle system. JPEN J Parenter Enteral Nutr. 2008 Nov-Dec;32(6):606-12.,单营养素输注显著增加营养治疗患者不良事件发生率,Pan H, Cai S, Ji J, et al. The impact of nutritional status, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center, prospective cohort study in Chinese teaching hospitals. Nutr Cancer. 2013;65(1):62-70.,中国的多中心、前瞻性、队列研究，结果显示：对于肿瘤住院患者来说，如果采用单营养素输注方式进行肠外营养，则抗肿瘤治疗相关不良事件的发生率甚至显著高于“无营养支持”的患者,单瓶输注、序贯输注或串输，显著增加血流感染率,Turpin R S, Solem C, Pontes-Arruda A, et al. The impact of parenteral nutrition preparation on bloodstream infection risk and costsJ. European journal of clinical nutrition, 2014, 68(8): 953-958.,2014年美国一项肠外营养与血流感染风险的相关性研究结果显示：与“全合一”输注相比，无论单营养素输注、序贯输注还是串输，其血流感染的发生率都显著增高。,单瓶输注、序贯输注或串输感染风险比“全合一”方式高1.5倍,Turpin R S, Solem C, Pontes-Arruda A, et al. The impact of parenteral nutrition preparation on bloodstream infection risk and costsJ. European journal of clinical nutrition, 2014, 68(8): 953-958.,单营养素输注血流感染风险增加1.53倍序贯或串输血流感染风险增加1.46倍,院内配制大多数人不需要,个体化营养支持，仅适用于5-10%的特殊患者院内配置的“全合一”营养液用于满足5-10%特殊住院患者个体化治疗的需要ESPEN指南推荐：对于没有严重并存疾病的患者来说，没有必要给予个体化营养支持,陈伟, 周春凌, 李海龙, 等. 肠外营养预混配方与全合一配液配方的临床应用调查. 中华普通外科杂志. 2011;26(9):762-5.Braga M, Ljungqvist O, Soeters P, et al; ESPEN. ESPEN Guidelines on Parenteral Nutrition: surgery. Clin Nutr. 2009 Aug;28(4):378-86.,ESPEN指南并不推荐常规使用：“Individualized nutrition is often unnecessary in patients without serious co-morbidity (Grade C).”“对于无严重并存疾病的患者来说，没必要给予个体化营养支持。”欧洲临床营养与代谢学会（ESPEN）,院内配制对设备、人员要求高，存在污染风险,对设备、人员要求高，存在污染风险需要单独、全封闭、无菌的操作环境需要接受过专业培训的操作人员工作流程极为严格,院内配制增加血流感染发生率,Turpin RS, Canada T, Rosenthal V, et al; IMPROVE Study Group. Bloodstream infections associated with parenteral nutrition preparation methods in the United States: a retrospective, large database analysis. JPEN J Parenter Enteral Nutr. 2012 Mar;36(2):169-76.,回顾性、多中心、多变量研究，比较院内配制和预混多腔袋对肠外营养患者血流感染（BSI）发生率的影响。,ASPEN指南推荐：肠外营养应采用标准化“全合一”方式,Boullata JI, Gilbert K, Sacks G, et al; American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. clinical guidelines: parenteral nutrition ordering, order review, compounding, labeling, and dispensing. JPEN J Parenter Enteral Nutr. 2014 Mar-Apr;38(3):334-77.,“预灌装多腔袋肠外营养制剂是患者的适宜选择”“Premade multichambered PN formulations be considered as an available option for patients”-美国肠外与肠内营养学会（ASPEN），2014,ESPEN指南推荐,Singer P, Berger M M, Van den Berghe G, et al. ESPEN guidelines on parenteral nutrition: intensive careJ. Clinical nutrition, 2009, 28(4): 387-400.,“肠外营养混合液应以“全合一”方式输注”“PN admixtures should be administered as a complete all-in-one bag (Grade B)”-欧洲临床营养与代谢学会（ESPEN），2009,“全合一”是正确的肠外营养实施方式,Solassol C L, Joyeux H, Etco L, et al. New techniques for long-term intravenous feeding: an artificial gut in 75 patientsJ. Annals of surgery, 1974, 179(4): 519.,同时包括人体所需的各种营养素，如：水、电解质、葡萄糖、氨基酸、脂肪乳、维生素、微量元素等,全营养素,各种营养素应依据合理比例，如：热氮比、糖脂比,合理比例,保证各营养素按比例同时进入人体，从而均衡利用,一个容器中充分混合,全,合,一,“全合一”的特性和优势,Tristan - Udriot M. et al. Md Hyg 51, 1668-1171, 1993.Velickovich G et al. Md Hyg 51, 1976-1980, 1995.,提高糖脂利用率，促进氮平衡，减少代谢性并发症,减少污染机会，降低导管感染的风险,减少血栓和静脉炎的形成,较少的并发症、治疗费用,缩短病人的住院时间,单瓶输注换为全合一，导管相关感染发生风险下降42%-50%,Durand-Zaleski I, Delaunay L, Langeron O, et al. Infection risk and cost-effectiveness of commercial bags or glass bottles for total parenteral nutritionJ. Infection control and hospital epidemiology, 1997: 183-188.,对于ICU患者，如果将单瓶输注转换为“全合一”方式输注，则导管相关感染风险下降50%,对于外科术后患者，如果将单瓶输注转换为“全合一”方式输注，则导管相关感染风险下降42%,“全合一”方式，显著减少不良事件,Pan H, Cai S, Ji J, et al. The impact of nutritional status, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center, prospective cohort study in Chinese teaching hospitalsJ. Nutrition and cancer, 2013, 65(1): 62-70.,中国的多中心、前瞻性、队列研究，结果显示：对于肿瘤住院患者来说，如果采用单瓶输注方式进行肠外营养，则抗肿瘤治疗相关不良事件的发生率甚至显著高于“无营养支持”的患者。而“全合一