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卒中单元NICU杨中华卒中后营养的重要性卒中患者营养不良的发生率N（%）1week31(35)5weeks29(33)3months18(20)6months20(22)theJournalofNutrition,Health&Aging2007;11:75-793低热卡摄入与血液感染CritCareMed2004;32:350–357DaysSinceMICUAdmissionP<0.05>50%<75%<25%>75%>=25%<50%1.000.750.500.250.0002040ProportionWithoutFirstICUBSI4Food试验的基线特征NormalOverweightUndernourishedProportionaliveTimesincerandomisation(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ArchNeurol.2008;65(1):39-436急性卒中后营养不良对临床结局的影响Stroke.1996;27:1028-1032Scoreat1moMalnourishedNonmalnourishedNo.%No.%PCSS≤51666.71522.40.0001BI0.012≥95416.72841.8

55-90312.51522.4

≤501770.82435.8

7吞咽困难是卒中后营养不良

的最重要的机制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-吞咽困难vs无吞咽困难10

卒中相关性肺炎的发生频率-误吸vs无误吸

Review:ArticleComparison:01IncidenceofPneumoniaReview:02Figure2-IncidenceofPneumoniainStrokePatients-AspiratorsvsNon-AspiratorsStudyAspiratorsNon-AspiratorsRR(Random)WeightRR(Random)Orsub-categoryn/Nn/N95%CL%95%CLHolasetal,19948/611/537.366.95[0.90,53.78]Schmidtetal,19945/261/337.186.35[0.79,51.03]Kiddetal,199517/252/3511.5411.90[3.02,46.94]Smithardetal,19967/2012/7416.742.16[0.98,4.76]Teaselletal,199610/842/35710.5821.25[4.74,95.18]Reynoldsetal,199812/349/6817.032.67[1.25,5.70]Ding&Logeman,200060/18540/19320.441.56[1.11,2.21]Mengetal,20003/70/134.5912.25[0.72,208.21]Limetal,20015/260/244.5610.19[0.59,174.94]Total(95%CL)4688501004.45[2.25,8.81]Totalevents:127(Aspirators),67(Non-Aspirators)Testforheterogeneity:Chi2=24.70,df=8(P=0.002),I2=67.6%TestforOveralleffect:Z=4.28(P<0.0001)0.10.20.512510Non-AspiratorsAspirators11ASPIRATIONPNEUMONITISANDASPIRATIONPNEUMONIA右肺下叶局部形成空洞（箭头所指）NEnglJMed,2001,344(9):665-67112吞咽筛选试验任意程度的意识水平下降；饮水之后声音变化；自主咳嗽减弱；饮一定量的水时发生咳嗽；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。13正规吞咽筛查对肺炎的影响Stroke2005;36:1972-197614正规吞咽筛查对肺炎的影响-卒中严重程度Stroke2005;36:1972-197615选择肠内还是肠外营养国内肠内营养的现状18k1.8k200235k6k2007PN:EN=10:1PN:EN=6:117国外肠内营养概况IntensiveCareMed.2003Jun;29(6):867-918ENvsPN-死亡率Nutrition2004;20:843–848.19ENvsPN-感染并发症Nutrition2004;20:843–848.20肠外营养是院内感染的危险因素VariablePOddsratio95%CIAge<0.052.171.06-4.44Presenceofinfectiononadmission<0.0010.20.09-0.47Parenteralnutrition

0.023.221.53-6.8Presenceofcentralvenouscatheter

0.0047.931.92-32.71Jpn.J.Infect.Dis.,60,87-91,200721肠内营养应用之科室分布北京和广州药剂科数据22早期喂养与延迟喂养早期肠内营养vs延迟营养-感染并发症CritCareMed2001;29:2264–227024早期肠内营养vs延迟营养-非感染并发症CritCareMed2001;29:2264–227025早期肠内营养vs延迟营养-住院时间CritCareMed2001;29:2264–227026早期肠内营养vs延迟营养-死亡CritCareMed2001;29:2264–227027Foodtrial2-MRSatfollow-up859patientswereenrolledby83hospitalsin15countriesintotheearlyversusavoidtrialreductioninriskofdeathof5.8%(95%CI-0.8to12.5,p=0.09)reductionindeathorpooroutcomeof1.2%(-4.2to6.6,p=0.7).Lancet2005;365:764–7228早期喂养面临的问题

胃排空延迟

经胃喂养vs经空肠喂养创伤患者胃排空-13C标记苯丙氨酸试验DigSurg1999;16:192–196normalhistoriccontrolswas4.57+/-1.48mmol/l30创伤患者胃排空normalhistoriccontrolswas7.08+/-0.33.DigSurg1999;16:192–19631克服胃排空延迟

监测胃内容物残留量

CritCareMed2001;29:1955–196132胃排空延迟选择经空肠喂养使用胃肠动力药物合理的胃内容物监测33肠内营养途径的选择肠内营养管饲的途径管饲鼻胃管鼻空肠管PEGPEJ35鼻胃管36PEG372005ESPENguidelinesforPEGClinicalNutrition(2005)24,848–86138非急性老年病房:NGTvsPEG-生存率PEG减少老年非急性患者的死亡率(hazardratio(HR)=0.41;95%confidenceinterval(CI)0.22-0.76;P=0.01).PEG减少误吸的风险(HR=0.48;95%CI0.26-0.89)PEG减少自拔管率(HR=0.17;95%CI0.05-0.58)ClinicalNutrition(2001)20(6):535±54039CONCLUSION非急性期，长期肠内营养的患者使用PEG可以提高存活率PEG具有更好的耐受性降低误吸的风险ClinicalNutrition(2001)20(6):535±54040Food3-早期PEGvsNGT对mRS的影响321patientswereenrolledby47hospitalsin11countries早期PEG绝对增加1%(-10.0to11.9,p=0.9)的死亡风险早期PEG增加死亡或者不良预后，7.8%(0.0to15.5,p=0.05)Lancet2005;365:764–7241FOODtrial3:EffectoffeedingviaPEGversusnasogastrictubeLancet2005;365:764–7242FOODTrial3结论卒中早期PEG没有能够提高患者的生存率，并且会增加患者的致残率，2-3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PEG喂养432008ESO缺血性卒中指南CerebrovascDis2008;25:457–50744喂养流程Intensivecareunit(ICU)feedingalgorithmJAMA.2008;300(23):2731-41.46管饲–腹泻的肠内营养流程JAMA.2008;300(23):2731-41.47高营养vs普通饮食FOOD-1:经口强化营养对住院卒中患者的影响Lancet2005;365:755–63ModifiedRankinscalegradeNosupplementsSupplements(n=2007)(n=2016)0159(8%)164(8%)1313(16%)308(15%)2352(18%)343(17%)3456(23%)507(25%)4242(12%)228(11%)5220(11%)218(11%)Dead253(13%)241(12%)AlivebutMRSnotknown5(0%)3(0%)Outcomenotknown7(0%)4(0%)MRS3–5(pooroutcome)918(46%)953(47%)Deathorpooroutcome1171(58%)1194(59%)537大卡热量22.5g蛋白4023patientswereenrolledby125hospitalsin15countries49FOODtrial1经口强化营养对卒中患者死亡的影响Lancet2005;365:755–