ESPEN指南：外科临床营养

ESPEN将养分整合入患者整体治理避开长时间术前禁食术后尽早重建立经口喂养一旦养分风险变得明显，早期开头养分疗法将养分整合入患者整体治理避开长时间术前禁食术后尽早重建立经口喂养一旦养分风险变得明显，早期开头养分疗法代谢把握，例如血糖削减加重应激相关分解代谢或影响胃肠功能的因素缩短用于术后呼吸机治理的麻醉药物使用时间早期活动以促进蛋白质合成和肌肉功能恢复缩写缩写BM：生物医学终点GPP：良好实践要点。依据指南制定小组临床阅历推举的最正确实践方法。HE：医疗卫生经济终点IE：整合传统终点与患者报告终点QL：生活质量TF：管饲者在麻醉前两个小时应喝清流质。麻醉前六小时前应允许进食固体食物〔BM、者在麻醉前两个小时应喝清流质。麻醉前六小时前应允许进食固体食物〔BM、IE、QL〕。推举等级：A，高度共识〔97%同意〕时间，对大手术患者可考虑术前使用碳水化合物〔0，BM、HE〕。推举等级：A/B，高度共识〔100%同意〕在完成过程中由工作小组依据最荟萃分析下调等级〔100%同意〕〔BM、IE〕。推举等级：A，高度共识〔90%同意〕等级：GPP，高度共识〔100%同意〕〔同意〕GPP，高度共识〔100%同意〕5507GPP，高度共识〔92%同意〕假设能量和养分需求不能仅通过经口和肠道摄入满足〔＜50%〕超禁忌证如肠梗阻〔A〕，应尽快赐予肠外养分〔BM〕。推举等级：GPP/A，高度共识〔100%同意〕〔三腔袋或药房配制〔BM、HE〕。推举等级：B，高度共识〔100%同意〕等级：GPP，高度共识〔100%同意〕PN脉补充谷氨酰胺〔0，BM、B，共识〔76%同意〕，在完成过程中由工作小组依据最近的PRCT〔100%同意〕仅对因肠内喂养缺乏而需要肠外养分的患者应考虑术后肠外养分包括使用ω-3脂肪酸〔BM、HE〕。推举等级：B，大多数同意〔65%同意〕对承受癌症大手术养分不良的患者应在围手术期或至少术后使用富含免疫养分HE〕。目前没有明确的证据说明在围手术期使用这些富含免疫养分素的配方优于标准的口服养分补充剂。推举等级：B/0，共识〔89%同意〕〔A〕，即使手术，包括那些癌症，必需推迟〔BM〕7～14A/0，高度共识〔95%同意〕/肠内途径识〔100%同意〕服养分补充剂，不管他们的养分状况如何。推举等级：GPP，共识〔86%同意〕术前应对全部养分不良的癌症患者和进展腹部大手术的高风险患者赐予口服养分等级：A，高度共识〔97%同意〕术前肠内养分/口服养分补充剂应在入院前使用，以避开不必要的住院治疗和降低院内感染的风险〕EN7～14同意〕对不能早期开头经口养分摄入、经口摄入缺乏〔＜50%〕7的患者〔A，BM〕严峻创伤包括颅脑损伤的患者〔A，BM〕手术时有明显养分不良的患者〔A，BM，GPP〕推举等级：A/GPP，高度共识〔97%同意〕一般不建议使用厨房制备的膳食〔匀浆膳〕TF。推举等级：GPP，高度共识〔94%同意〕至于养分不良患者的特别方面，对全部承受上消化道和胰腺大手术患者进展TFB，高度共识〔95%同意〕同意〕10～由于肠道耐受性有限，5～7GPP，共识〔85%同意〕TF〔＞4〕，如重症颅脑损伤，建议经皮置管〔如经皮内镜下胃造口—PEG〕。推举等级：GPP，高度共识〔94%同意〕等级：GPP，高度共识〔97%同意〕TF。推举等级：GPP，高度共识〔100%同意〕建议。推举等级：GPP，高度共识〔100%同意〕识〔97%同意〕24内养分。推举等级：GPP，高度共识〔100%同意〕等级：GPP，高度共识〔93%同意〕高度共识〔100%同意〕高度共识〔100%同意〕高度共识〔100%同意〕/针刺导管空肠造口术。推举等级：0，共识〔87%同意〕〔94%同意〕ClinNutr.2023Jun;36(3):623-650.ESPENguideline:Clinicalnutritioninsurgery.n,a,i,ir,k,oLjungqvistO,LoboDN,MartindaleR,WaitzbergDL,BischoffSC,SingerP.KlinikumSt.Georg,Leipzig,Germany;SanRaffaeleHospital,Milan,Italy;McGillUniversity,MontrealGeneralHospital,Montreal,Canada;FujitaHealthUniversity,Toyoake,Aichi,Japan;CentreHospitalierUniversitaireVaudois(CHUV),Lausanne,Switzerland;StanleyDudrick”sMemorialHospital,Skawina,Krakau,Poland;Universita“LaSapienza“Roma,Roma,Italy;OrebroUniversity,Orebro,Sweden;NottinghamUniversityHospitalsandUniversityofNottingham,Queen”sMedicalCentre,Nottingham,UK;OregonHealth&ScienceUniversity,Portland,OR,USA;UniversityofSaoPaulo,SaoPaulo,Brazil;UniversitatHohenheim,Stuttgart,Germany;RabinMedicalCenter,BeilinsonHospital,PetahTikva,Israel.Earlyoralfeedingisthepreferredmodeofnutritionforsurgicalpatients.Avoidanceofanynutritionaltherapybearstheriskofunderfeedingduringthepostoperativecourseaftermajorsurgery.Consideringthatmalnutritionandunderfeedingareriskfactorsforpostoperativecomplications,earlyenteralfeedingisespeciallyrelevantforanysurgicalpatientatnutritionalrisk,especiallyforthoseundergoinguppergastrointestinalsurgery.ThefocusofthisguidelineistocovernutritionalaspectsoftheEnhancedRecoveryAfterSurgery(ERAS)conceptandthespecialnutritionalneedsofpatientsundergoingmajorsurgery,e.g.forcancer,andofthosedevelopingseverecomplicationsdespitebestperioperativecare.Fromametabolicandnutritionalpointofview,thekeyaspectsofperioperativecareinclude:integrationofnutritionintotheoverallmanagementofthepatientavoidanceoflongperiodsofpreoperativefastingre-establishmentoforalfeedingasearlyaspossibleaftersurgerystartofnutritionaltherapyearly,assoonasanutritionalriskbecomesapparentmetaboliccontrole.g.ofbloodglucoseBM:BM:biomedicalendpointsGPP:Goodpracticepoints.RecommendedbestpracticebasedontheclinicalexperienceoftheguidelinedevelopmentgroupHE:healthcareeconomyendpointIE:integrationofclassicalandpatient-reportedendpointsQL:qualityoflifeTF:tubefeedingreductionoffactorswhichexacerbatestress-relatedcatabolismorimpairgastrointestinalfunctionminimizedtimeonparalyticagentsforventilatormanagementinthepostoperativeperiodearlymobilisationtofacilitateproteinsynthesisandmusclefunctionTheguidelinepresents37recommendationsforclinicalpractice.1.1.Preoperativefastingfrommidnightisunnecessaryinmostpatients.PatientsPatientsundergoingsurgery,whoareconsideredtohavenospecificriskofofaspiration,shalldrinkclearfluidsuntiltwohoursbeforeanaesthesia.SolidsSolidsshallbealloweduntilsixhoursbeforeanaesthesia(BM,IE,QL).GradeGradeofrecommendationA-strongconsensus(97%agreement)2.Inordertoreduceperioperativediscomfortincludinganxietyoralpreoperativecarbohydratetreatment(insteadofovernightfasting)thenightbeforeandtwohoursbeforesurgeryshouldbeadministered(B)(QL).Toimpactpostoperativeinsulinresistanceandhospitallengthofstay,preoperativecarbohydratescanbeconsideredinpatientsundergoingmajorsurgery(0)(BM,HE).ConsensusConference:GradeofrecommendationA/B-strongconsensus(100%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotheveryrecentmeta-analysis(with100%agreementwithintheworkinggroupmembers)Ingeneral,oralnutritionalintakeshallbecontinuedaftersurgerywithoutinterruption(BM,IE).GradeofrecommendationA-strongconsensus(90%agreement)Itisrecommendedtoadaptoralintakeaccordingtoindividualtoleranceandtothetypeofsurgerycarriedoutwithspecialcautiontoelderlypatients.GradeofrecommendationGPP-strongconsensus(100%agreement)Oralintake,includingclearliquids,shallbeinitiatedwithinhoursaftersurgeryinmostpatients.GradeofrecommendationA-strongconsensus(100%agreement)Itisrecommendedtoassessthenutritionalstatusbeforeandaftermajorsurgery.GradeofrecommendationGPP-strongconsensus(100%agreement)Perioperativenutritionaltherapyisindicatedinpatientswithmalnutritionandthoseatnutritionalrisk.Perioperativenutritionaltherapyshouldalsobeinitiated,ifitisanticipatedthatthepatientwillbeunabletoeatformorethanfivedaysperioperatively.Itisalsoindicatedinpatientsexpectedtohaveloworalintakeandwhocannotmaintainabove50%ofrecommendedintakeformorethansevendays.Inthesesituations,itisrecommendedtoinitiatenutritionaltherapy(preferablybytheenteralroute-ONS-TF)withoutdelay.GradeofrecommendationGPP-strongconsensus(92%agreement)Iftheenergyandnutrientrequirementscannotbemetbyoralandenteralintakealone(<50%ofcaloricrequirement)formorethansevendays,acombinationofenteralandparenteralnutritionisrecommended(GPP).Parenteralnutritionshallbeadministeredassoonaspossibleifnutritiontherapyisindicatedandthereisacontraindicationforenteralnutrition,suchasinintestinalobstruction(A)(BM).GradeofrecommendationGPP/A-strongconsensus(100%agreement)Foradministrationofparenteralnutritionanall-in-one(three-chamberbagorpharmacyprepared)shouldbepreferredinsteadofmultibottlesystem(BM,HE).GradeofrecommendationB-strongconsensus(100%agreement)Standardisedoperatingprocedures(SOP)fornutritionalsupportarerecommendedtosecureaneffectivenutritionalsupporttherapy.GradeofrecommendationGPP-strongconsensus(100%agreement)Parenteralglutaminesupplementationmaybeconsideredinpatientswhocannotbefedadequatelyenterallyand,therefore,requireexclusivePN(0)(BM,HE).ConsensusConference:GradeofrecommendationB-consensus(76%agreement)-downgradedbytheworkinggroupduringthefinalizationprocessaccordingtotherecentPRCT(with100%agreementwithintheworkinggroupmembers).Postoperativeparenteralnutritionincludingomega-3-fattyacidsshouldbeconsideredonlyinpatientswhocannotbeadequatelyfedenterallyand,therefore,requireparenteralnutrition(BM,HE).GradeofrecommendationB-majorityagreement(65%agreement)Peri-oratleastpostoperativeadministrationofspecificformulaenrichedwithimmunonutrients(arginine,omega-3-fattyacids,ribonucleotides)shouldbegiveninmalnourishedpatientsundergoingmajorcancersurgery(B)(BM,HE).Thereiscurrentlynoclearevidencefortheuseoftheseformulaeenrichedwithimmunonutrientsvs.standardoralnutritionalsupplementsexclusivelyinthepreoperativeperiod.GradeofrecommendationB/0-consensus(89%agreement)Patientswithseverenutritionalriskshallreceivenutritionaltherapypriortomajorsurgery(A)evenifoperationsincludingthoseforcancerhavetobedelayed(BM).Aperiodof7-14daysmaybeappropriate.GradeofrecommendationA/0-strongconsensus(95%agreement)Wheneverfeasible,theoral/enteralrouteshallbepreferred(A)(BM,HE,QL).GradeofrecommendationA-strongconsensus(100%agreement)Whenpatientsdonotmeettheirenergyneedsfromnormalfooditisrecommendedtoencouragethesepatientstotakeoralnutritionalsupplementsduringthepreoperativeperiodunrelatedtotheirnutritionalstatus.GradeofrecommendationGPP-consensus(86%agreement)Preoperatively,oralnutritionalsupplementsshallbegiventoallmalnourishedcancerandhigh-riskpatientsundergoingmajorabdominalsurgery(BM,HE).Aspecialgroupofhigh-riskpatientsaretheelderlypeoplewithsarcopenia.GradeofrecommendationA-strongconsensus(97%agreement)Immunemodulatingoralnutritionalsupplementsincludingarginine,omega-3fattyacidsandnucleotidescanbepreferred(0)(BM,HE)andadministeredforfivetosevendayspreoperatively(GPP).Gradeofrecommendation0/GPP-majorityagreement,64%agreementPreoperativeenteralnutrition/oralnutritionalsupplementsshouldpreferablybeadministeredpriortohospitaladmissiontoavoidunnecessaryhospitalizationandtolowertheriskofnosocomialinfections(BM,HE,QL).GradeofrecommendationGPP-strongconsensus(91%agreement)PreoperativePNshallbeadministeredonlyinpatientswithmalnutritionorseverenutritionalriskwhereenergyrequirementcannotbeadequatelymetbyEN(A)(BM).Aperiodof7-14daysisrecommended.GradeofrecommendationA/0-strongconsensus(100%agreement)Earlytubefeeding(within24h)shallbeinitiatedinpatientsinwhomearlyoralnutritioncannotbestarted,andinwhomoralintakewillbeinadequate(<50%)formorethan7days.Specialriskgroupsare:patientsundergoingmajorheadandneckorgastrointestinalsurgeryforcancer(A)(BM)patientswithseveretraumaincludingbraininjury(A)(BM)patientswithobviousmalnutritionatthetimeofsurgery(A)(BM)(GPP).GradeofrecommendationA/GPP-strongconsensus(97%agreement)Inmostpatients,astandardwholeproteinformulaisappropriate.Fortechnicalreasonswithtubeclotggingandtheriskofinfectiontheuseofkitchen-made(blenderized)dietsfortubefeedingisnotrecommendedingeneral.GradeofrecommendationGPP-strongconsensus(94%agreement)Withspecialregardtomalnourishedpatients,placementofanasojejunaltube(NJ)orneedlecatheterjejunostomy(NCJ)shouldbeconsideredforallcandidatesfortubefeedingundergoingmajoruppergastrointestinalandpancreaticsurgery(BM).GradeofrecommendationB-strongconsensus(95%agreement)Iftubefeedingisindicated,itshallbeinitiatedwithin24haftersurgery(BM).GradeofrecommendationA-strongconsensus(91%agreement)Itisrecommendedtostarttubefeedingwithalowflowrate(e.g.10-max.20ml/h)andtoincreasethefeedingratecarefullyandindividuallyduetolimitedintestinaltolerance.Thetimetoreachthetargetintakecanbeverydifferent,andmaytakefivetosevendays.GradeofrecommendationGPP-consensus(85%agreement)IflongtermTF(>4weeks)isnecessary,e.g.insevereheadinjury,placementofapercutaneoustube(e.g.percutaneousendoscopicgastrostomy-PEG)isrecommended.GradeofrecommendationGPP-strongconsensus(94%agreement)Regularreassessmentofnutritionalstatusduringthestayinhospitaland,ifnecessary,continuationofnutritiontherapyincludingqualifieddietarycounsellingafterdischarge,isadvisedforpatientswhohavereceivednutritiontherapyperioperativelyandstilldonotcoverappropriatelytheirenergyrequirementsviatheoralroute.GradeofrecommendationGPP-strongconsensus(97%agreement)Malnutritionisamajorfactorinfluencingoutcomeaftertransplantation,somonitoringofthenutritionalstatusisrecommended.Inmalnutrition,additionaloralnutritionalsupplementsoreventubefeedingisadvised.GradeofrecommendationGPP-strongconsensus(100%agreement)Regularassessmentofnutritionalstatusandqualifieddietarycounsellingshallberequiredwhilemonitoringpatientsonthewaitinglistbeforetransplantation.GradeofrecommendationGPP-strongconsensus(100%agreement)Recommendationsforthelivingdonoran