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疾病營養支持-圍手術期腸內營養

發布日期:(2015-8-14)   點擊次數:2267

一、背景

腸內營養與腸外相比具有更符合生理、有利于維持腸道粘膜細胞結構與功能完整性、并發癥少且價格低廉等優點,因此,只要患者存在部分胃腸道消化吸收功能,也應當盡可能首先考慮腸內營養支持。嚴重營養不良是影響外科手術患者結局的重要因素[13];而不適當的營養支持同樣會給患者帶來危害[4]。 對圍手術期患者而言,恰當的營養支持十分必要。

二、證據

有關術前禁食及術后飲食恢復時間

術前1012小時禁食,這一傳統的準備措施可使患者過早進入分解代謝狀態,不利于患者術后康復。有證據表明術前2h~3h進食流食并不增加反流與誤吸的風險,因此,許多國家的麻醉學會已將擇期手術患者術前禁食時間改為6小時,而術前禁水只需2小時[58]。取而代之的是在手術前夜與術前2小時給予大手術患者一定量碳水化合物。結直腸手術和髖關節置換手術患者,術前口服低滲性碳水化合物飲料,可減輕術后胰島素抵抗,有助于減少骨骼肌分解,患者耐受性良好,且術后一月肌力的提高優于對照組 [915]。

結直腸手術和膽囊切除術患者術后早期進食或腸內營養有益。有證據表明術后早期進食或腸內營養(包括術后1~2天即開始進食流食),不影響結直腸吻合口愈合[1621]。但早期經消化道營養攝入對上腹部胃腸道大手術患者的影響尚不清楚。專家共識認為應根據患者的胃腸功能和耐受能力決定術后早期進食或腸內營養的開始時間和劑量。

圍手術期腸內營養支持的適應癥與禁忌癥

營養風險篩查同圍手術期腸外營養支持。

存在營養不良的大手術患者,術前10~14d的營養支持能降低手術并發癥的發生率[2225]。

術前超過14天以上不能保證足量經口進食與手術死亡率相關[26],多因素分析表明,營養不良是術后并發癥發生率的獨立危險因素,并與死亡率、住院時間及住院費相關[27]。在35RCT研究中24個表明EN降低了術后感染相關并發癥,縮短了住院時間,降低了住院費;另外8個結果陰性。對營養不良的胃腸道腫瘤患者,早期腸內營養比TPN降低了術后感染的發生率,但營養狀態正常的患者則沒有這種作用[28]。兩個Meta-分析表明,接受EN的患者其感染率和住院時間都較接受PN者為低[29,30]。目前尚無聯合應用腸內外營養支持的對照研究結果,但對于那些有營養支持的適應癥,而經由腸內途徑無法滿足能量需要(<60%的熱量需要)時,多數專家認為可以考慮聯合應用腸外營養。

圍手術期腸內營養的禁忌癥

腸梗阻,血流動力學不穩定,腸缺血。

管飼營養的適應癥與方法

頭頸部及腹部惡性腫瘤的患者術前營養不良較常見,其術后感染的風險較高,術后由于吻合口水腫、梗阻或胃排空障礙等常導致延遲經口進食,這些患者應考慮應用管飼喂養,在術后24小時內就可進行管飼營養[3135]。

腹部大手術患者術中置經皮空腸穿刺放置喂養管是安全的[3638];胰十二指腸切除術患者置鼻空腸營養管也是安全的[39]。近端胃腸道吻合術后,可通過頂端位于吻合口遠端的營養管進行腸內營養[4044]。

長期(大于4周)管飼營養的患者(如嚴重頭頸部外傷患者),如果無需腹部手術,可考慮經皮內鏡下胃造瘺置管(PEG)。

由于腸道耐受力有限,應以較低的滴速(如10-20ml/h)開始管飼營養,可能需5-7天才能達到足量營養攝入[4547]。

圍手術期接受營養支持的患者,住院期間應常規進行營養狀況再評估,如有必要,出院后應繼續營養支持。

腸內營養配方的種類

專家共識為標準的整蛋白配方適合大部分患者的腸內營養支持。Meta-分析表明因腫瘤接受頸部大手術(喉切除術,咽部分切除術)患者、腹部腫瘤大手術(食管切除術,胃切除術和胰十二指腸切除術)患者在圍手術期應用含有免疫調節成分(精氨酸,ω-3脂肪酸和核苷酸)的腸內營養可減少術后并發癥并縮短住院時間[4852]。但對于有全身性感染、危重癥患者,含有精氨酸的“免疫腸內營養”可能反而導致死亡率增加53]。

三、推薦意見

1.   無胃癱的擇期手術患者不常規推薦在進行術前12小時禁食。(A)。

2.   有營養不良風險的患者,大手術前應給予10-14天的營養支持。 (A)

3.   以下患者應盡早開始營養支持(盡可能通過腸內途徑):預計圍手術期禁食時間大于7天;預計10天以上經口攝入量無法達到推薦攝入量的60%以上。(D)

4.   對于有營養支持指征的患者,經由腸內途徑無法滿足能量需要(<60%的熱量需要)時,可考慮聯合應用腸外營養。(D)

5.   圍手術期腸內營養禁忌癥:腸梗阻,血流動力學不穩定,腸缺血。(A

6.   術前鼓勵那些不能從正常飲食中滿足能量需要的患者接受口服營養支持,在住院之前就可以開始腸內營養支持。沒有特殊的誤吸風險及胃癱的手術患者,建議僅需麻醉前2小時禁水,6小時禁食。(A

7.   手術后應盡早開始正常食物攝入或腸內營養。大部分接受結腸切除術的患者,可以在術后數小時內開始經口攝入清淡流食,包括清水。(A

8.   對不能早期進行口服營養支持的患者,應用管飼喂養,特別是以下患者:

l   因為腫瘤接受了大型的頭頸部和胃腸道手術。(A

l   嚴重創傷。(A

l   手術時就有明顯的營養不良。(A

l   大于10天不能經口攝入足夠的(>60%)營養。(D)

9.   在術后24小時內對需要的患者進行管飼營養。(A

10.由于腸道耐受力有限,管飼腸內營養推薦采用輸注泵以較低的滴速(10-20ml/h)開始,可能需要5-7天才能達到目標攝入量。(D

11.對圍手術期接受了營養支持的患者,在住院期間常規進行營養狀態的再評估,如果需要的話,出院后繼續營養支持。(D

12.在所有接受腹部手術的患者的管飼營養裝置中,推薦放置較細的空腸造瘺管或鼻空腸管。(A

13.近端胃腸道吻合術后患者,可通過頂端位于吻合口遠端的營養管進行腸內營養。(B

14.長期(大于4周)管飼營養患者(如嚴重頭部外傷),可考慮放置經皮內鏡下胃造瘺(如PEG)。(D

15.標準的整蛋白配方適用于大部分患者。(D

16.對以下患者可考慮在圍手術期應用含有免疫調節成分(精氨酸,ω-3脂肪酸和核苷酸)的腸內營養:(B

l   因為腫瘤接受大型的頸部手術(喉切除術,咽部分切除術);

l   接受大型的腹部腫瘤手術(食管切除術,胃切除術和胰十二指腸切除術);

17.不推薦將含有精氨酸的“免疫腸內營養”用于合并重度創傷、全身感染和危重癥患者。(A

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