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.)

成年危重病患者營(yíng)養(yǎng)支持治療的實(shí)施與評(píng)估指南：美國(guó)危重病醫(yī)學(xué)會(huì)(SCCM)與美國(guó)腸外腸內(nèi)營(yíng)養(yǎng)學(xué)會(huì)(ASPEN)

Taylor BE, McClave SA, Martindale RG, et al. Crit Care Med 2016; 44: 390-438

A. NUTRITION ASSESSMENT 營(yíng)養(yǎng)評(píng)估

Question: Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?

問(wèn)題：營(yíng)養(yǎng)風(fēng)險(xiǎn)篩查工具能否鑒別哪些患者最可能從營(yíng)養(yǎng)治療中獲益？

A1. Based on expert consensus, we suggest a determination of nutrition risk (for example, nutritional risk score [NRS-2002], NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from early EN therapy.

根據(jù)專(zhuān)家共識(shí)，我們建議對(duì)收入ICU且預(yù)計(jì)攝食不足的患者進(jìn)行營(yíng)養(yǎng)風(fēng)險(xiǎn)評(píng)估（如營(yíng)養(yǎng)風(fēng)險(xiǎn)評(píng)分NRS-2002，NUTRIC 評(píng)分）。高營(yíng)養(yǎng)風(fēng)險(xiǎn)患者的識(shí)別，最可能使其從早期腸內(nèi)營(yíng)養(yǎng)治療中獲益。

A2. Based on expert consensus, we suggest that nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration. We suggest not using traditional nutrition indicators or surrogate markers, as they are not validated in critical care.

根據(jù)專(zhuān)家共識(shí)，我們建議營(yíng)養(yǎng)評(píng)估應(yīng)當(dāng)包括對(duì)于合并癥、胃腸道功能以及誤吸風(fēng)險(xiǎn)的評(píng)估。我們建議不要使用傳統(tǒng)的營(yíng)養(yǎng)指標(biāo)或其替代指標(biāo)，因?yàn)檫@些指標(biāo)在ICU的應(yīng)用并非得到驗(yàn)證。

Question: What is the best method for determining energy needs in the critically ill adult patient?

問(wèn)題：確定成年危重病患者能量需求的最佳方法是什么？

A3a. We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement.

[Quality of Evidence: Very Low]。

如果有條件且不影響測(cè)量準(zhǔn)確性的因素時(shí)，建議應(yīng)用間接能量測(cè)定(間接測(cè)熱法，indirect calorimetry，IC) 確定能量需求。

［證據(jù)質(zhì)量：非常低］

A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-based equation (25–30 kcal/kg/ day) be used to determine energy requirements. (see section Q for obesity recommendations.)

根據(jù)專(zhuān)家共識(shí)，當(dāng)沒(méi)有IC時(shí)，我們建議使用已發(fā)表的預(yù)測(cè)公式或基于體重的簡(jiǎn)化公式(25–30 kcal/kg/ day)確定能量需求。（見(jiàn)Q部分有關(guān)肥胖患者的推薦意見(jiàn)。）

Question: Should protein provision be monitored independently from energy provision in critically ill adult patients?

問(wèn)題：對(duì)于成年危重病患者，除能量提供外，是否需要單獨(dú)監(jiān)測(cè)提供的蛋白質(zhì)量？

A4. Based on expert consensus, we suggest an ongoing evaluation of adequacy of protein provision be performed.

根據(jù)專(zhuān)家共識(shí)，我們建議連續(xù)評(píng)估蛋白質(zhì)供給的充分性。

B. INITIATE EN 開(kāi)始腸內(nèi)營(yíng)養(yǎng)(EN)

Question: What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?

問(wèn)題：對(duì)于成年危重病患者而言，與不給予或延遲給予EN相比，早期EN有何益處？

B1. We recommend that nutrition support therapy in the form of early EN be initiated within 24–48 hours in the critically ill patient who is unable to maintain volitional intake.

[Quality of Evidence: Very Low]

對(duì)于不能維持自主進(jìn)食的危重病患者，我們推薦在24 – 48小時(shí)內(nèi)通過(guò)早期EN開(kāi)始營(yíng)養(yǎng)支持治療。

［證據(jù)質(zhì)量：非常低］

Question: Is there a difference in outcome between the use of EN or PN for adult critically ill patients?

問(wèn)題：成年危重病患者使用EN或PN對(duì)預(yù)后的影響有何不同？

B2. We suggest the use of EN over PN in critically ill patients who require nutrition support therapy.

[Quality of Evidence: Low to Very Low]

對(duì)于需要營(yíng)養(yǎng)支持治療的危重病患者，我們建議首選EN而非PN的營(yíng)養(yǎng)供給方式。

［證據(jù)質(zhì)量：低至非常低］

Question: Is the clinical evidence of contractility (bowel sounds, flatus) required prior to initiating EN in critically ill adult patients?

問(wèn)題：在成年危重病患者開(kāi)始EN前是否需要有腸道蠕動(dòng)的證據(jù)（腸鳴音，排氣）？

B3. Based on expert consensus, we suggest that, in the majority of MICU and SICU patient populations, while GI contractility factors should be evaluated when initiating EN, overt signs of contractility should not be required prior to initiation of EN.

基于專(zhuān)家共識(shí)，我們建議，對(duì)于多數(shù)MICU和SICU患者，盡管啟用EN時(shí)需要對(duì)胃腸道蠕動(dòng)情況進(jìn)行評(píng)估，但此前并不需要有腸道蠕動(dòng)的體征。

Question: What is the preferred level of infusion of EN within the GI tract for critically ill patients? How does the level of infusion of EN affect patient outcomes?

問(wèn)題：危重病患者胃腸道輸注EN的最佳速度是多少？EN輸注速度如何影響患者預(yù)后？

B4a. We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or those who have shown intolerance to gastric EN.

[Quality of Evidence: Moderate to High]

對(duì)于具有誤吸高危因素（見(jiàn)D4部分）或不能耐受經(jīng)胃喂養(yǎng)的重癥患者，我們推薦減慢EN輸注的速度。

［證據(jù)質(zhì)量：中至高］

B4b. Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach.

基于專(zhuān)家的共識(shí)，我們建議經(jīng)胃開(kāi)始喂養(yǎng)是多數(shù)危重病患者可接受的EN方式。

Question: Is EN safe during periods of hemodynamic instability in adult critically ill patients?

問(wèn)題：對(duì)于成年危重病患者，血流動(dòng)力學(xué)不穩(wěn)定時(shí)EN是否安全？

B5. Based on expert consensus, we suggest that in the setting of hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support.

根據(jù)專(zhuān)家共識(shí)，我們建議在血流動(dòng)力學(xué)不穩(wěn)定時(shí)，應(yīng)當(dāng)暫停EN直至患者接受了充分的復(fù)蘇治療和（或）病情穩(wěn)定。對(duì)于正在撤除升壓藥物的患者，可以考慮謹(jǐn)慎開(kāi)始或重新開(kāi)始EN。

C. DOSING OF EN EN的劑量

Question: What population of patients in the ICU setting does not require nutrition support therapy over the first week of hospitalization?

問(wèn)題：哪些患者住ICU的第一周內(nèi)無(wú)需營(yíng)養(yǎng)支持治療？

C1. Based on expert consensus, we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity (for example, NRS-2002 ≤ 3 or NUTRIC score ≤ 5) who cannot maintain volitional intake do NOT require specialized nutrition therapy over the first week of hospitalization in the ICU.

根據(jù)專(zhuān)家共識(shí)，我們建議那些營(yíng)養(yǎng)風(fēng)險(xiǎn)較低及基礎(chǔ)營(yíng)養(yǎng)狀況正常、疾病較輕（例如NRS-2002 ≤ 3 或 NUTRIC評(píng)分≤ 5）的患者，即使不能自主進(jìn)食，住ICU的第一周內(nèi)不需要特別給予營(yíng)養(yǎng)治療。

Question: For which population of patients in the ICU setting is it appropriate to provide trophic EN over the first week of hospitalization?

問(wèn)題：哪些ICU患者在住院第一周內(nèi)適合滋養(yǎng)型喂養(yǎng) (trophic EN)？

We recommend that either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS)/acute lung injury (ALI) and those expected to have a duration of mechanical ventilation ≥ 72 hours, as these two strategies of feeding have similar patient outcomes over the first week of hospitalization.

[Quality of Evidence: High]

對(duì)于急性呼吸窘迫綜合征(ARDS)/急性肺損傷(ALI)患者以及預(yù)期機(jī)械通氣時(shí)間≥ 72小時(shí)的患者，我們推薦給予滋養(yǎng)型或充分的腸內(nèi)營(yíng)養(yǎng)，這兩種營(yíng)養(yǎng)補(bǔ)充策略對(duì)患者住院第一周預(yù)后的影響并無(wú)差異。

［證據(jù)質(zhì)量：高］

Question: What population of patients in the ICU requires full EN (as close as possible to target nutrition goals) beginning in the first week of hospitalization? How soon should target nutrition goals be reached in these patients?

問(wèn)題：哪些ICU患者住院第一周需要足量EN（盡可能接近目標(biāo)喂養(yǎng)量）？這些患者應(yīng)多長(zhǎng)時(shí)間達(dá)到目標(biāo)量？

C3. Based on expert consensus, we suggest that patients who are at high nutrition risk (for example, NRS-2002 > 5 or NUTRIC score ≥ 5, without interleukin-6) or severely malnourished should be advanced toward goal as quickly as tolerated over 24–48 hours while monitoring for refeeding syndrome. Efforts to provide > 80% of estimated or calculated goal energy and protein within 48–72 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization.

根據(jù)專(zhuān)家共識(shí)，我們建議具有高營(yíng)養(yǎng)風(fēng)險(xiǎn)患者（如：NRS-2002 > 5 或不考慮IL-6情況下NUTRIC評(píng)分≥ 5）或嚴(yán)重營(yíng)養(yǎng)不良患者， 應(yīng)在24 – 48小時(shí)達(dá)到并耐受目標(biāo)喂養(yǎng)量；監(jiān)測(cè)再喂養(yǎng)綜合征。爭(zhēng)取于48 – 72小時(shí)提供> 80%預(yù)計(jì)蛋白質(zhì)與能量供給目標(biāo)，從入院第一周的EN中獲益。

Question: Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?

問(wèn)題：蛋白質(zhì)供給量對(duì)成年危重病患者臨床結(jié)局有何不同影響？

C4. We suggest that sufficient (high-dose) protein should be provided. Protein requirements are expected to be in the range of 1.2–2.0g/kg actual body weight per day, and may likely be even higher in burn or multi- trauma patients (see sections M and P).

[Quality of Evidence: Very Low]

我們建議充分的（大劑量的）蛋白質(zhì)供給。蛋白質(zhì)需求預(yù)計(jì)為1.2 – 2.0 g/kg（實(shí)際體重）/天，燒傷或多發(fā)傷患者對(duì)蛋白質(zhì)的需求量可能更高（見(jiàn)M和P部分）。

［證據(jù)質(zhì)量：非常低］