危重病人营养治疗的时机、途径及并发症.ppt

Conclusion: Negative energy balances were correlated with increasing number of complications, particularly infections. -------------- Delaying initiation of nutritional support exposes the patients to energy deficits that cannot be compensated later on. 小 结 EN 的感染率低于 PN 总之，经胃肠道途径供给营养应是重症病人首先考虑的营养支持途径。因为它可获得与肠外营养相似的营养支持效果，并且在全身性感染等并发症发生及费用方面较全肠外营养更具有优势。 肠外营养支持是合并有肠功能障碍病人治疗的重要组成部分 荟萃分析表明：早期PN支持（入ICU或创伤后24小时内）与延迟的EN相比，前者感染性并发症明显降低。 胃肠道仅能接受部分的营养物质的补充的重症病人，可采用部分肠内与部分肠外营养相结合的联合营养支持方式，目的在于支持肠功能。 一旦病人胃肠道可以安全使用时，则逐渐减少及至停止肠外营养支持，联合肠道喂养或开始经口摄食。 肠内营养支持（EN） 应用指征 胃肠道功能存在（或部分存在），但不能经口正常摄食的重症病人。 重症病人在条件允许时应尽早开始肠内营养（B级） 禁忌症 ●当重症病人出现肠梗阻、肠道缺血 ●严重腹胀或腹腔间室综合症时 ●严重腹胀、腹泻，经一般处理无改 善的病人，建议暂时停用肠内营养 EN 3、延迟EN 的死亡率高于 PN 2、营养不良增加死亡率 4、EN 的感染率低于 PN 5、EN 与 PN 的死亡率无差别 6、PN是有肠功能障碍病人治疗的重要组成部分 1、危重病人的营养支持应尽早开始。 * * Intention to treat trials demonstrated reduced mortality associated with parenteral nutrition use. A priori subgroup analysis attributed this reduction to trials comparing parenteral to delayed enteral nutrition. Standard care was defined as the gradual reintroduction of an oral diet as tolerated after its interruption was caused by a disease or a surgical procedure that resulted in several days of inadequate nutrient intake and the use of intravenous dextrose or fluids for hydration. The effect of caloric intake on infection has been a central issue in the debate about whether to feed critically ill patients. Malnutrition has been associated with poor immune function, which increases the risk of systemic infection (13). On the other hand, continuous enteric feeding has been associated with an increased risk of ventilator associated pneumonia, presumably due to an increased risk of aspiration (14). Moreover, total parenteral nutrition (TPN) compared with enteral feeding has been associated with greater risk of infection (15–17). (Hiller L, Lowery JC, Davis JA, et al. Nutritional status classification in the Department of Veterans Affairs. J Am Diet Asso