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1.确定营养素需要量应当根据疾病状况、体重与体成分组成、生理功能变化等方而进行个体化评估, 制定合理 化配方. (B)

2.大部分住院患者的实际能量消能通常低于经典的方程式或教科书上的公式推算山来的值。(D)

3.在败血症或创伤的急性代谢期. 不主张采用高热卡营养支持获得正氮平衡或氮平衡.(C)

4.允许性低摄人有益于回手术期患者的临床结局. (A)

5.水、电解质生理需要量是维持生命所必需. (A)

6.无论肠内或肠外营养支持患者, 都需要监测出入液量、水肿或脱水症状体征、血电解质水平等. 并及时调整 补充剂量,根据病情选择肠内或肠外途径补充. (A)

7.重症疾病状态下是否需要增加维生素与微量元素的供给量 ,目前无确定性结论,在合理用药的前提下,可参 照美国FDA 推荐剂量。根据医生的判断,结合患者需求,调整部分维生素的应用剂量.(D)

成入营养素需要量

1.NRS 2002 采用评分的优点在于有临床RCT 的基础、简便、医患有沟通. (A)

2.在临床上, 医生/营养师/护士都可以进行操作。 结合临床后,是决定是否进行肠外肠内营养支持的依据. (A)

住院患者营养风险筛查

1.对于有重度营养风险、需要肠外营养支持的患者, 如果没有特殊代谢限制的话, 推荐选用所含氨基酸种类 完整的平衡氨基酸溶液. (C)

2.对于需要PN支持的外科术后患者, 推荐在PN 配方中添加谷氨酸胺双肽. (A)

3.接受PN支持的危重症患者, PN配方中也应包括谷氨酸胺双肽. (A)

氨基酸 肠外营养素

1.应用肠外营养的成人患者其肠外营养配方中常规推荐使用脂肪乳. (A)

2.但对于有高脂血症(甘油三酯>3. 5mmoI/L)或脂代谢障碍的患者应根据患者的代谢状况决定是否应用脂肪乳 , 使用时应充分权衡其可能的风险与获益. (D)

3.重度高甘油三酯血症(甘油三酯>4—5mmoI/L),应避免使用脂肪乳。

4.脂肪乳在肠外营养中的供能比例应根据患者的脂代谢情况决定, 一般应占非蛋白热量的25%--50%。无脂代谢 障碍的创伤和危重症患者建议选择高脂肪乳配方, 可使用中长链脂肪乳或用鱼油脂肪乳替代部分普通长链脂肪 乳。(0)

5.鱼油脂肪乳有益于减少腹部大手术后患者的感染性并发症, 缩短住院时间。(C)

脂肪乳 肠外营养素

1.鼻胃管适用于接受肠内营养时间少于2-3 周的患者; 管饲时患者头部抬高30—45度,可减少吸入性肺炎的发 生.(C) 

2.接受腹部手术并且术后需要较长时间肠内营养的患者, 建议术中放置空肠造瘘管. (C)

3.施行近端胃肠道吻合术、需要肠内营养的患者, 应当经吻合口远端的空肠营养管喂养. (8)

4.非腹部手术患者,若需要接受大于2-3 周的肠内营养,如严重的头部外伤患者. 经皮内镜下胃造口术(PEG) 是 首选的管饲途径。(C)

肠内营养管饲途径 营养支持输注系统

1.对危重症患者(如短肠综合征、炎性肠病、部分肠梗阻、肠瘘、急性胰腺炎等) 重大手术后患者在刚开始接受肠内营养时, 推荐使用肠内营养输注泵。(C)

2.对接受2-3 周及以上肠内营养支持或长期(6 个月或更长〉采用PEG进行肠内营养的患者. 推荐使用输注泵输注优于重力滴注. (A)

3.对血糖波动较大的患者( 高渗非酮症性昏迷或低血糖反应及其他严重的代谢性并发症) 推荐使用肠内营养输注泵. (A)

4.对老年卧床患者进行肠内营养时, 推荐使用肠内营养输注泵。(D)

5.对输入肠内营养液的"速度" 较为敏感的患者, 推荐使用肠内营养输注泵. (D)

6.下述情况均推荐使用肠内营养输注泵:肠内营养液粘度较高〈如高能量密度的肠内营养液) . 进行直接的十二指肠或空肠喂养时, 需要严格控制输注速度时, 输注大剂量、高渗透压的营养液时, 家庭肠内营养支持. (D)

肠内营养输注泵 营养支持输注系统

1.经周围静脉缓慢均匀输注能够耐受常规能量与蛋白质密度的肠外营养配方全合一溶液,但不建议连续输注时 间超过10-14天. (C)

2.如果经周围静脉输入出现3 次以上静脉炎, 考虑系药物所致, 应采用CVC 或PICC置管. (D)

3.肠外营养支持时间预计> 10 - 14 天, 建议采用CVC 或PICC 置管.(B)

4.在成人患者中, 需要综合考虑患者的病情、血管条件、可能需要的营养液输注天数、操作者的资质与技术熟 练程度, 谨慎决定置管方式. ( C)

5.若静脉置管单纯为输注肠外营养, 通常不推荐采用输液港. (D)

6.成人患者周围静脉穿刺常规首选上肢远端部位. (C)

7.PICC 穿刺常规首选肘窝区, 应尽可能避免选择接受乳房切除术和/或腋窝淋巴结消扫、接受放射治疗的患侧 上肢. (C)

8.CVC 穿刺部位首选锁骨下静脉. (B)

9.超声引导颈内静脉置管的成功率显著高于体表标志法, 而行锁骨下静脉置管体表标志法的成功率高于超声引 导置管法. (A)

10.中心静脉置管(包括PICC) 后应常规行影像学检查, 确定导管尖端部位, 并排除气胸。超声引导穿刺例外 . (A)

11.PICC 导管尖端必须位于腔静脉内. (A)

12.中心静脉置管须严格按无菌操作规范进行. (B)

13.穿刺局部消毒2%洗必泰优于10%聚维酮碘。(A)

14.纱布敷料和聚亚胺酯透明敷料均可用于穿刺部位. (A)

15.如果穿刺部位有出血或渗出, 纱布敷料较聚亚胺酯敷料为佳. (C)

16.敷料一且发生潮湿、松脱, 需要及时更换. (C)

17.不推荐穿刺部位使用抗生素药膏. 这样做反而增加真菌感染和耐药的发生, 并可能破坏聚亚胺酯敷料. (B)

18.小剂量肝素可能有效预防导管堵塞. (A)

19.头端剪口与侧向瓣膜中心静脉导管相比, 对预防血栓发生无影响.(A)

20.PICC置管且置管后护理应由经专门培训、具有资质的护理人员进行.(B)

21.长期肠外营养建议选用硅胶、聚亚胺酯材料. (C)

22.CVC 和PICC 的体内最长保留时间尚无明确报道. 美国AVA 曾建议不超过1年, 但未成立文件. 但应当经常 对穿刺部位进行监测, 怀疑导管感染或其他相关并发症时, 应立即拔除导管. (C)

肠外营养输注途径 营养支持输注系统

1.推荐对所有外科住院患者在入院后, 采用NRS 工具进行营养风险筛查, 无营养风险的患者结合临床分析, 用糖电解质输液. (A)

2.术后应给予满足成年患者维持生理基本需要的水和电解质. (A)

3.成人(以体重60kg 为例) 糖电解质输液的推荐方案水必需量为2000-250Oml . 电解质Na+ 为50mmol, Cl- 为 50mmol . K+ 为20-50mmol(A). 配方合理、输注安全和使用方便的产业化的复方糖电解质输液产品进行维持输 液是国际上广为接受的方案, 推荐根据患者的水电解质平衡状况及需要量, 给以复方维持输液。(D)

术后糖、电解质输液 疾病营养支持

1.围手术期有营养风险或有营养不良的患者, 以及由于各种原因导致连续5—1O 天以上无法经口摄食达到营养 需要量的患者, 应给于肠外营养支持(A) .

2.围手术期需要肠外营养支持的患者. 可添加特殊营养素谷氨酰胺(Gln) ( A )

3.围手术期有营养不良或有营养风险需要肠外营养支持的患者. 尤其是危重症患者可添加特殊营养素ω—3 脂 肪酸( C) .

围手术期肠外营养 疾病营养支持

1.无胃瘫的择期手术患者不常规推荐在进行术前12小时禁食. (A)

2.有营养不良风险的患者. 大手术前应给予10-14 天的营养支持. (A)

3.以下患者应尽早开始营养支持(尽可能通过肠内途径): 预计围手术期禁食时间大于7天 ;预计10天以上经口摄入量无法达到推荐摄人量的60 % 以上. (D)

4.对于有营养支持指征的患者, 经由肠内途径无法满足能量需要<60%的热量需要) 时,可考虑联合应用肠外营养. (D)

5.围手术期肠内营养禁忌证:肠梗阻、 血流动力学不稳定, 肠缺血. ( A)

6.术前鼓励那些不能从正常饮食中满足能量需要的患者接受口服营养支持, 在住院之前就可以开始肠内营养支持. 没有特殊的误吸风险及胃瘫的手术患者, 建议仅需麻醉前2小时禁水. 6小时禁食.(A)

7.手术后应尽早开始正常食物摄入或肠内营养. 大部分接受结肠切除术的患者, 可以在术后数小时内开始经口摄入消淡流食, 包括清水. (A)

8.对不能早期进行口服营养支持的患者. 应用管饲喂养,特别是以下患者:因为肿瘤接受了大型的头颈部和胃肠道手术(A);严重创伤 (A);手术时就有明显的营养不良(A);大于10 天不能经口摄入足够的(>60 % ) 营养.(D)

9.在术后24 小时内对需要的患者进行管饲营养.( A )

10.由于肠道耐受力有限,管饲肠内营养推荐采用输注泵以较低的滴速( 10-20ml/h)开始,可能需要5- 7 天才能达到目标摄入量. (D)

11.对围手术期接受了营养支持的患者, 在住院期间常规进行营养状态的再评估, 如果需要的话, 出院后继续营养支持. (D)

12.在所有接受腹部手术的患者的管饲营养装置中. 推荐放置较细的空肠造瘘管或鼻空肠管. (A)

    近端胃肠道吻合术后患者, 可通过顶端位于吻合口远端的营养管进行肠内营养. (B)

    长期(大于4 周) 管饲营养患者(如严重头部外伤) . 可考虑放置经皮内镜下胃造瘘(如PEG). (D)

13.标准的整蛋白配方适用于大部分患者. (D)

14.对以下患者可考虑在围手术期应用含有免疫调节成分(精氨酸,ω—3脂肪酸和核苷酸) 的肠内营养(B):因为肿熠接受大型的颈部手术(喉切除术, 咽部分切除术) ;接受大型的腹部肿瘤手术(食管切除术, 胃切除术和膜十二指肠切除术) 。

15.不推荐将含有精氨酸的"免疫肠内营养" 用于合并重度创伤、全身感染和危重症患者. (A)

围手术期肠内营养 疾病营养支持

EN is recommended in cardiac cachexia to stop or reverse weight loss on the basis of physiological plausibility. (C) There is no indication for enteral nutrition (EN) in the prophylaxis of cardiac cachexia.

Chronic heart failure (CHF) ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology

1.There is limited evidence that COPD patients profit from EN per se. (B) EN in combination with exercise and anabolic pharmacotherapy has the potential to improve nutritional status and function.

2.Frequent small amounts of oral nutritional supplements (ONS) are preferred to avoid postprandial dyspnoea and satiety and to improve compliance.(B)

3.In stable COPD there is no additional advantage of disease specific low carbohydrate, high fat ONS compared to standard high protein or high energy ONS.(B)

Chronic obstructive pulmonary disease (COPD) ESPEN Guidelines on Enteral Nutrition: Cardiology and Pulmonology

Indications for enteral nutrition are: prevention and treatment of undernutrition, improvement of growth and development in children and adolescents, improvements in quality of life, acute phase therapy, peri-operative nutrition,maintenance of remission in chronic active disease.

Indications Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

1.In adults use enteral nutrition as sole therapy for the acute phase mainly when treatment with corticosteroids is not feasible.(A)

2.Use combined therapy (enteral nutrition and drugs) in undernourished patients as well as in patients with inflammatory stenosis of the intestine.(C)

3.In children with CD enteral nutrition is considered as the first line therapy.(C)

Active disease Indications Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

1.In case of persistent intestinal inflammation (e.g.steroid dependent patients) use oral nutritional supplements.(B)

2.In longstanding (41 year) clinical remission and in the absence of nutritional deficits a benefit of enteral nutrition (oral nutritional supplements or tube feeding) or supplements (vitamins and trace elements) has not been demonstrated.(B)

Maintenance of remission Indications Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

Use peri-operative nutrition in CD patients with weight loss prior to surgery and low albumin.(B)

Peri-operative nutrition Indications Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

1.Use tube feeding and/or oral nutritional supplements in addition to normal food to improve nutritional status and to eliminate consequences of undernutrition such as growth retardation. (A)

2.Correct specific deficits (trace elements, vitamins) by supplementation.(C)

3.Use continuous tube feeding rather than bolus delivery because of the lower complication rate.(B)

Application Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

1.Using oral nutritional supplements, a supplementary intake of up to 600 kcal/day can be achieved in addition to normal food. (A )

2.Use tube feeding if a higher intake is necessary. (C )

3.Tube feeding can be safely delivered by nasogastric tube or percutaneous endoscopic gastrostomy.(B )

Route Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

1.There are no significant differences in the effect of free amino acid, peptide-based and whole protein formulae for tube feeding.(A)

2.Free amino acid or peptide-based formulae are not generally recommended.

3.Modified enteral formulae (fat modified, omega-3 fatty acids, glutamine, TGF-b-enriched) are not recommended because no clear benefits have been shown.(A)

Active disease Type of formula Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

Enteral nutrition may improve the quality of life in undernourished CD patients.(C)

Undernutrition Crohn’s disease ESPEN Guidelines on Enteral Nutrition:Gastroenterology

1. Screening for nutrition risk is suggested for hospitalized patients. (E)

2. Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening. (E)

3. Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished. (C)

Nutrition Support Guideline Recommendations in Adult Nutrition Screening and Assessment

1. The labels for EN formula administration containers, bags, or syringes should be standardized. (C)

2. Patient transfer between and within healthcare environments require clinician-to-clinician communication to promote the accurate transfer of the EN prescription. (C)3. All EN labels in any healthcare environment shall express clearly and accurately what the patient is receiving at any time. (C)

4. The EN label should be compared with the EN order for accuracy and hang time or beyond-use date before administration. (C)

5. Clearly label human breast milk (HBM) with the patient’s name and medical record number in order to prevent errors in delivery of HBM to infant. Preprinted labels and/or bar coding systems may help avoid breast milk mixups.(C)

Labeling of Enteral Nutrition ORDERING AND LABELING OF ENTERAL NUTRITION

1. Screening for nutrition risk is suggested for hospitalized patients. (E)

2. Nutrition assessment is suggested for all patients who are identified to be at nutrition risk by nutrition screening. (E)

3. Nutrition support intervention is recommended for patients identified by screening and assessment as at risk for malnutrition or malnourished. (C)

Nutrition Support Guideline Recommendations in Adult Nutrition Screening and Assessment

1. Facilities should establish a formulary of available EN formulas specific to the institution. (C)

2. A specific EN formulary should be established based on patient population and estimated nutrient needs rather than specific diagnosis. (C)

3.When the facility participates in corporate buying groups for the purchase of EN products, a clinician with expertise in nutrition support should be involved in the selection process of available formulas that best meets the patient’s nutrient requirements. (C)

Formulary Selection Process ORDERING AND LABELING OF ENTERAL NUTRITION

1. Standardized order forms (paper or CPOE) should be developed and designed for adult and pediatric EN regimens to aid prescribers in meeting each patient’s nutrition needs and to improve order clarity. (C)

2. EN orders should include 4 elements: 1) patient identifiers, 2) the formula, 3) the enteral access delivery site/device, and 4) the administration method and rate.(C)3. Order protocols may also incorporate feeding advancement, transitional orders, and implementation of ancillary orders.(C)

4. The use of generic terms to describe EN formulas is encouraged. (C)

5. Avoid the use of dangerous abbreviations or inappropriate numerical expressions. (C)

6. All elements of the EN order must be completed when EN is modified or re-ordered. (C)

Enteral Nutrition Order Forms ORDERING AND LABELING OF ENTERAL NUTRITION

1. The veracity (accuracy, credibility) of adult enteral formula labeling and product claims is dependent on formula vendors. (C)

2. Nutrition support clinicians and consumers are responsible for determining the veracity of adult enteral formulas. (C)

3. The U.S. government regulates the veracity of infant formula labeling and product claims. (C)

4. Interpret enteral formula content/labeling and health claims with caution until such time as more specific regulations are in place. (C)

ENTERAL FORMULA (MEDICAL FOOD) AND INFANT FORMULA REGULATION

1. Each institution should define an ongoing quality control process for EN formula preparation, distribution, storage, handling, and administration. (B)

2. Institutions should maintain written policies and procedures for safe EN formula and HBM preparation and handling, as well as maintain an ongoing surveillance program for contamination. These should be based on the ADA infant feeding guidelines, HACCP, and the USP good compounding practices. (B)

3. EN formulas should be prepared for patient use in a clean environment using aseptic technique by specially trained personnel. Strict aseptic technique should be used in the preparation and administration of enteral formulas. (A)

4. All personnel involved in preparing, storing, and administering EN formulas and HBM should be capable and qualified for the tasks, and follow accepted best practices. (C)

5. Sterile, liquid EN formulas should be used in preference to powdered, reconstituted formulas whenever possible. (A)

6. Store unopened commercially-available liquid EN formulas under controlled (dark, dry, cool) conditions. (B)

7. Maintain a rapid enteral feeding formula inventory turnover well within the product’s expiration date. (C)

8. Formulas reconstituted in advance should be immediately refrigerated, and discarded within 24 hours of preparation if not used; formulas should be exposed to room temperature for no longer than 4 hours, after which they should be discarded. (B)

9. Use a purified water or sterile water for irrigation supply for formula reconstitution and medication dilution. Consider purified water for enteral access device flushes in at-risk patients. (B)

10. Strict adherence to manufacturer’s recommendations for product use results in less contamination of EN. (B)

11. Use of disposable gloves is recommended in the administration of EN. (A)

12. Formula decanted from a screw cap is preferable instead of a flip top. (A)

13. A recessed spike on a closed system container is preferable. (B)

14. A feeding pump with a drip chamber prevents retrograde contamination of the EN formula from the feeding tube. (A)

15. Sterile, decanted formula should have an 8-hour hang time unless used for a neonate where hang time should be limited to 4 hours. (B)

16. Administration sets for open system enteral feedings should be changed at least every 24 hours. (B)

17. Powdered, reconstituted formula, HBM, and EN formula with additives should have a 4-hour hang time. (C)

18. Closed-system EN formulas can hang for 24-48 hours per manufacturer’s guidelines. (A)

19. Administration sets for closed-system EN formulas should be changed per manufacturer guidelines. (A)

20. Administration sets for HBM should be changed every 4 hours. (C)

21. All products used for pediatric patients should be DEHP free. (B)

WATER AND ENTERAL FORMULA SAFETY AND STABILITY

1. Select an enteral access device based on patientspecific factors. (C)

2. Nasojejunal route for enteral feedings in ICU patients are not required unless gastric feeding intolerance is present. (A)

3. Patients with persistent dysphagia should have a long-term enteral access device placed. (B)

Selection of Enteral Access Devices ENTERAL ACCESS DEVICES: SELECTION, INSERTION, AND MAINTENANCE CONSIDERATIONS

1. Obtain radiographic confirmation that any blindly-placed tube (small-bore or large-bore) is properly positioned in the GI tract prior to its initial use for administering feedings and medications in adult patients. (B)

2. When attempting to insert a feeding tube into the stomach of an adult patient, it may be helpful to use capnography to detect inadvertent entry of the tube into the trachea. Be aware that a radiograph is still needed before the tube is used for feedings. (B)

3. When attempting to insert a feeding tube into the small bowel, observe for a change in the pH and in the appearance of aspirates as the tube progresses from the stomach into the small bowel; use the findings to determine when a radiograph is likely to confirm small bowel placement. (B)

4. In adult patients, do not rely on the ausculatory method to differentiate between gastric and respiratory placement. The auscultatory method may be used as an adjunct method in the pediatric population. (A)

5. Do not rely on the ausculatory method to differentiate between gastric and small bowel placement. (A)

6. Mark the exit site of a feeding tube at the time of the initial radiograph; observe for a change in the external tube length during feedings. If a significant increase in the external length is observed, use other bedside tests to help determine if the tube has become dislocated. If in doubt, obtain a radiograph to determine tube location. (B)

7. In pediatrics and neonates, all methods but X-ray verification of enteral tube placement have been shown to be inaccurate. X-ray use in children should be as judicious as possible given the radiation exposure. (B)

Maintenance Considerations ENTERAL ACCESS DEVICES: SELECTION, INSERTION, AND MAINTENANCE CONSIDERATIONS

1. Long-term feeding devices should be considered when the need for enteral feeding is at least 4 weeks in adults, children, and infants after term age. (C)

2. Premature infants who do not have anomalies associated with inability to eat by mouth at the normal time for development of oral feeding skills should not have a long-term device considered before the usual age of development of independent oral feeding. (C)

3. Evaluation by a multidisciplinary team is indicated prior to insertion of a long-term feeding device to establish whether: a. benefit outweighs the risk of access placement; b. insertion of feeding tubes near end of life is warranted; or c. insertion of feeding tubes is indicated in the situation where patients are close to achieving oral feeding. (B)

4. Abdominal imaging should be performed prior to permanent feeding device placement if a possible anatomic difficulty exists. ©

5. Gastrostomy tube placement does not mandate fundoplication. The possible exception is children with neurological abnormalities who also have abnormal pH probe findings. (B)

6. Direct placement of a jejunostomy tube is indicated in patients requiring a long-term jejunostomy. (B)

7. Document tube type, tip location, and external markings in the medical record and in follow-up examinations. (C)

8. Avoid placement of catheters or tubes not intended for use as enteral feeding devices, such as urinary or GI drainage tubes which usually are without an external anchoring device. Use of such tubes leads to enteral misconnection as well as tube migration, which can potentially cause obstruction of the gastric pylorus or small bowel and aspiration. (B)

Long-Term Enteral Access ENTERAL ACCESS DEVICES: SELECTION, INSERTION, AND MAINTENANCE CONSIDERATIONS

友情链接


中华医学会肠外肠内营养学分会

http://www.cspen.org/


欧洲肠外肠内营养学会

http://www.espen.org/


美国肠外肠内营养学会

http://www.nutritioncare.org/

   

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