胰腺炎营养治疗的国际共识指南

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1、胰腺炎营养治疗国际共识指南InternationalConsensusGuidelinesforNutritionTherapyinPancreatitisIndicationforNutritionTherapy营养治疗的适应症Pancreatitispatientsareatnutritionriskandshouldbescreened.(GradeB:Gold)胰腺炎患者进行营养治疗的风险应进行评估筛选。(B级：黄金)Formildtomoderatedisease,analgesics,intravenous(IV)fluids,andnilperos(NPO)withagradua

2、ladvancementtodiet(usuallywithin3胡days)arerecommended.(GradeC:Silver)2轻度至中度AP,建议给予止痛药，静脉输液，禁食并逐步进食(通常在3-4天内完成过度).(C级：银)Theneedfornutritiontherapy(NT)bytheenteralorparenteralrouteshouldbebasedontheextentofdiseaseandnutritionstatusofthepatient.肠内或肠外途径营养治疗(NT)需要根据病人疾病和营养状况的程度决定。3. NTisnotgenerallyneede

3、dformildtomoderatediseaseunlesscomplicationsensue.(GradeA:Platinum)轻度至中度的AP一般不需要NT，除非发生并发症.(A级：白金)NTshouldbeconsideredinanypatientregardlessofdiseaseseverityiftheanticipateddurationofbeingNPOis5days.(GradeB:Gold)任何患者如果预期禁食时间大于5-7天，不论病情严重程度都应考虑NT(B级：黄金)NTisneededinmildtomoderatediseasewhenthepatienth

4、asbeenNPCfor5days.(GradeB:Gold)轻度到中度AP患者禁食5-7天需要NT(B级：黄金)EarlyNTisindicatedforseverepancreatitis.(GradeA:Platinum)重症胰腺炎需早期NT(A级：白金)NTisusefulinthemanagementofpatientswhodevelopcomplicationsofsurgery.(GradeB:Gold)有手术并发症的病人NT非常有用.(B级：黄金)UseofEnteralNutrition肠内营养的使用Enteralnutrition(EN)isgenerallyprefer

5、redoverparenteralnutrition(PN),oratleastENshould,iffeasible,beinitiatedfirst.(GradeA:Platinum)肠内营养(EN)般优于肠外营养(PN),如果EN可行应作为首选.(A级：白金)ENmaybeusedinthepresenceofpancreaticcomplicationssuchasfistulas,ascites,andpseudocysts.(GradeC:Silver)EN也可用于发生胰腺并发症者如痿，腹水，假性胰腺囊肿(C级：银)ContinuousENinfusionispreferredov

6、ercyclicorbolusadministration.(GradeB:Gold)EN采用连续性输入方法优于周期性定时输入或推注的给予方法.(B级：黄金)NasogastrictubesmaybeusedforadministrationofEN.Postpyloricplacementisnotnecessarilyrequired.(GradeB:Gold)鼻胃管也可用于EN的输入，不一定要越过幽门后放置鼻空肠管(B级：黄金)12.ForEN,considerasmallpeptide-basedmediumchainimprovetolerance.（GradeB:Gold）12.对

7、于EN,考虑以小肽为基础的含中链脂肪酸（金）triglyceride（MCT）oilformulatoMCT)的配方以提咼耐受性.(B级：黄UseofParenteralNutrition肠外营养的使用13.UsePNifNTisindicated,whenENiscontraindicatedornotwelltolerated.（GradeA:15. Platinum）如果需要NT,当禁忌行EN或不耐受时使用PN.（A级：白金）IVfatemulsionsaregenerallysafeandwelltoleratedaslongasbaselinetriglyceridesarebelo

8、w400mg/dL（4.4mmol/L）andthereisnoprevioushistoryofhyperlipidemia.（GradeB:Gold）14.只要甘油三酯低于400毫克/分升（4.4毫摩尔/升）和既往无高脂血症历史的患者静注脂肪乳剂通常是安全的（B级：黄金）Glucoseisthepreferredcarbohydratesourcewithmetaboliccontrolofglucoseasclosetonormalaspossible.（GradeC:Silver）葡萄糖是的首选碳水化合物来源,糖代谢尽可能控制接近正常.（C级：银）Consideruseofglutam

9、ine（0.30g/kgAla-Glndipeptide）.1. （GradeC:Silver）谷氨酰胺可以考虑使用（ALA-谷氨酰胺肽0.30克/公斤）.（C级：银）NospecificcomplicationsofPNareuniquetopatientswithpancreatitis.Ingeneral,avoidoverfeeding.（GradeC:Silver）胰腺炎患者行PN没有特殊并发症，一般情况下避免过度营养（C级：银）BothEnteralandParenteralNutrition肠内和肠外营养MeetmacronutrientrequirementswithNT.（G

10、radeB:Gold）Calories:2535kcal/kg/dProtein:1.2-1.5g/kg/dNT营养素要求满足（B级：黄金）：a.卡路里:25-35千卡/公斤/天；b.蛋白质：1.2-1.5克/公斤/天胰腺炎营养治疗的国际共识指南营养治疗的适应症胰腺炎患者进行营养治疗的风险应进行评估筛选。（B级：黄金）PN对病人有过度营养的风险,这可能会产生不利影响JeejeebhoyKN.Totalparenteralnutrition:potionorpoison?AmJClinNutr2001;74（2）:1603.重症急性胰腺炎患者,尤其那些有慢性酒精中毒和营养不良史的患者可能发生重新

11、喂养综合征（refeedingsyndrome）.CrookMA,HallyV,PanteliJV.Theimportanceoftherefeedingsyndrome.Nutrition2001;17:6327.100.KraftMD,BtaicheIF,SacksGS.Reviewoftherefeedingsyndrome.NutrClinPract2005;20:62533.轻度至中度AP,建议给予止痛药，静脉输液，禁食并逐步进食（通常在3-4天内完成过度）.（C级：银）肠内或肠外途径营养治疗（NT）需要根据病人疾病和营养状况的程度决定。3轻度至中度的AP一般不需要NT,除非发生并发

12、症.(A级：白金)SaxHC,WarnerBW,TalaminiMA.Earlytotalparenteralnutritioninacutepancreatitis:lackofbeneficialeffects.AmJSurg1987;153:117-24任何患者如果预期禁食时间大于5-7天，不论病情严重程度都应考虑NT(B级：黄金)Nevertheless,inseverecasesthatarecatabolicand/orhaveandanticipatedperiodofinadequateoralintake(1000kcal/day)Iongerthan5days,itispr

13、udenttobeginartificialnutritioneitherviathejejunumorstomach81-84assoonaspossibleinordertopreventtheclinicalconsequencesofmalnutrition.81. Kumar,SinghN,PrakashS,SarayaA,JoshiYK.Earlyenteralnutritioninsevereacutepancreatitis:aprospectiverandomizedcontrolledtrialcomparingnasojejunalandnasogastricroutes

14、.JClinGastroenterol2006;40(5):4314EatockFC,ChongP,MenezesN,MurrayL,McKayCJ,CarterCR,etal.Arandomizedstudyofearlynasogastricversusnasojejunalfeedinginsevereacutepancreatitis.AmJGastroenterol2005;100(2):432-9.82. EatockFC,BrombacherGD,StevenA,ImrieCW,McKayCJ,CarterR.Nasogastricfeedinginsevereacutepanc

15、reatitismaybepracticalandsafe.IntJPancreatol2000;28(1):239EckerwallGE,AxelssonJB,AnderssonRG.Earlynasogastricfeedinginpredictedsevereacutepancreatitis:aclinical,randomizedstudy.AnnSurg2006;244(6):959-5.4. 轻度到中度AP患者禁食5-7天需要NT(B级：黄金)SaxHC,WarnerBW,TalaminiMA.Earlytotalparenteralnutritioninacutepancrea

16、titis:lackofbeneficialeffects.AmJSurg1987;153:117-24重症胰腺炎需早期NT(A级：白金)McClaveSA,ChangWK,DhaliwalR,HeylandDK.Nutritionsupportinacutepancreatitis:asystematicreviewoftheliterature.JPENJParenterEnteralNutr2006;30:143-56.MarikPE.Whatisthebestwaytofeedpatientswithpancreatitis?CurrOpinCritCare2009;15:131-8.

17、PetrovMS,PylypchukRD,UchuginaAF.Asystematicreviewonthetimingofartificialnutritioninacutepancreatitis.BrJNutr2009;101:787-93.有手术并发症的病人NT非常有用.(B级：黄金)肠内营养的使用肠内营养(EN)般优于肠外营养(PN),如果EN可行应作为首选.(A级：白金)最近的荟萃分析得岀，与PN相比，EN降低感染导致的死亡率和减少住院时间11,12,16(IB)oYi,F.,L.Ge,etal.(2012).Meta-analysis:TotalParenteralNutriti

18、onVersusTotalEnteralNutritioninPredictedSevereAcutePancreatitis.InternalMedicine51(6):523-530.PetrovMS,KukoshMV,EmelyanovNV.Arandomizedcontrolledtrialofenteralversusparenteralfeedinginpatientswithpredictedsevereacutepancreatitisshowsasignificantreductioninmortalityandininfectedpancreaticcomplication

19、swithtotalenteralnutrition.DigSurg2006;23:336-44.PetrovMS,VanSantvoortHC,BasselinkMG,VanderHeijdenGJ,WindsorJA,GooszenHG.Enteralnutritionandtheriskofmortalityandinfectionscomplicationsinpatientswithsevereacutepancreatitis:ameta-analysisofrandomizedtrials.ArchSurg2008;143:1111-7.MarikPE.Whatisthebest

20、waytofeedpatientswithpancreatitis?CurrOpinCritCare2009;15:131-8.2010年由科克伦EN在降低死亡率，多器官功能衰竭，全身性感染和手术方面显著优于PN,它减少局部感染并发症，住院天数13Al-omranM,AlBalawiZH,TashkandiMF,Al-AnsaryLA.Enteralversusparenteralnutritionforacutepancreatitis.CochraneDatabaseSystRev2010;20:CD002837.EN也可用于发生胰腺并发症者如痿，腹水，假性胰腺囊肿(C级：银)Woodco

21、ckNP,ZeiglerD,PalmerMD,BuckleyP,MitchellCJ,MacFieJ.Enteralversusparenteralnutrition:apragmaticstudy.Nutrition2001;17:1-12EN采用连续性输入方法优于周期性定时输入或推注的给予方法.(B级：黄金)鼻胃管也可用于EN的输入，不一定要越过幽门后放置鼻腔肠管(B级：黄金)Kumar,SinghN,PrakashS,SarayaA,JoshiYK.Earlyenteralnutritioninsevereacutepancreatitis:aprospectiverandomizedc

22、ontrolledtrialcomparingnasojejunalandnasogastricroutes.JClinGastroenterol2006;40(5):431F.82. EatockFC,ChongP,MenezesN,MurrayL,McKayCJ,CarterCR,etal.Arandomizedstudyofearlynasogastricversusnasojejunalfeedinginsevereacutepancreatitis.AmJGastroenterol2005;100(2):432-9.83. EatockFC,BrombacherGD,StevenA,

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24、级：黄金)Thereistheoreticaltoleranceadvantagefavorabletothesemielementaldiet,asitcontainssmallpeptidesandmiddle-chainlipids,thatdonotrequirepancreaticenzymestobedigested,but,intheopinionoftheexperts,polymericdietsmaybeusedsafely22(IV).ZieglerF,OllivierJM,CynoberL,MasiniJP,Coudray-LucasC,LevyEetal.Effici

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