ESPEN指南：外科临床营养

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1、espeN旨南：外科临床营养早期经口喂养是手术患者营养的首选方式。营养疗法可避免大手术后喂养不 足的风险。考虑到营养不良和喂养不足是术后并发症的风险因素，早期肠内喂养对于任何有营养风险的手术患者尤为重要，特别是那些进行上消化道手术的患者。 该指南的重点是涵盖术后加速康复外科 （ERAS概念和进行大手术患者的特殊营 养需求，例如癌症，虽然提供最佳围手术期医疗，但是仍然出现严重并发症。从 代谢和营养角度而言，围手术期治疗重点包括：?将营养整合入患者整体管理?避免长时间术前禁食?术后尽早重新建立经口喂养? 一旦营养风险变得明显，早期开始营养疗法?代谢控制，例如血糖?减少加重应激相关分解代谢或影响胃肠

2、功能的因素?缩短用于术后呼吸机管理的麻醉药物使用时间?早期活动以促进蛋白质合成和肌肉功能恢复缩写? BM生物医学终点? GPP良好实践要点。根据指南制定小组临床经验推荐的最佳实践方法。? HE医疗卫生经济终点? IE :整合传统终点与患者报告终点? QL生活质量? TF:管饲该指南共提出37项临床实践推荐意见：1. 对大多数患者从午夜开始术前禁食是不必要的。被认为无任何误吸风险的手术患 者在麻醉前两个小时应喝清流质。麻醉前六小时前应允许进食固体食物（BMIE、 QL。推荐等级：A,高度共识（97%同意）2. 为了减少围术期不适症状包括焦虑，前一天晚上和术前两小时应给予经口进食碳水化合物处理（而

3、非夜间禁食）（B，QL o为改善术后胰岛素抵抗和缩短住院 时间，对大手术患者可考虑术前使用碳水化合物 （0, BM HE 推荐等级：A/B， 高度共识（100%同意）在完成过程中由工作小组根据最新荟萃分析下调等级（工作小组内成员100%同意）3. 一般情况下，术后经口营养摄入应持续不中断（BM IE ）。推荐等级：A,高度 共识（90%同意）4. 建议根据个人耐受性和实施的手术类型来调整经口摄入，特别关注老年患者。推荐等级：GPP高度共识（100%同意）5. 大多数患者应在术后数小时内开始经口进食清流质。 推荐等级：A,高度共识（100% 同意）6. 建议在大手术前后评定营养状况。推荐等级：G

4、PP高度共识（100%C意）7. 营养不良患者和存在营养风险的患者有指征进行围手术期营养疗法。如果预计患者在围手术期不能进食超过5天，也应启动围手术期营养疗法。预计患者经口摄 入少，不能维持推荐摄入量的50%以上超过7天也是指征。在这些情况下，建议 立即给予营养疗法（首选肠内途径 ONS或TF）。推荐等级：GPP高度共识（92% 同意）8. 如果能量和营养需求不能仅通过经口和肠道摄入满足（V能量需求的50%超过7天，建议肠内联合肠外营养（GPP。如果有营养疗法指征，但有肠内营养禁 忌证如肠梗阻（A），应尽快给予肠外营养（BM。推荐等级：GPP/A高度共识（100% 意）9. 对使用肠外营养，应

5、首选全合一（三腔袋或药房配制），而非多瓶输注系统（BMHE。推荐等级：B,高度共识（100%同意）10. 推荐按标准化操作流程（SOP进行营养支持，以确保有效的营养支持疗法。推荐等级：GPP高度共识（100%同意）11. 对因肠内喂养不足而需要专用 PN的患者可考虑静脉补充谷氨酰胺（0, BM HE。推荐等级B,共识（76%同意），在完成过程中由工作小组根据最近的PRCTF调等级（工作小组内成员100祠意）12. 仅对因肠内喂养不足而需要肠外营养的患者应考虑术后肠外营养包括使用-3脂肪酸（BM HE。推荐等级：B,大多数同意（65祠意）13. 对接受癌症大手术营养不良的患者应在围手术期或至少术

6、后使用富含免疫营养素（精氨酸、-3脂肪酸、核苷酸）的特定配方（B, BM HE。目前没有明确 的证据表明在围手术期使用这些富含免疫营养素的配方优于标准的口服营养补 充剂。推荐等级：B/0，共识（89%同意）14. 有严重营养风险的患者应在大手术前接受营养疗法（A）,即使手术，包括那些癌症，必须推迟（BM。这个时间为714天是合适的。推荐等级：A/0，高度 共识（95%同意）15. 只要可行，应首选经口 /肠内途径（A, BM HE QL。推荐等级：A,高度共识（100% 意）16. 当患者从正常的食物中获取的能量不能满足需求，建议鼓励这些患者术前采取口服营养补充剂，不管他们的营养状况如何。推荐

7、等级：GPP共识（86%C意）17. 术前应对所有营养不良的癌症患者和进行腹部大手术的高风险患者给予口服营 养补充剂（BM H日。患肌肉减少症的老年人是一群特殊的高风险患者。推荐等 级：A,高度共识（97%同意）18. 免疫调节型口服营养补充剂包括精氨酸、3 -3脂肪酸和核苷酸可首选（0, BM HE，术前使用57天（GPP。推荐等级：O/GPP,大多数同意，64%同意19. 术前肠内营养/ 口服营养补充剂应在入院前使用，以避免不必要的住院治疗和降 低院内感染的风险（BM HE QL）。推荐等级：GPP高度共识（91%同意）20. 术前PN只用于营养不良患者或存在严重营养风险而能量需求不能通过

8、EN完全满足的患者（A, BM。建议使用714天。推荐等级：A/0 ,高度共识（100%同意）21. 对不能早期开始经口营养摄入、经口摄入不足（V 50%超过7天的患者应尽早 启动TF （24小时内）。特别高风险人群包括：接受头颈部或胃肠癌症大手术的 患者（A, BM严重创伤包括颅脑损伤的患者（A, BM手术时有明显营养不良的 患者（A, BM, GPP推荐等级：A/GPP高度共识（97%同意）22. 对大多数患者，标准整蛋白配方是合适的。为避免因技术原因堵管和感染风险， 一般不建议使用厨房制备的膳食（匀浆膳）进行 TF。推荐等级：GPP高度共识（94%同 意）23. 至于营养不良患者的特殊方

9、面，对所有接受上消化道和胰腺大手术患者进行TF应考虑放置鼻空肠管（NJ或行针刺导管空肠造口术（NCJ BM。推荐等级：B, 高度共识（95%同意）24. 如有TF指征，应在术后24小时内启动（BM。推荐等级：A,高度共识（91% 同意）25. 建议以较慢的输注速率开始 TF （如 10最大20ml/h ），由于肠道耐受性有限， 增加输注速率要谨慎、个体化。达到目标摄入量的时间差别会很大，可能需要5 7天。推荐等级：GPP共识（85%同意）26. 如果必须长期TF（ 4周），如重症颅脑损伤，建议经皮置管（如经皮内镜下胃 造口一 PEG。推荐等级：GPP高度共识（94%同意）27. 如必要，在住院

10、期间定期评定营养状况，建议围手术期接受营养疗法和通过经口途径仍不能满足能量需求的患者出院后继续营养疗法包括合理的膳食指导。推荐等级：GPP高度共识（97%同意）28. 营养不良是影响移植后预后的主要因素， 因此建议对营养状况进行监测。对营养 不良患者，建议给予额外的口服营养补充剂甚至 TF。推荐等级：GPP高度共识（100%同 意）29. 在对等待移植的患者进行监测时，必须定期评定营养状况和给予合理的膳食指导 建议。推荐等级：GPP高度共识（100%同意）30. 对活体供者和受者的推荐意见与腹部大手术患者相同。推荐等级：GPP高度共识（97%同意）31. 心脏、肺、肝、胰、肾移植术后，建议在

11、24小时内尽早摄入正常食物或进行肠 内营养。推荐等级：GPP高度共识（100%同意）32. 即使在小肠移植后，肠内营养也可尽早启动，但在第一周内加量应非常小心。 推 荐等级：GPP高度共识（93%同意）33. 必要时应肠内联合肠外营养。建议对所有移植患者进行长期营养监测和合理的膳 食指导。推荐等级：GPP高度共识（100%同意）34. 减肥手术后建议早期经口摄入。推荐等级：0,高度共识（100%同意）35. 简单的减肥手术不需要肠外营养。推荐等级：0,高度共识（100%同意）36. 万一出现较大并发症需要再次开腹手术，可考虑使用鼻空肠管/针刺导管空肠造口术。推荐等级：0，共识（87%同意）37

12、. 更多的推荐意见与那些接受腹部大手术的患者相同。推荐等级：0，高度共识（94%同意）Clin Nutr. 2017 Jun;36（3）:623-650.ESPEN guideline: Clinical nutrition in surgery.Weima nrA, Braga M, Carli F, Higashiguchi T, Hu bn er M, Klek S, Lavia no A, Ljun gqvistO, Lobo DN, Martindale R, Waitzberg DL, Bischoff SC, Singer P.Klinikum St. Georg, Leipzi

13、g, Germany; San Raffaele Hospital, Milan, Italy; McGillUniversity,Montreal General Hospital, Montreal, Canada; Fujita Health University,Toyoake, Aichi, Japa n; Centre Hospitalier Un iversitaire Vaudois （CHUV）, Lausa nne, Switzerland; Stanley Dudricks Memorial Hospital, Skawina, Krakau, Poland;Uni ve

14、rsita La Sapie nza Roma, Roma, Italy; Orebro Uni versity, Orebro, Swede n;Nott in gham Un iversity Hospitals and Un iversity of Notti ngham, Quee ns MedicalCen tre, Notti ngham, UK; Oregon Health & Scie nee Uni versity, Portla nd, OR, USA;University of Sao Paulo, Sao Paulo, Brazil; Universitat Hohen

15、heim, Stuttgart,Germany; Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.Early oral feedi ng is the preferred mode of nu triti on for surgical patie nts. Avoida nee of any nu triti onal therapy bears the risk of un derfeedi ng duri ng the postoperative course after major surgery.Con si

16、deri ng that mal nutritio n and un derfeed ing are risk factors for postoperative complications, early enteral feeding is especially releva nt for any surgical patie nt at nu tritio nal risk, especially for those un dergo ing upper gastr oin test inal surgery. The focus of this guideline is to cover

17、 nutritionalaspects of the Enhanced Recovery AfterSurgery （ERAS） con cept and the special nu triti onal n eeds of patie ntsundergoing major surgery, e.g. for cancer, and of those developing severe complicati ons despite best perioperative care. From a metabolic andnutritionalpoint of view, the key a

18、spects of perioperative care include:? in tegratio n of nu tritio n into the overall man ageme nt of the patie nt? avoida nee of long periods of preoperative fasti ng? re-establishme nt of oral feed ing as early as possible after surgery? start of nutritionaltherapy early, as soon as a nutritionalri

19、sk becomesappare nt? metabolic con trol e.g. of blood glucose? reduction of factors which exacerbate stress-related catabolism or impair gastroi ntesti nal fun cti on? mini mized time on paralytic age nts for ven tilator man ageme nt in the postoperative period? early mobilisatio n to facilitate pro

20、tein syn thesis and muscle fun ctio n The guideli ne prese nts 37 recomme ndati ons for cli nical practice.BM: biomedical en dpo intsGPP: Good practice poin ts. Recomme nded best practice based on the cli ni calexperie nee of the guideli ne developme nt groupHE: health care economy en dpo intIE: in

21、tegrati on of classical and patie nt-reported en dpo intsQL: quality of lifeTF: tube feedi ng1. Preoperative fast ing from mid night is unn ecessary in most patie nts.Patients undergoing surgery, who are considered to have no specific risk of aspiration, shall drink clear fluids until two hours befo

22、re anaesthesia. Solids shall be allowed until six hours before anaesthesia (BM, IE, QL). Grade of recomme ndatio n A - stro ng consen sus (97% agreeme nt)2. In order to reduce perioperative discomfort including anxiety oral preoperative carbohydrate treatme nt (in stead of over ni ght fast ing) then

23、ight before and two hours before surgery should be administered (B) (QL). To impact postoperative in suli n resista nee and hospital le ngth of stay, preoperative carbohydrates can be considered in patients undergoing major surgery (0) (BM, HE). Consen sus Conferen ce: Grade of recomme ndatio n A/B-

24、strong consen sus (100% agreeme nt)- dow ngraded by the work ing groupduri ng the fin alizati on process accord ing to the very rece ntmeta-a nalysis (with 100% agreeme nt within the worki ng group members)3. In gen eral, oral nu triti onal in take shall be con ti nued after surgerywithout interrupt

25、ion (BM, IE). Grade of recommendation A - strong consen sus (90% agreeme nt)4. It is recomme ndedto adapt oral in take accordi ng to in dividual tolera nee and to the type of surgery carried out with special cauti on to elderlypatients.Grade of recommendation GPP- strong consensus (100% agreement)5.

26、 Oral in take, in clud ing clear liquids, shall be in itiated withi n hoursafter surgery in most patie nts. Grade of recomme ndati on A - strongconsen sus (100% agreeme nt)6. It is recommendedto assess the nutritional status before and after major surgery. Grade of recommendation GPP- strong consens

27、us (100% agreement)7. Perioperative nutritional therapy is indicated in patients withmalnutrition and those at nutritional risk. Perioperative nutritionaltherapy should also be initiated, if it is anticipated that the patientwill be unable to eat for more than five days perioperatively. It is also i

28、n dicated in patie nts expected to have low oral in take and who cannotmaintain above 50%of recommendedntake for more than seven days. In these situations,it is recommendedto initiatenutritionaltherapy (preferablyby the enteral route - ONS-TF)without delay. Grade of recommendation GPP -strong consen

29、 sus (92% agreeme nt)8. If the en ergy and nu trie nt requireme nts cannot be met by oral and en teralin take alone (50% of caloric requireme nt) for more tha n seve n days, a comb in ati on of en teral and pare nteral nu tritio n is recomme nded (GPP). Parenteral nutrition shall be administered as

30、soon as possible if nutritiontherapy is indicated and there is a contraindicationfor enteralnu triti on, such as in in test inal obstructi on (A) (BM). Grade of recomme ndati on GPP/A - stro ng consen sus (100% agreeme nt)9. For administrationof parenteralnutritionan all-in-one (three-chamberbag or

31、pharmacy prepared) should be preferred in stead of multibottlesystem (BM, HE). Grade of recomme ndati on B - stro ng consen sus (100% agreeme nt)lO.Sta ndardised operati ng procedures (SOP) for nu tritio nal support arerecommendedto secure an effectivenutritionalsupport therapy. Grade ofrecomme ndat

32、i on GPP - stro ng consen sus (100% agreeme nt)11. Parenteral glutamine supplementation may be considered in patients who cannot be fed adequately en terally and, therefore, require exclusive PN(0) (BM, HE). Consensus Conference: Grade of recommendation B - consensus (76% agreement) - downgraded by

33、the working group during the finalization process accord ing to the rece nt PRCT (with 100% agreeme nt withi n the work ing group members).12. Postoperativeparenteral nutritionincluding omega-3-fatty acids shouldbe considered only in patients who cannot be adequately fed enterally and, therefore, re

34、quire parenteral nutrition (BM, HE). Grade of recommendation B - majority agreeme nt (65% agreeme nt)13. Peri- or at least postoperative admi nistrati on of specific formula en riched with immunonu trie nts (arg inine, omega-3-fatty acids, ribonucleotides) should be given in malnourished patients un

35、dergoing major can cer surgery (B) (BM, HE). There is curre ntly no clear evide neefor the use of these formulae enriched with immunonutrients vs. standard oral nutritional supplements exclusively in the preoperative period.Grade of recomme ndatio n B/0 - consen sus (89% agreeme nt)14. Patients with

36、 severe nutritional risk shall receive nutritional therapyprior to major surgery (A) even if operations including those for cancer have to be delayed (BM). A period of 7-14 days may be appropriate. Grade of recomme ndatio n A/0 - stro ng consen sus (95% agreeme nt)15. Whenever feasible,the oral/ente

37、ralroute shall be preferred (A) (BM, HE,QL). Grade of recomme ndati on A - stro ng consen sus (100% agreeme nt)16. Whe n patie nts do not meet their en ergy n eeds from no rmal food it is recomme nded to en courage these patie nts to take oral nu triti onalsupplements during the preoperative period

38、unrelated to their nutritional status. Grade of recomme ndati on GPP - consen sus (86% agreeme nt)17. Preoperatively, oral nutritional supplements shall be given to allmalno urished can cer and high-risk patie nts un dergo ing major abdo minal surgery (BM, HE). A special group of high-risk patie nts

39、 are the elderly people with sarcopenia. Grade of recommendation A - strong consensus (97% agreeme nt)18mmune modulating oral nutritional supplements including arginine, omega-3 fatty acids and nu cleotides can be preferred (0) (BM, HE) and adm ini stered for five to seve n days preoperatively (GPP)

40、. Grade of recomme ndati on 0/GPP - majority agreeme nt, 64% agreeme nt19. Preoperative enteral nutrition/oral nutritional supplements should preferably be admi nistered prior to hospital admissi on to avoid unn ecessary hospitalizati on and to lower the risk of no socomial infections (BM, HE, QL).

41、Grade of recomme ndati on GPP - stro ng consen sus (91% agreeme nt)20. PreoperativePNshall be administered only in patients with malnutritionor severe nutritional risk where energy requirement cannot be adequately met by EN (A) (BM). A period of 7-14 days is recomme nded. Grade of recomme ndati on A

42、/0 - stro ng consen sus (100% agreeme nt)21. Early tube feeding (within 24 h) shall be initiated in patients in whom early oral nu triti on cannot be started, and in whom oral in take will bein adequate (4 weeks) is necessary, e.g. in severe head injury, placeme nt of a percuta neous tube (e.g. perc

43、uta neous en doscopic gastrostomy - PEG) is recomme nded. Grade of recomme ndati on GPP - stro ng consen sus (94% agreeme nt)27. Regular reassessment of nutritional status during the stay in hospitaland, if necessary, continuationof nutritiontherapy includingqualifieddietary coun sell ing after disc

44、harge, is advised for patie nts who have received nutrition therapy perioperatively and still do not cover appropriately their en ergy requireme nts via the oral route. Grade of recomme ndati on GPP - stro ng consen sus (97% agreeme nt)28. Ma Inu tritio nis a major factor in flue ncingoutcome after

45、tran spla ntati on,so monitoring of the nutritionalstatus is recommended. In malnutrition,additionaloral nutritionalsupplements or even tube feeding is advised.Grade of recomme ndatio n GPP - stro ng consen sus (100% agreeme nt)29. Regular assessme nt of nu tritio nal status and qualified dietarycou

46、nselling shall be required while monitoring patients on the waiting list before tran spla ntati on. Grade of recomme ndati on GPP - stro ng consen sus (100% agreeme nt)30. Recomme ndatio ns for the livi ngdonor and recipie nt are not differe ntfromthose for patie nts un dergo ing major abdo minal su

47、rgery. Grade ofrecomme ndati on GPP - stro ng consen sus (97% agreeme nt)31. After heart, lung, liver, pancreas, and kidney transplantation, earlyin take of no rmal food or en teral nu triti on is recomme nded within 24 h.Grade of recomme ndatio n GPP - stro ng consen sus (100% agreeme nt)32. Even a

48、fter transplantationof the small intestine,enteral nutritioncanbe in itiated early, but should be in creased very carefully withi n thefirst week. Grade of recommendation GPP- strong consensus (93%agreement) 33f n ecessary en teral and pare nteral nu tritio n should be comb in ed.Long-term nutrition

49、al monitoring and qualified dietary counselling are recomme nded for all tran spla nts. Grade of recomme ndati on GPP - stro ng consen sus (100% agreeme nt)34. Early oral in take can be recomme nded after bariatric surgery. Grade of recomme ndati on 0 - strong consen sus (100% agreeme nt)35. Parente

50、ral nutritionis not required in uncomplicated bariatric surgery.Grade of recomme ndatio n 0 - stro ng consen sus (100% agreeme nt)36n case of a major complication with relaparotomy the use of a nasojejunal tube/needle catheter jeju no stomy may be con sidered. Grade of recomme ndati on 0 - consen su

51、s (87% agreeme nt)37.Further recomme ndati ons are not differe nt from those for patie nts un dergo ing major abdo minal surgery. Grade of recomme ndati on 0 - strong consen sus (94% agreeme nt)KEYWORDSERAS; En teral nutritio n;Pare nteraln utritio n;Perioperativen utritio n;Prehabilitati on; SurgeryPMID 28385477Pll : S0261-5614(17)30063-8欢 迎 您 的 下 载资 料 仅 供 参