2022年医学专题—用EN须尽早————早期肠内.ppt

用EN须尽早(jn zo)-早期肠内营养（EEN）,第一页，共三十二页。,一项Meta分析纳入了6个RCT，研究24h内给予ICU患者早期肠内营养（EEN）相对于24h后开始(kish)EN，对患者临床结局的影响,Doig GS,et al.Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically ill patients:a meta-analysis of randomized controlled trials.Intensive Care Med,2009;35:201827,第二页，共三十二页。,EEN可降低(jingd)ICU患者的死亡率,Doig GS,et al.Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically ill patients:a meta-analysis of randomized controlled trials.Intensive Care Med,2009;35:201827,第三页，共三十二页。,EEN可降低(jingd)ICU患者肺炎的发生率,Doig GS,et al.Early enteral nutrition,provided within 24 h of injury or intensive care unit admission,significantly reduces mortality in critically ill patients:a meta-analysis of randomized controlled trials.Intensive Care Med,2009;35:201827,第四页，共三十二页。,EEN对外科术后患者(hunzh)的影响,一项研究(ynji)纳入1173例胃肠外科术后患者，24h内给予EEN的试验组，与不给于EN的对照组相比，对临床结局的影响,Lewis SJ,et al.Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding:a systematic review and meta-analysis.J Gastrointest Surg,2009;13(3):569-75.,第五页，共三十二页。,EEN降低外科(wik)患者的死亡率,Lewis SJ,et al.Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding:a systematic review and meta-analysis.J Gastrointest Surg,2009;13(3):569-75.,第六页，共三十二页。,EEN对烧伤(shoshng)患者的影响,Mosier MJ,et al.Early enteral nutrition in burns:compliance with guidelines and associated outcomes in a multicenter study.J Burn Care Res,2011;32(1):104-9.,一项研究纳入153例烧伤患者，试验组给予(jy)24h内EEN，对照组在烧伤24h后开始EN。,第七页，共三十二页。,EEN影响烧伤患者的ICU住院(zh yun)时间,Mosier MJ,et al.Early enteral nutrition in burns:compliance with guidelines and associated outcomes in a multicenter study.J Burn Care Res,2011;32(1):104-9.,第八页，共三十二页。,EEN对颅脑外伤患者(hunzh)的影响,Chiang YH,et al.Early Enteral Nutrition and Clinical Outcomes of Severe Traumatic Brain Injury Patients in Acute Stage:A Multi-Center Cohort Study.J Neurotrauma,2011 Aug 4.Epub ahead of print,GCS评分4-8分的严重创伤性脑损伤患者中，试验组145例在受伤(shu shng)后48h内接受EN，对照组152例给予静脉补液治疗,第九页，共三十二页。,EEN 提高sTBI患者的生存率和GCS 恢复，改善(gishn)预后，尤其对GCS 评分6-8的患者效果显著,HR,95%CI：8.5824.91,Chiang YH,et al.Early Enteral Nutrition and Clinical Outcomes of Severe Traumatic Brain Injury Patients in Acute Stage:A Multi-Center Cohort Study.J Neurotrauma,2011 Aug 4.Epub ahead of print,P0.05,第十页，共三十二页。,早期空肠喂养改善SAP的临床(ln chun)结局,Hegazi R,et al.Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr,2011,35(1):91-6.Erratum in:JPEN J Parenter Enteral Nutr,2011,;35(2):276.,一项回顾性研究，观察ICU中早期(zoq)空肠喂养对SAP患者临床结局的影响,第十一页，共三十二页。,早期开始DJF直接(zhji)影响患者的死亡率,17天,7天,Hegazi R,et al.Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr,2011,35(1):91-6.Erratum in:JPEN J Parenter Enteral Nutr,2011,;35(2):276.,（天）,P0.05,第十二页，共三十二页。,及早达到目标量可缩短住院(zh yun)时间,A组：从未达目标(mbio)量；B组：开始DJF后超过3天达目标量；C组：开始DJF后3天内达目标量,Hegazi R,et al.Early jejunal feeding initiation and clinical outcomes in patients with severe acute pancreatitis.JPEN J Parenter Enteral Nutr,2011,35(1):91-6.Erratum in:JPEN J Parenter Enteral Nutr,2011,;35(2):276.,45.3,18.0,10.0,P0.05,P0.05,第十三页，共三十二页。,结肠癌术后患者早期口服营养(yngyng)补充（ONS）,Lobato Dias Consoli M,et al.Early postoperative oral feeding impacts positively in patients undergoing colonic resection:results of a pilot study.Nutr Hosp,2010;25(5):806-9.,两组均术前12h禁食，早期EN组术后第1天起即给予500ml口服EN制剂，传统(chuntng)治疗组排气后才恢复进食POD：术后天数,第十四页，共三十二页。,结肠癌术后患者(hunzh)早期ONS,早期(zoq)ONS组（n=15）,传统(chuntng)治疗组（n=14）,7%,7%,86%,7%,Lobato Dias Consoli M,et al.Early postoperative oral feeding impacts positively in patients undergoing colonic resection:results of a pilot study.Nutr Hosp,2010;25(5):806-9.,46%,47%,早期ONS组较传统组患者的营养状况差，但两组吻合口瘘的发生率相似,P0.05,第十五页，共三十二页。,结肠癌术后早期ONS促进肠功能恢复缩短(sudun)住院时间,早期ONS组患者肠蠕动恢复(huf)所需时间显著缩短（D1排气，对照组D2排气），住院时间显著提前（中位数3天，对照组5天）；对照组的腹泻发生率是试验组的1.86倍（P0.05）,Lobato Dias Consoli M,et al.Early postoperative oral feeding impacts positively in patients undergoing colonic resection:results of a pilot study.Nutr Hosp,2010;25(5):806-9.,P0.05,第十六页，共三十二页。,EEN的必要性,大量研究证实EEN对降低并发症的发生率、加速康复、降低死亡率、缩短住院(zh yun)时间意义重大空肠喂养有助SAP和有反流、误吸风险的患者实现EEN，同时行胃肠减压，可降低风险结肠癌术后早期ONS虽短期内不利营养状态的改善，但可加速康复、缩短住院时间,第十七页，共三十二页。,有人认为只给EN，不能提供机体足够的能量(nngling)，尽快纠正负担平衡到底用EN还是PN呢？,第十八页，共三十二页。,最新一项大规模的临床研究中，2312例ICU患者(hunzh)48h内给予EN+PN；2328例ICU患者给予早期EN，8天后才给予PN，观察早期PN和晚期PN对临床结局的影响,Casaer MP,et al.Early versus Late Parenteral Nutrition in Critically Ill Adults.N Engl J Med,2011;365(6):506-17.,第十九页，共三十二页。,第二十页，共三十二页。,第二十一页，共三十二页。,晚期PN组患者存活(cn hu)出ICU比例高,HR：1.0695%CI：1.001.13P=0.04,第二十二页，共三十二页。,晚期PN组患者(hunzh)存活出院比例高,HR：1.0695%CI：1.001.13P=0.04,第二十三页，共三十二页。,首选(shu xun)EN，EN为主，PN必要时作补充,有营养风险，但无营养不良的患者入住ICU开始早期EN，如果7d内无法达到目标量时，第8天开始联用PN Casaer MP,et al.N Engl J Med,2011如果患者入ICU前身体健康且没有营养不良，肠外营养应在住院(zh yun)7d后才开始。EN达到摄入量的60%以上，不必联用PN,ASPEN 2009,ASPEN 2009,第二十四页，共三十二页。,什