肠内营养对接受呼吸机治疗患者营养状态、呼吸功能和控制感染的影响

目的 评价肠内营养对接受呼吸机患的临床应用。方法 采用随机、对照的实验设计，32例患分肠内营养（EN）组（11例）、肠外营养（PN）组（10例）和普通组（11例）。EN和PN组患接受等氮等热量的6天营养支持，普通组仅给予常规输液；对比研究在血气指标、氮平衡、血浆蛋白和临床预后等方面的不同作用。结果 EN组和PN组在6天累积氮平衡和血浆前白蛋白的结果相似（P＞0.05)，与普通组差异有显性（P＜0.05)。血气指标三组结果相似（P＞0.05)，但EN组略好；肺部感染治愈率EN和PN组结果相似，优于普通组。PN组的营养费用显高于EN组（P＜0.05)，并且有穿刺并发症出现。结论 综合临床效能，肠内营养是接受呼吸机治疗患较好的营养支持方法。     

重型颅脑损伤患者营养支持的临床研究

目的 探讨重型颅脑损伤营养支持的临床疗效及最佳途径。方法 64例重型颅脑损伤患随机分为肠内营养组（EN组）和肠外营养组（PN组）,每组32例。急诊手术后36－48h开始经不同途径进行额定热卡和氮量的营养支持,监测各项营养指标、代谢指标及营养支持并发症,计算营养费用。结果 EN与PN均有效地维持了各项营养指标,但PN组代谢指标、营养支持并发症及营养费用均显高于EN组。结论 早期EN与PN均能改善机体的营养状况。EN更具有营养全面、简易安全、方便价廉等优点,应作为营养支持的首选途径。     

肠内和肠外营养支持方式对胃癌术后营养状况的影响分析

目的：研究胃癌术后肠内肠外营养支持对患者营养况的影响。方法：将需要营养支持的胃癌患者78例,随机分为两组,分别为肠内组（EN）和肠外组（PN）,两组营养支持均等热量、等氮量。记录两组患者手术前和手术后的基本营养状况,及两组患者手术后并发症的情况。结果：（1）EN组体重、上臂围（MAC）、上臂肌围（AMC）、三头肌皮褶厚度（TSF）和、血红蛋白（Hb）均高于PN组,但差异无统计学意义（P〉0.05）;（2）PN组血浆白蛋白（ALB）、总淋巴细胞（LYM）下降较EN组明显（P〈0.05）;（3）术后并发症发生率EN组为10.52%,PN组为23.68%;两组比较差异有统计学意义（P〈0.05）。结论：胃癌术后EN在改善患者营养方面优于PN,并且EN可降低胃癌手术后并发症的发生率,提高手术后的疗效。     

肠外与肠内营养对胰腺外分泌和急性重症胰腺炎的影响

肠外营养(PN)不能改变胰腺炎自然病程,能降低并发症和病死率,但导管感染和肠源性并发症增加。近年来,肠内营养（EN）应用受到重视,但在急性重症胰腺炎（SAP）中的应用仍有争议。从EN对胰腺外分泌和SAP自然病程的影响分析,提出经空肠喂养不会刺激胰腺分泌,也不会加重SAP的病情。在临床实际应用中,应结合SAP的分期和临床状况,采用PN和EN联合应用来达到营养支持的目的。     

老年患者胰十二指肠切除术后不同营养支持方法对肝功能和临床结局的影响

目的比较胰十二指肠切除术后老年患者肠外营养（PN）联合肠内营养（EN）与单纯PN对术后内毒素血症、肝功能与临床结局的影响。方法回顾性总结我院不同时段接受胰十二指肠切除术老年患者共48例,其中术后接受PN联合EN营养支持的患者25例为研究组（PN＋EN组）,单纯给予PN营养支持的患者23例为对照组（PN组）。记录其一般资料、比较术后内毒素水平和肝功能变化,以及临床结局（死亡率、并发症、术后住院日和总住院费用等）。结果两组内毒素水平术后1d较术前均有升高趋势,但组间比较差异无统计学意义（P〉0．05）,后随时间逐渐下降,其中术后7和14d分别与术后1d的差值比较,PN＋EN组的下降幅度显著大于PN组（P〈0．01）;两组谷丙转氨酶、谷草转氨酶、总胆红素和直接胆红素值术后1d较术前均有升高趋势,但组间比较差异无统计学意义（P〉0．05）,术后逐渐下降,术后14d与术后1d的差值PN＋EN组下降幅度显著高于PN组（P〈0．05）;PN＋EN组感染并发症（2／25,8．0％）显著低于PN组（6／23,26．0％,P〈0．05）;总并发症发生率、术后住院日、总住院费用两组差异无统计学意义（P〉0．05）。结论老年患者胰十二指肠切除术后PN联合EN可降低内毒素血症、改善肝功能、减少术后感染并发症。     

肠内营养对接受呼吸机治疗病人营养状态、呼吸功能和控制感染的影响

目的 评价肠内营养对接受呼吸机病人的临床作用。方法 采用随机、对照的实验设计，分出EN组、PN组和普通组，共32例。EN和PN组病人接受等氮等热量的6天营养支持，普通组仅给予常规输液；对比研究在血气指标、氮平衡、血浆蛋白和临床预后等方面的不同作用。结果 EN组和PN组在6天累积氮平衡和血浆前白蛋白的结果相似，与普通组有显性差别（P＜0．05）。血气指标三组结果相似，但EN组略好；肺部感染治愈率EN和PN组结果，优于普通组。PN组的营养费用显高于EN组（P＜0．05），并且有穿刺并发症出现。结论 结合临床效能，肠内营养是接受呼吸机治疗病人较好的营养支持方法。     

肠内和肠外联合阶段性营养对重症急性胰腺炎患者治疗效果的影响

目的观察肠内和肠外联合阶段性营养对重症急性胰腺炎患者治疗效果的影响。方法重症急性胰腺炎患者45例分为完全胃肠外营养组（TPN组，n=25）和肠内营养加肠外阶段性营养组（PN＋EN组，n=20）。观察两组治疗结果以及临床指标的变化。结果营养支持后PN＋EN组的APACHEⅡ评分和CT评分均显著低于TPN组（P〈0．01）。营养支持两周后两组患者的血糖、血清淀粉酶和血肌酐水平均较营养支持前显著下降（P〈0．01），血清白蛋白、总蛋白、血钙水平均较营养支持前显著升高（P〈0．01），但是两组的各项指标比较无显著性差异（P〉0．05）。PN＋EN组患者的感染并发症发生率显著低于TPN组（P〈0．01），平均住院天数也显著短于TPN组（P〈0．01）。结论肠内和肠外联合阶段性营养支持方式的疗效优于完全胃肠外营养，对重症急性胰腺炎的治疗起了积极作用。     

肠外或肠内营养支持对有营养风险患者临床结局的影响

研究表明,肠外营养（parenteral nutrition,PN）可降低有明显营养不良（不足）患者的非感染性并发症,对营养不足的患者应用肠内营养（enteral nutrition,EN）可以减少感染性并发症并缩短住院时间,对营养状况基本正常患者的结局则无明显改善。欧洲肠外肠内营养学会营养风险筛查专题组在对128个关于营养支持与临床结局随机对照研究报告分析的基础上,     

机械通气患者营养支持的应用

目的 比较肠外 肠内营养与肠内营养对施行机械通气的危重患影响。探讨对呼吸衰竭患如何给予合理的营养支持。方法 将40例机械通气患随机分为肠外 肠内营养A组（PN EN）和肠内营养B组（EN），同时进行营养状况评定。血气指标分析及血流动力学测定。结果　A组患早期换气及弥散功能均较B组轻度下降，但随着营养支持的继续，A组患全身营养状况及呼吸功能改善较B组明显，脱机时间缩短。血流动力学无明显变化。结论 对呼吸衰竭患行肠外 肠内营养有利于患恢复体重。提高免疫力，呼吸功能恢复快。     

ICU重症肠外、肠内营养支持初步评价

目的 重症病人多合并营养不良及营养代谢性疾病，为进一步探讨营养支持方案及其疗效对预后的影响，进行了营养不同的ICU重症肠外、肠内营养支持的初步评价。方法 选择最近三年ICU住院时间及营养支持时间≥7天的各类重症38例，依营养支持方法不同分成TPN组、PN＋EN组及TEN组。调查ICU治疗前后的血清白蛋白、血糖、血清离子、肝肾功能及相关并发症；营养支持途径（中心静脉、周围静脉、鼻胃管词、口入）；营养素摄入量。热能的摄入PN＋EN组较TPN组增加差异显（P＜0．05），蛋白质摄入PN＋EN组较TPN组增加差异非常显（P＜0．001） ，三组间脂肪、碳水化物无显性差异（P＜0．05）。三组年龄、ICU住院时间比较无显差异（P＜0．05）。结果 以血清白蛋白为营养评价的指标中，各组间比较及三组营养支持后与营养支持前比较均无显性差异（P＜0．05）。PN EN组较TPN组各种感染发生率、高血糖发生率及死亡率明显降低。结论 ICU重症因多种因素营养素不足的问题较为普遍，本热能、蛋白质的摄入PN＋EN组较TPN组对氮平衡维持的影响要小。尽管三组ICU治疗时间短，尚未显示出血清白蛋白的明显转归，但从治疗后的均值看PN＋EN组较TPN组下降幅度要小，发生的各种感染率、高血糖率、死亡率较低。说明ICU重症能量的补给以维持能量平衡、氮平衡为重要。营养支持方法的选择只要病情允许，肠外与肠内营养支持方法结合营养素的摄入量相对适宜，也有利消化道功能的恢复。从而减少严重分解状态加上热能、蛋白质摄入不足，引起肌蛋白大量分解，氮及谷氨酰胺大量选择和消耗，体内脂肪大量动员，水和电解质代谢紊乱，病人迅速消耗导致的短期内死亡。     

Parenteral nutrition in the critically-ill patient: more harm than good?

While many studies have reported that providing parenteral nutrition (PN) can change nutritional outcomes, there are limited data that demonstrate that PN influences clinically-important end points in critically-ill patients. The purpose of the present paper is to systematically review and critically appraise the literature to examine the relationship between PN and morbidity and mortality in the critically-ill patient. Studies comparing enteral nutrition (EN) with PN and studies comparing PN with no PN were reviewed. The results suggest that EN is associated with reduced infectious complications in some critically-ill subgroups. PN, on the other hand, is associated with increased morbidity and mortality in critically-ill patients. When nutritional support is indicated, EN should be used preferentially over PN. Further studies are needed to define the optimal timing and composition of PN in patients not tolerating sufficient EN. Strategies to optimize EN delivery and minimize PN utilization in critically-ill patients are indicated.     

Nutrition Support and the Gastrointestinal Microbiota: A Systematic Review

BackgroundLow microbial diversity or altered microbiota composition is associated with many disease states. In the treatment of many conditions, enteral (EN) or parenteral (PN) nutrition is frequently required.ObjectiveThis systematic review aimed to identify and evaluate the evidence of the effect of EN vs PN on the gastrointestinal microbiota.MethodA comprehensive systematic literature search of 5 databases was completed to review studies published until February 2020. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized in completion of the review with the Academy of Nutrition and Dietetics quality criteria checklist and Grading of Recommendations Assessment, Development and Evaluation to evaluate the included studies. The review was registered on PROSPERO (CRD42018091328). Studies were eligible for inclusion if participants were older than 3 years, patients received either EN, PN or both, with some patients receiving each mode of nutrition support. The main outcome was any assessment of the gastrointestinal microbiota, including diversity or taxa abundance.ResultsEleven articles (n = 367 patients) met the inclusion criteria and were evaluated. Seven studies (n = 237) reported greater abundance of Proteobacteria with the provision of PN compared to EN; 6 studies (n = 172) reported lower Firmicutes and 5 studies (n = 155) lower Bacteroidetes. In 7 studies (n = 282), microbial diversity was lower with provision of PN than EN. The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was very low.ConclusionsProvision of PN may lead to greater abundance of Proteobacteria and reduced microbial diversity; however, there is limited literature on this topic and additional research is warranted to improve understanding of the impact of EN vs PN on the microbiota.     

ESPEN Guidelines on Parenteral Nutrition: Pancreas

Assessment of the severity of acute pancreatitis (AP), together with the patient's nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5–7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided.PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased.When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered.In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.     

Nutrition support in acute pancreatitis: a systematic review of the literature

BACKGROUND: Failure to use the gastrointestinal (GI) tract in patients with acute pancreatitis may exacerbate the stress response and disease severity, leading to greater incidence of complications and prolonged hospitalization. The objectives of this study were to determine the optimum route for nutrition support, whether nutrition therapy is better than no artificial nutrition support, whether specific additives to enteral or parenteral therapy can further enhance their efficacy, and whether methodologic differences in delivery of enteral nutrition (EN) influence tolerance. METHODS: A computerized search was performed of MEDLINE, Cochrane database, EMBASE, and reference lists of pertinent review articles for prospective randomized trials in adult patients with acute pancreatitis that evaluated interventions with nutrition therapy. Primary outcome data and surrogate endpoint parameters (for nutrition indices, stress markers, and measures of the inflammatory/immune response) were extracted in duplicate independently. Where appropriate, meta-analysis was performed by random-effects model. RESULTS: From 119 articles screened, 27 randomized controlled trials were included and analyzed. In patients admitted for acute pancreatitis, meta-analysis of 7 trials showed that use of EN was associated with a significant reduction in infectious morbidity (risk ratio [RR] = 0.46; 95% confidence interval [CI], 0.29 - 0.74; p = .001) and hospital length of stay (LOS; weighted mean difference [WMD] = -3.94; 95% CI, -5.86 to -2.02; p < .0001), a trend toward reduced organ failure (RR = 0.59; 95% CI, 0.28-1.27; p = .18), with no effect on mortality (RR = 0.88; 95% CI, 0.43-1.79; p = .72) when compared with use of parenteral nutrition (PN). Results from individual studies suggest that EN in comparison to PN reduces oxidative stress, hastens resolution of the disease process, and costs less. Insufficient data exist to determine whether EN improves outcome over standard therapy (no artificial nutrition support) in patients admitted for acute pancreatitis. However, in those patients requiring surgery for complications of acute pancreatitis, meta-analysis of 2 trials indicates that provision of EN postoperatively may reduce mortality (RR = 0.26; 95% CI, 0.06 - 1.09; p = .06) compared with standard therapy. PN provided early within 24 hours of admission was shown to worsen outcome, whereas PN provided later after full-volume resuscitation appeared to improve outcome when compared with standard therapy. In early individual studies, specific supplements added to EN, such as arginine, glutamine, omega-3 polyunsaturated fatty acids, and probiotics, may be associated with a positive impact on patient outcome in acute pancreatitis, compared with EN alone without the supplements, but studies are too few to make strong treatment recommendations. Supplementation of PN with parenteral glutamine was shown to reduce oxidative stress and improve patient outcome (reduced duration of nutrition therapy and decreased hospital LOS) compared with PN alone in patients with acute pancreatis. A wide range of tolerance to EN exists, irrespective of known influences such as mode (continuous vs bolus) and level of infusion within the GI tract (gastric vs postpyloric). CONCLUSIONS: Patients with acute severe pancreatitis should begin EN early because such therapy modulates the stress response, promotes more rapid resolution of the disease process, and results in better outcome. In this sense, EN is the preferred route and has eclipsed PN as the new "gold standard" of nutrition therapy. When PN is used, it should be initiated after 5 days. The favorable effect of both EN and PN on patient outcome may be further enhanced by supplementation with modulators of inflammation and systemic immunity. Individual variability allows for a wide range of tolerance to EN, even in severe pancreatitis.     

Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature

OBJECTIVE: Nutritional support is part of the standard of care for the critically ill adult patient. In the average patient in the intensive care unit who has no contraindications to enteral nutrition (EN) or parenteral nutrition (PN), the choice of route for nutritional support may be influenced by several factors. Because EN and PN are associated with risks and benefits, we systematically reviewed and critically appraised the literature to compare EN with PN the critically ill patient. METHODS: We searched computerized bibliographic databases, personal files, and relevant reference lists to identify potentially eligible studies. Only randomized clinical trials that compared EN with PN in critically ill patients with respect to clinically important outcomes were included in this review. In an independent fashion, relevant data on the methodology and outcomes of primary studies were abstracted in duplicate. The studies were subsequently aggregated statistically. RESULTS: There were 13 studies that met the inclusion criteria and, hence, were included in our meta-analysis. The use of EN as opposed to PN was associated with a significant decrease in infectious complications (relative risk = 0.64, 95% confidence interval = 0.47 to 0.87, P = 0.004) but not with any difference in mortality rate (relative risk = 1.08, 95% confidence interval = 0.70 to 1.65, P = 0.7). There was no difference in the number of days on a ventilator or length of stay in the hospital between groups receiving EN or PN (Standardized Mean Difference [SMD] = 0.07, 95% confidence interval = -0.2 to 0.33, P = 0.6). PN was associated with a higher incidence of hyperglycemia. Data that compared days on a ventilator and the development of diarrhea in patients who received EN versus PN were inconclusive. In the EN and PN groups, complications with enteral and parenteral access were seen. Four studies documented cost savings with EN as opposed to PN. CONCLUSION: The use of EN as opposed to PN results in an important decrease in the incidence of infectious complications in the critically ill and may be less costly. EN should be the first choice for nutritional support in the critically ill.     

营养支持治疗在老年危重患者救治中的应用

目的探讨不同营养支持方式在老年危重患者救治中的作用。方法选择老年危重患者98例,根据不同营养支持方式分为肠外营养(PN)组30例,肠内营养(EN)组32例,PN+EN组36例。摄入同等总热量和同等氮量,营养支持治疗时间14 d。治疗0 d和连续营养支持治疗14 d后,检测血清白蛋白(Alb)、前白蛋白(PA)、血红蛋白(Hb)、淋巴细胞总数(TLC)、免疫球蛋白(IgA、IgG、IgM)值并进行回顾性对比分析。结果 3组患者Hb均较治疗前增高。EN+PN组患者Alb、PA较PN组及EN组治疗后增高。营养支持治疗后,3组患者TLC明显增高。EN组IgA、IgM,EN+PN组IgA、IgG、IgM均较PN组增高。PN+EN组并发症低于PN组及EN组。结论老年危重患者救治中应根据老年人特点及疾病不同情况合理选择营养支持方式,PN+EN联合应用更有利于改善老年危重患者营养状况及免疫功能,减少并发症发生,促进疾病的康复。     

临床营养支持模式与实施方法对成年急性重症患者近期临床结局的影响

目的 评估临床营养支持模式与实施方法对成年急性重症患者近期临床结局的影响.方法 回顾性分析1994年1月至2009年12月在海南省人民医院重症医学科收治的1503例成年急性重症患者的营养支持相关资料,比较不同营养支持模式与实施方法对营养支持并发症、患者在ICU停留时间、感染与多器官功能障碍综合征（MODS）发生率和病死率的影响.结果 所有患者营养风险筛查评分（NRS）均≥3分.早期肠内营养（EN）组患者在ICU的停留时间明显短于非早期EN组（P＜0.001）和肠外营养（PN）组（P＜0.001）,感染发生率（P均＜0.001）、MODS发生率（P均＜0.001）及病死率（P均＜0.001）也均明显低于非早期EN组和PN组患者.PN液中添加谷氨酰胺组患者在ICU停留时间明显短于未添加者（P=0.0000）,感染（P=0.0252）和MODS发生率（P=0.0030）及病死率（P=0.0305）均明显低于未添加者.强化胰岛素治疗组患者在ICU停留时间明显短于常规胰岛素治疗组（P=0.0000）,感染（P=0.0001）和MODS发生率（P=0.0237）及病死率（P=0.0427）均明显低于常规胰岛素治疗组.结论 重症患者普遍存在营养风险,需要给予营养支持.早期EN、PN液中添加谷氨酰胺及给予强化胰岛素治疗能够缩短患者在ICU停留的时间,降低感染和MODS发生率及病死率.     

Effect of Early Full‐Calorie Nutrition Support Following Esophagectomy: A Randomized Controlled Trial

Background: Early use of enteral nutrition (EN) is indicated following surgical resection of esophageal cancer. However, early EN support does not always meet the optimal calorie or protein requirements, and the benefits of supplementary parenteral nutrition (PN) remain unclear. We aimed to evaluate the efficacy and safety of early supplementary PN following esophagectomy. Materials and Methods: We enrolled 80 consecutive patients who underwent esophagectomy. Resting energy expenditure and body composition measurements were performed in all patients preoperatively and postoperatively. EN was administered after surgery, followed by randomization to either EN+PN or EN alone. The amount of PN administered was calculated to meet the full calorie requirement, as measured by indirect calorimetry, and 1.5 g protein/kg fat‐free mass (FFM) per day was added as determined by body composition measurement. The clinical characteristics were compared between the 2 groups. Results: Patients in the EN+PN group but not in the EN group preserved body weight (0.18 ± 3.38 kg vs ?2.15 ± 3.19 kg, P < .05) and FFM (1.46 ± 2.97 kg vs ?2.08 ± 4.16 kg) relative to preoperative measurements. Length of hospital stay, postoperative morbidity rates, and standard blood biochemistry profiles were similar. However, scores for physical functioning (71.5 ± 24.3 vs 60.4 ± 27.4, P < .05) and energy/fatigue (62.9 ± 19.5 vs 54.2 ± 23.5, P < .05) were higher in the EN+PN group 90 days following surgery. Conclusion: Early use of supplemental PN to meet full calorie requirements of patients who underwent esophagectomy led to better quality of life 3 months after surgery. Moreover, increased calorie and protein supplies were associated with preservation of body weight and FFM.     

胃肠外营养支持治疗在恶性肿瘤化疗中的应用

恶性肿瘤病人通常因伴有厌食或机械性梗阻妨碍正常进食。抗癌化疗带来的消化道副反应更影响病人对热量和营养素的摄取，但恶性肿瘤病人对热量和蛋白质的需求量反而增加［‘j。因此化疗病人常消瘦，体质下降，需要科学地使用胃肠外营养支持治疗手段。本文就与化疗配合实施的胃肠外营养支持治疗方法及有关问题探讨如下。一、胃肠外营养概念又称静脉营养。通过周围静脉或中心静脉输入能量及各种营养素的一种营养支持治疗方法。是按照病人的生理需要输入包括脂肪、碳水化合物、氨基酸、维生素、电解质、微量元素和水的全部营养物质，是全面的、…