重型颅脑损伤患者的早期肠内营养支持

目的：探讨重型颅脑损伤患者早期应用肠内营养支持的治疗效果.方法：回顾316例早期应用肠内营养支持治疗的重型颅脑损伤患者的临床资料.结果：316例患者中,除14例因严重并发症停止或暂时停止肠内营养支持治疗外,其余患者均较顺利地接受了早期肠内营养支持治疗.结论：肠内营养支持治疗方便、经济、并发症少,不仅可以提供患者所需要的营养要素,而且能增强患者的免疫功能、减少感染发生.     

Does artificial nutrition improve outcome of critical illness? An alternative viewpoint!

Recent studies challenge the beneficial role of artificial nutrition provided to critically ill patients and point out the limitations of existing studies in this area. We take a differing view of the existing data and refute many of the arguments put forward by previous authors. We review the mechanistic, observational, and experimental data supporting a role for early enteral nutrition in the critically ill patient. We conclude without question that more, high-quality research is needed to better define the role of artificial nutrition in the critical care setting, but until then early and adequate delivery of enteral nutrition is a legitimate, evidence-based treatment recommendation and we see no evidence-based role for restricting enteral nutrition in critically ill patients. The role of early supplemental parenteral nutrition continues to be defined as new data emerge.     

新型冠状病毒感染患者营养支持治疗专家建议(2023)

规范化营养支持治疗可有效改善新型冠状病毒感染患者的营养状况、免疫功能和临床结局,加速机体康复并降低复发风险,提高生活质量,在新型冠状病毒感染患者的治疗与康复中发挥着重要作用。《新型冠状病毒感染诊疗方案(试行第十版)》中也明确提出,应将营养支持治疗纳入新型冠状病毒感染患者治疗与康复的全过程。为此,北京市临床营养治疗质量控制和改进中心组织相关专家,在结合最新临床营养指南、研究证据及临床实践经验的基础上,制订了《新型冠状病毒感染患者营养支持治疗专家建议(2023)》。本建议提出,应建立并遵循包括营养筛查、营养诊断、营养支持治疗和临床监测在内的规范化营养管理路径与策略,并结合新型冠状病毒感染患者的临床特点,实施个体化营养管理,旨在为临床医生和临床营养医师等专业人员开展规范化营养支持治疗提供借鉴。     

食管与胃手术后病人经鼻空肠营养的护理

笔对62例食管与胃术后病人经鼻早期空肠营养护理情况进行总结、分折。提出：术前对特殊病人置管口服石蜡油能提高置管成功率，且防止出血；术后妥善固定营养管防止滑脱；输入营养液时根据病人的适应情况，逐渐增加量和速度，并注意温度；密切观察空肠营养的并发症并采取相应措施；放置鼻空肠营养管，以保证术后早期肠内营养支持，防止吻合口水肿及瘘的形成。     

Nutrition intervention in pediatric patients with thermal injuries who require laparotomy

Increased intra-abdominal pressure is a complication of thermal injuries that is most commonly noted during burn shock or sepsis. Severely elevated intra-abdominal pressure requires surgical treatment by laparotomy to avert cardiac, respiratory, and renal compromise. The purpose of this retrospective study was to examine the manipulation of the nutrition program and outcomes in response to such a procedure. Open laparotomy for increased intra-abdominal pressure was necessary for 6 patients admitted to a pediatric burn facility from March 1993 to April 1999. One patient was excluded from the review because he died 2 days after the burn injury (1 day after the laparotomy) and nutrition intervention was not initiated. Four of the five remaining patients received parenteral nutrition within 48 hours of surgery. One patient did not receive parenteral nutrition because the enteral regimen was at the goal by 5 days after the laparotomy. Trophic enteral feedings were initiated in all 5 patients within 48 hours of the operations. Tube feedings were gradually increased and the parenteral nutrition rate was decreased in accordance with gastrointestinal tolerance (abdominal girth, bowel motility). Enteral nutrition was started before abdomen closure in all of the patients. No mechanical, infectious, or mortality-related complications related to the initiation of enteral nutrition after open laparotomies were noted. Surgical intervention by open laparotomy interrupts the postburn nutrition regimen but does not preclude the safe postoperative delivery and advancement of enteral feedings.     

The New York State Health Care Proxy Law and the issue of artificial hydration and nutrition

The New York State Health Care Proxy (HCP) Law allows a surrogate to make medical decisions for an individual when he or she loses the capacity to make them. In the area of artificial hydration and nutrition, however, this law dictates that if the agent is not aware of the patient's wishes regarding hydration and nutrition, the agent cannot decide about this treatment.     

About the lecture by a physician

As I had been lectured to by a physician about the dangers of morphine use in my child, I agonized over allowing its administration, which only prolonged my son's suffering. It is one of my biggest regrets upon looking back on Austin's time here on earth. A lack of education on the positive benefits of morphine actually increased the time of his suffering. It's still hard to digest. When Austin received morphine he did not stop breathing, die, or lose his personality as I had feared. Instead, he was able to regain some of the weight he had lost during his bouts with dystonia and spasticity and could enjoy life within reason. He could even smile again, something that I had not seen in a full month of his suffering in the hospital. He died at age 14, but not before enduring other periods of time dealing with horrific spasms. Austin's pain became unmanageable in February 2005 and I had to make the painful decision to withdraw nutrition and hydration in order to end his horrible suffering, as there was no cure for the disease he had and no end in sight for the pain.     

Parenteral versus enteral nutrition: effect on serum cytokines and the hepatic expression of mRNA of suppressor of cytokine signaling proteins,insulin-like growth factor-1 and the growth hormone receptor in rodent sepsis

Introduction  

Early nutrition is recommended for patients with sepsis, but data are conflicting regarding the optimum route of delivery. Enteral nutrition (EN), compared with parenteral nutrition (PN), results in poorer achievement of nutritional goals but may be associated with fewer infections. Mechanisms underlying differential effects of the feeding route on patient outcomes are not understood, but probably involve the immune system and the anabolic response to nutrients. We studied the effect of nutrition and the route of delivery of nutrition on cytokine profiles, the growth hormone–insulin-like growth factor-1 (IGF-I) axis and a potential mechanism for immune and anabolic system interaction, the suppressors of cytokine signaling (SOCS), in rodents with and without sepsis.     

脂肪乳剂应用于急性中毒的研究进展

脂肪乳剂不仅在临床上作为营养药物,近年来还用于脂溶性药物中毒的辅助治疗。这类中毒多会导致呼吸心搏骤停,应用传统方法救治困难。实验室研究和临床案例报告越来越多地接受脂肪乳剂作为脂溶性药物中毒的治疗方法之一。本文主要就脂肪乳剂治疗脂溶性药物中毒的进展予以综述,为临床使用脂肪乳剂解救中毒提供参考。     

婴幼儿心脏术后的胃肠道护理

通过对55例心脏术后婴幼儿患者的胃肠道护理,认为胃肠道护理的重点是:常规留置胃管并予开放,及时进行胃肠减压;经常观察腹胀情况,及时解除腹胀;尽早给予胃肠道内营养治疗。笔者认为加强对心脏术后婴幼儿患者的胃肠道护理,有助于减少和防止因腹胀而影响呼吸、心率、血压等,并及早进行胃肠内营养治疗,改善营养不良状况,加速患儿的康复,同时减少感染的发生。     

Enteral nutrition: better navigation,yet unknown destination?

The nutrition dose truly absorbed by a patient is crucial information in the management or the investigation of nutrition during critical illness. In the present issue of Critical Care, assessment of nutritional losses in stools was studied. These losses together with enteral nutrition lost in gastric fluids and enteral nutrition prescribed but never infused make up the difference between the dose supposedly given to a patient and the amount effectively taken up. Additionally, the optimal dosing and timing of nutrition during critical illness are still debated. When enteral nutrition is insufficient, the options are limited.     

早期肠内营养对胃癌术后病人营养状况改善的临床观察和护理体会

目的 评价早期肠内营养对胃癌术后病人营养状况的改善作用,观察相关并发症的发生,探讨护理工作中的防治措施.方法 将76例病人随机分为肠内营养组(n=38)和肠外营养组(n=38).于术后早期进行营养支持,在营养支持前和第7天分别测定血清白蛋白(Albumin,ALB)、转铁蛋白(Trans-ferrin,TFN)和前白蛋白(Prealbumin,PA),评价病人营养状况的改善效果.同时观察病人在进行肠内营养支持过程中发生的各种并发症,总结护理过程中的观察重点和防治措施.结果 7 d内,肠内营养组和肠外营养组病人血清白蛋白浓度变化在营养支持前后均无统计学意义(P0.05),而血清前白蛋白的浓度变化有统计学意义(P<0.05);肠内营养组病人血清转铁蛋白浓度变化在营养支持前后无统计学意义(P0.05),而肠外营养组病人血清转铁蛋白浓度变化有统计学意义(P<0.05).同时肠内营养组有8例病人出现并发症,其中腹泻5例,腹胀2例,堵管1例,经护理干预后,约97%以上的并发症得到有效改善.结论 肠内营养和肠外营养都能够使胃癌术后病人的营养状况得到改善,两者都是可行途径,临床实践中可根据病情灵活选择;采取积极有效的医疗护理措施,可以减少并发症的发生,促进病人早日康复.     

家长营养知识和文化程度对儿童营养状况的影响

目的探讨家长营养知识、文化程度与儿童营养状况之间的关系,促进小儿健康成长。方法对213例0～6岁儿童行体格检查,了解其营养状况;采用自行设计的问卷调查家长文化程度和营养知识掌握情况。对家长的文化程度、营养知识掌握情况与子女的营养状况进行stearman相关分析,了解其相关性。结果儿童的营养状况与父母文化程度无明显关系,父母营养知识与子女营养状况有明显相关性(P<0.01)。结论儿童的营养状况主要与家长对营养知识掌握的程度密切相关,应采用各种健康教育措施提高家长营养知识,尤其不能忽略文化程度高的家长。     

Introduction of a community nutrition risk assessment tool

This article describes the introduction of a community nutrition risk assessment (CNRA) initiative in liaison with a local primary care trust (PCT). A pilot was undertaken in order to produce local evidence of the benefits of nutrition risk screening and thus gain support from the PCT for full implementation of the CNRA. The results from the pilot, which indicated that a substantial financial saving for the PCT was possible with a corresponding improvement in patient care, were sufficiently convincing for the PCT to sanction the introduction of the CNRA throughout the local community. Seven steps for success are recommended which may be of use to other healthcare professionals who are considering such a process for their own community patients or indeed any other multiprofessional initiative which requires PCT support. Such steps include identification of those who may help or hinder the process and a thorough preparation of a concise evidence-based proposal which should assist in persuading those less enthusiastic to accept and support the vision.     

15例特重度烧伤俯卧位通气患者早期幽门后喂养不减速的护理

总结15例特重度烧伤俯卧位通气患者早期幽门后喂养不减速的实施经验与成效。护理内容主要如下。构建多学科俯卧位通气肠内营养团队,动态调整个性化精准营养方案,管理喂养目标速率,实施以腹内压指导下的喂养不减速策略,有效预防胃肠不耐受。15例患者经精心护理后,24～48 h内肠内营养达标率为20%～60%,1周肠内营养达标率为50%～95%,胃肠耐受较好,以腹内压为目标导向的早期幽门后喂养不减速在特重度烧伤俯卧位通气患者中的应用安全有效。     

Faut-il des preuves pour nourrir ?

Asking the question “do we need evidence for feeding?” raises several concerns that are closely linked in clinical practice. What is the nature of the evidence in medicine? What are the specificities of the evidence in clinical nutrition, management of the evidence and of the uncertainty, as well as ethical implications? Searching for the evidence is an old issue that became more relevant in the eighties with the development of the evidence-based medicine (EBM) theory and the increasing importance of randomised controlled trials. Except some specific clinical situations, the level of proof is often weak in clinical nutrition. Two examples illustrate this situation: the glycemic control and the early enteral nutrition in critically ill patients. Some methodological issues may explain the discrepancies between the studies, but more deeply, these discrepancies demonstrate that, in opposition with the view of EBM promoters, the proof has always two components: a factual and a contextual one. Facts do not occur alone, a scientific fact cannot be isolated from its emerging context. Asking the question “do we need evidence for feeding?” refers to the specificities of clinical nutrition in comparison with other treatments. Nutrition is not only a “cure” but also a “care” with all its complexity. Stopping nutrition is associated with death. To initiate, continue or stop nutritional support should be associated with an ethical approach. In summary, in clinical practice, physicians are not facing an automatic application of the evidence but have to deal with uncertainty and manage ethical issues.     

序贯式肠内营养在脑梗死伴吞咽障碍老年患者中的应用

目的:探讨序贯式肠内营养在脑梗死伴吞咽障碍老年患者中的应用效果。方法:采用随机抽样法选取在某三级甲等医院卒中单元住院的脑梗死老年患者95例,随机分为观察组48例和对照组47例。观察组先采用短肽型肠内营养制剂,并逐步过渡到整蛋白型肠内营养剂;对照组在整个研究过程中一直使用整蛋白型肠内营养剂。比较两组肠内营养并发症发生情况,于入院第2、14天比较两组神经功能指标恢复情况[采用美国国立卫生研究院卒中量表(NIHSS)、Barthel指数(BI)]及吞咽功能分级(采用洼田饮水试验)。结果:观察组肠道感染、肺部感染、尿道感染、胃出血等并发症总发生率低于对照组(P<0.05);入院第14天,观察组NIHSS评分低于对照组(P<0.05),吞咽功能分级优于对照组(P<0.05)。结论:序贯式肠内营养支持能够降低脑梗死老年患者肠内营养并发症发生率,促进神经功能和吞咽功能恢复,值得临床推广应用。     

Specialized nutrition support

Specialized nutrition support should be offered to patients who are malnourished or at risk of becoming malnourished when it would benefit patient outcomes or quality of life. Improving the nutritional value of ingested food and tailoring intake to the patient's preferences, abilities, and schedule should be the first measures in addressing nutritional needs. When these interventions alone are insufficient to meet nutritional requirements, oral nutritional supplements should be considered. Nutritional status should be evaluated in patients before specialized nutrition sup- port is considered. Enteral nutrition is used when patients have a functional gastrointestinal tract but are unable to safely swallow. Although a variety of enteral formulas are available, evidence for choosing a specific formula is often lacking. Parenteral nutrition should be used only when enteral nutrition is not feasible. There are no known benefits of parenteral nutrition over the enteral route, and the risk of serious complications is much greater with parenteral nutrition. Even when the parenteral route is necessary, some enteral nutrition is beneficial when possible. Specialized nutrition support can provide an effective bridge until patients are able to return to normal food and, in rare cases, may be continued as long-term home enteral or parenteral nutrition. Specialized nutrition support is not obligatory and can be harmful in cases of futile care and at the end of life.     

About the Lecture by a Physician

ABSTRACT

As I had been lectured to by a physician about the dangers of morphine use in my child, I agonized over allowing its administration, which only prolonged my son's suffering. It is one of my biggest regrets upon looking back on Austin's time here on earth. A lack of education on the positive benefits of morphine actually increased the time of his suffering. It's still hard to digest. When Austin received morphine he did not stop breathing, die, or lose his personality as I had feared. Instead, he was able to regain some of the weight he had lost during his bouts with dystonia and spasticity and could enjoy life within reason. He could even smile again, something that I had not seen in a full month of his suffering in the hospital. He died at age 14, but not before enduring other periods of time dealing with horrific spasms. Austin's pain became unmanageable in February 2005 and I had to make the painful decision to withdraw nutrition and hydration in order to end his horrible suffering, as there was no cure for the disease he had and no end in sight for the pain.