营养支持治疗在ICU中的应用

本文报告１４例危重病人，在治疗原发病和其它生命支持治疗的同时，给予全胃肠外营养（ＴＰＮ）和肠道内营养（ＥＮ）收到良好效果。１４例中ＭＳＯＦ１０例，其中衰竭脏器≥４个者５例。９例入ＩＣＵ时呈昏迷状态，９例为腹部或胸部手术后病人（其中２次手术者２例，３次...     

短期静脉营养对肺心病心衰和呼衰病人的疗效影响

作者观察了短期静脉营养疗法对肺心病合并心衰、呼衰伴有营养不良病人的疗效影响。４８例病人分成治疗组（２５例）、对照组（２３例），对照组给予常规治疗；治疗组给予常规治疗加静脉内滴注复方氨基酸和Ｉｎｔｒａｌｉｐｉｄ，每天１次，２周为一疗程。观察临床疗效、营...     

胃肠道肿瘤术后的肠外营养支持

２９例胃肠道恶性肿瘤病人，均作肿瘤切除术。根据术后不同的ＰＮ支持方法分为三组。Ａ组（９例）术后给予常规静脉补液（葡萄糖热能４１．８ｋＪ／ｋｇ·ｄ－１）；Ｂ组（１０例）连续５ｄ给予葡萄糖热能１２５．５ｋＪ／（ｋｇ·ｄ）和１４－氨基酸－８０００．１７ｇ氮...     

早产儿、低体重儿人工胃肠支持

本研究把不能正常吸吮的４例早产儿、３例低体重儿分为三组。母乳全肠内营养（ＴＥＮ）组２例，肠内加静脉营养（ＥＮ＋ＰＮ）组３例，全静脉营养（ＴＰＮ）组２例。产后１～３ｄ、４～７ｄ、８～１４ｄ给予每个病儿的液体量分别为１２０ｍｌ／（ｋｇ·ｄ）、１５０ｍｌ／...     

TPN在外科危重病人中的应用（附17例临床应用体会）

自１９９４年以来，对１７例外科危重病人经周围静脉进行了全胃肠外营养。营养支持时间为４～４０ｄ，其中１４ｄ以上的７例病人进行了氮平衡监测，均获得了正氮平衡，有２例术后严重并发症病人经ＴＰＮ支持１个月以上，均顺利康复。临床观察表明：①只要应用得当，在基层...     

恶性肿瘤病人营养调查

恶性肿瘤病人营养低下是抗肿瘤治疗过程中一个重要问题。病人营养状况好坏直接影响着抗肿瘤治疗效果。了解并及时评价病人营养状况是进行营养治疗的首要程序。我们于１９９８年７、８两月对四川省德阳市人民医院住院的恶性肿瘤病人进行了营养调查，现将结果报告如下。１　对象和方法１．１　对象：为上述住院的恶性肿瘤患者，除拒绝参加调查或昏迷病人外，共有３１名患者参加此调查，其中男性２０名，女性１１名；平均年龄（中位数）为６２－９岁；早期患者９名，中期１６名，晚期６名；肺癌８例，肝癌５例，白血病４例，大肠癌３例，乳腺癌…     

肝移植围手术期的营养支持管理

目的:总结肝移植围手术期病人的营养支持管理,提高器官移植的成功率,减少术后并发症,促进康复. 方法:对71例肝移植病人围手术期的营养治疗方法和营养状况进行回顾性分析.术前给予适当热量、蛋白质和高维生素的肠内营养,同时加用支链氨基酸(BCAA)和谷氨酰胺(Gln),使病人尽快改善全身营养状况.术后给予静脉营养,同时尽早实施肠内营养,直至全肠内营养. 结果:除5例病人死于呼吸衰竭、2例死于出血性休克外,其余64例病人肝功能逐渐恢复,营养指标明显改善,移植肝功能良好. 结论:肝移植围手术期病人的营养管理十分必要,合理的营养支持有利于移植器官功能的早期恢复和受者营养状态的改善.     

全胃切除术后经空肠造口行早期肠内营养的临床研究

目的：通过对全胃切除术后经空肠造口早期给予肠内营养治疗的观察，评价其疗效及可行性。方法：选择本院收治的胃癌全胃切除病人25例，随机分为两组，I组（对照组）12例，术后接受外周静脉营养；Ⅱ组（试验组）13例，术后24h开始经空肠造口行肠内营养治疗（连续7天），两组基本等热量，并对两组病人术前、术后进行营养状态评价，比较术后肠功能恢复及住院费用等。结果：试验组病人术后体重及营养状态均较对照组有明显改善，两组差异显著（P＜0．01）。而且试验组术后平均住院时间明显短于对照组（P＜0．01）。结论：全胃切除术后经空肠造口行早期肠内营养治疗，不仅安全、可靠、简便、经济，而且能有效地改善病人术后营养状况。     

TPN在外科重危病人和外科术后严重并发症治疗中的应用

本文报告５例外科重症病人和５５例外科术后严重并发症病人，应用ＴＰＮ支持治疗的临床效果。本组病例中男４９例，女１１例，年龄在１６～７２岁，平均４４．５岁。经中心静脉全肠外营养（ＣＶ－ＴＰＮ）３例，经周围静脉全肠外营养（ＰＶ－ＴＰＮ）２８例；营养支持时间...     

严重多发伤病人静脉营养的治疗体会

作者将１９９４年３月至１９９５年１２月治疗的７４例严重多发伤病人静脉营养１周后治疗效果作回顾性分析，认为经中心静脉双能源供热２１例，血浆白蛋白值及末梢血淋巴细胞计数均提高（Ｐ＜０．０５）。２３例病人用双能源供热，周围静脉营养，血浆白蛋白水平及末梢血淋...     

危重病人营养与代谢支持策略的演变

已认识到全肠外营养在危重病人营养支持中的不足,主要是感染和肝功能的并发症较难克服。与全肠外营养相比,肠内营养具有并发症少,费用低等优点。但由于外科病人通过肠道进行营养支持有一定限制。为避免能量与蛋白质供给不足,可采用肠内 肠外的营养支持模式。过多供给能量与蛋白质,不仅不能改善病人的营养状态,反而对机体有害,危重病人的合理营养支持最好是按实际测量的能量消耗供给营养底物,要想进一步改善重危病人营养支持的效果。必须注重辅助疗法的应用。如谷氨酰胺、精氨酸、亚油酸、短链脂肪酸以及微生态营养。     

Enteral versus parenteral nutrition: a pragmatic study

Controversy persists as to the optimal means of providing adjuvant nutritional support. The aim of this study was to compare enteral nutrition (EN) and parenteral nutrition (TPN) in terms of adequacy of nutritional intake, septic and nonseptic morbidity, and mortality. This was a prospective pragmatic study, whereby the route of delivery of nutritional support was determined by the attending clinician's assessment of gastrointestinal function. Patients considered to have inadequate gastrointestinal function were given TPN (group 1), while those deemed to have a functioning gastrointestinal tract received EN (group 2). Patients in whom there was reasonable doubt as to the adequacy of intestinal function were randomized to receive either TPN (group 3) or EN (group 4). The trial setting was a large district general hospital with a dedicated nutrition team. A total of 562 patients were included in the study (331 males; median age 67 y). Gastrointestinal function on entry into the study was considered inadequate in 267 patients who were given TPN (group 1) and adequate in 231 whom received EN (group 2). There was clinical uncertainty about the adequacy of gut function in 64 patients (11.4%) who were randomized to receive either TPN (group 3, 32 patients) or EN (group 4, 32 patients). The incidence of inadequate nutritional intake was significantly higher in group 4 compared with group 3 (78.1% versus 25%, P < 0.001). Complications related to the delivery system and other feed-related morbidity were significantly more frequent in both EN groups compared with the respective TPN groups. EN was associated with a higher overall mortality in both nonrandomized and randomized patients. There were no significant differences observed in the incidences of septic morbidity between patients receiving TPN and those given EN. EN is associated with a higher incidence of inadequate nutritional intake, complications related to the delivery system, and other feed-related morbidity than TPN. There is no evidence from this study to support a difference between the two modalities in terms of septic morbidity. Patients in whom there is reasonable doubt as to the adequacy of gastrointestinal function should be fed by the parenteral route.     

肠外瘘病人肠内营养支持临床应用研究

目的：观察肠内营养在肠外瘘病人应用的时机、条件、途径及肠内营养制品的选择,研究肠内营养在肠外瘘病人中的作用。方法：收集１７０例肠外瘘病人诊断、住院总天数及全肠外营养（ＴＰＮ）、全肠内营养（ＴＥＮ）、肠内＋肠外营养（ＰＮ＋ＥＮ）、经口饮食的天数,计算不同营养支持方法期间,非蛋白质热量、蛋白质的供给量和并发症的发生率。收集ＴＰＮ、ＴＥＮ支持前和支持后满１５天病人的血清白蛋白浓度。另对４０例肠外瘘病人进行为期１５天的前瞻性观察,了解肠内营养对白蛋白、前白蛋白、转铁蛋白、纤维连结蛋白、总蛋白、球蛋白和肝酶谱的影响。结果：１７０例病人的总住院天数为１３５５３天,其中１６４人曾使用ＴＰＮ６０４０天（４４．６％）;１２９人使用ＴＥＮ３６７６天（２７．１％）;８３人使用肠内＋肠外营养４８９天（３．６％）;１２８人经口饮食２３３     

Enteral and parenteral nutrition: evidence-based approach.

Nutrition support for patients in hospital has become an essential form of therapy. Total parenteral nutrition (TPN) was the preferred way of giving nutrition to hospital patients for many years but enteral nutrition (EN) is now the preferred route. EN is believed to promote gut function and prevent translocation of intestinal bacteria, thus reducing the incidence of sepsis in critically ill patients. In consequence, the use of TPN has been discouraged as a dangerous form of therapy. Critical review of the data suggests that in the human subject TPN does not cause mucosal atrophy or increase translocation of bacteria through the small intestine. However, overfeeding, which is easy with TPN, can explain the results of studies which have shown that TPN increases sepsis. Furthermore, the risks of TPN-induced complications have been exaggerated. When there is risk of malnutrition and EN is not tolerated, or there is gut failure, TPN is an equally effective and safe alternative.     

早期全肠外营养及肠内、外混合营养对神经外科危重患者免疫功能的影响

目的探讨早期给予全肠外营养（TPN）及肠内营养（EN）、肠外营养（PN）混合支持对神经外科危重患者免疫功能的影响。方法采用前瞻性对照研究将神经外科危重患者按入院顺序随机分为TPN组及EN＋PN组,并对比营养支持前后两组CD3、CD4、CD8、CD4／CD8、CD3／CD25、IgA、IgG、IgM、血清白蛋白的变化。结果给予神经外科危重患者两种营养支持均可提高其CD3、CD4、CD8及CD3＋／CD25＋比值（P〈0．05,P〈0．01）;两种营养支持方式均可显著升高IgA、IgG、IgM、（P〈0．05）及血清白蛋白浓度（P〈0．01）。与TPN组比较,EN＋PN组CD3、CD4、CD8、CD4／CD8比值、IgA、IgG、IgM浓度及血清白蛋白水平均显著升高（P〈0．05,P〈0．01）。结论早期TPN及EN＋PN支持均可促进神经外科危重患者免疫功能的恢复及提高,EN＋PN的作用优于TPN,对于神经外科危重患者应早期给予营养支持治疗。     

老年胃肿瘤病人术后早期肠内营养的应用

目的:探讨早期肠内营养对改善老年胃肿瘤病人术后的营养免疫状况及减少并发症的作用.方法:将84例老年胃肿瘤病人随机分为肠内营养(EN)组及肠外营养(PN)组,于术后24 h开始予以相同热量及氮量营养支持,分别观察营养支持前后的营养和免疫指标及术后并发症.结果:两组的营养及免疫指标于营养支持后明显改善(P＜0.05),免疫指标EN组较PN组明显提高(P＜0.05);EN组与PN组相比,明显促进病人术后胃肠道功能恢复,减少并发症的发生及住院费用.结论:老年胃肿瘤病人术后早期肠内营养是一种安全、有效、简便、经济和理想的营养治疗方法.     

肠内营养对肝功能受损病人术后肠粘膜屏障的影响

目的：探讨严重肝功能损伤的病人术后施行肠内营养（EN）支持对胃肠道粘膜屏障的保护作用及临床意义。方法：将肝功能为ChildB级的成年病人共76例，随机分为肠内营养组（EN，n=30)、全肠外营养组（TPN，n=26)和对照组（CON，n=20)，分别检测三组病人术前1天，术后5天和10天时的营养状况及肝功能的变化，并检测尿中排泄的乳果糖（L）和甘露醇（M）的比值（L／M），观察不同营养方法对肠粘膜通透性的影响。结果：EN组和TPN组病人术后都无明显肝功能害加重的表现；EN组病人术后较早达到正氮平衡，体重减轻功较少，与TPN组相比差异显著（P＜0．05）；EN组病人手术前，后L／M值无明显变化（P＞0．05），而TPN组和CON组变化明显（P＜0．05）。结论：对肝功能严重受损的病人，EN是一种方便、安全、有效的临床营养支持方法；EN对肠道粘膜屏障具有明显的保护作用。     

Total parenteral nutrition: potion or poison?

The role of nutritional support in clinical care has burgeoned over the past 40 y. Initially, total parenteral nutri-tion (TPN) was considered to be the standard of care. Later, the concept that enteral nutrition (EN) promoted gut function and prevented the translocation of intestinal bacteria resulted in EN becoming the standard of care. Furthermore, TPN was consid-ered to be a dangerous form of therapy. Critical review of the data suggests that, in humans, TPN does not cause mucosal atrophy or increase bacterial translocation. Increased sepsis with TPN can be ascribed to overfeeding; the dangers of TPN-induced complications have been exaggerated. TPN is an equally effective alternative to EN when a risk of malnutrition is present and EN is not tolerated or when gut failure is present.     

Effects of artificial nutrition on the nutritional status of cancer patients

The paper critically analyzes available data on the nutritional and metabolic effects of total parenteral nutrition (TPN) and enteral nutrition (EN) in cachectic cancer patients. Only papers dealing with adult cancer patients and providing data regarding type of tumor, duration of the nutritional support, and administration rate of calories and amino acids, validated by statistical analysis of the results, are included. The main conclusions are the following: (1) No nutritional variable worsened in cancer patients receiving TPN or EN, in conditions in which progressive deterioration of the nutritional status is the rule. (2) The nutritional variables improved by TPN and EN were body weight, fat mass, and some indicators of lean body mass (nitrogen balance and whole body potassium). Thyroxin-binding prealbumin and retinol-binding protein increased only with TPN, whereas some immunologic indexes (complement factors and lymphocytes) improved only with EN. (3) The daily regimens which improved lean body mass and visceral proteins ranged from 35 to 55 kcal/kg and from 1.2 to 2.0 g of amino acids/kg for TPN; for EN it was 35 kcal/kg and 1.3 g of amino acids/kg. However, the enteral regimen capable of improving some immune responses included at least 42 kcal/kg and 2.3 g of amino acids/kg. (4) Only three randomized studies were performed to compare TPN and EN, and conflicting results were obtained. Only TPN showed some significant advantages with regard to weight gain, nitrogen balance, maintenance of serum albumin levels and some mineral balances. However, the advantage of TPN was not clear enough to recommend its indiscriminate use. The choice between TPN and EN should always consider the functionality of the GI tract, the need for hospitalization to start a TPN regimen, and the higher cost of intravenous feeding. (5) When comparing TPN to a standard oral diet, the following variables improved with the nutritional support: body weight, nitrogen balance, 3-methylhistidine, urinary excretion, and serum levels of transferrin, cholinesterase, thyroxin-binding prealbumin, and retinol-binding protein. (6) When comparing TPN with glucose vs TPN with glucose-lipids, no major difference was found with regard to most nutritional variables. In conclusion, nutritional support alone probably has a small role in managing a limited number of advanced cancer patients dying primarily because of malnutrition or mainly suffering from nutritional deterioration. It can also have a "permissive" role in those patients potentially candidate to an oncologic treatment which cannot be delivered because of a poor nutritional status.(ABSTRACT TRUNCATED AT 400 WORDS)     

Modulating effects of the feeding route on stress response and endotoxin translocation in severely stressed patients receiving thoracic esophagectomy

Experimental studies have demonstrated that the route of nutritional supply impacts the systemic metabolic responses after surgical injury. Intestinal mucosal atrophy, as induced by total parenteral nutrition (TPN) or prolonged bowel rest, has been reported to enhance bowel endotoxin translocation. The operative procedure for thoracic esophageal cancer, including thoracotomy, laparotomy, and three-field lymph-node dissection, is a particularly stressful surgery that requires long-term aggressive nutritional support and often results in the postoperative hypermetabolic state, leading to perturbation of postoperative immune function. Interleukin-6 (IL-6) plays an important role in host inflammatory responses, whereas IL-10 is linked to suppression of cellular immunity. The aim of this study was to investigate how the antecedent nutritional routes influence systemic IL-6 and IL-10 responses and endotoxin translocation after an operation for thoracic esophageal cancer. Twenty-nine patients who underwent esophagectomy with three-field lymphadenectomy were investigated. They were assigned to groups receiving either TPN (n = 18) or enteral nutrition (EN; n = 11) providing 35 kcal x kg(-1) x d(-1) of energy and approximately 1.2-1.5 g x kg(-1) x d(-1) of amino acids. These nutritional supports were conducted from 1 wk before the operation to 14 d after the operation. Serum IL-6, IL-10, and endotoxin concentration were measured before and during the operation and at 2 h and 1, 3, and 7 d after the operation. IL-6 in sera was significantly higher after the operation in both groups. In the EN group, however, significantly less IL-6 production was observed on the third and seventh postoperative days when compared with those patients in the TPN group. Similarly, serum IL-10 concentration in the TPN group showed a significantly higher level than that in the EN group. Serum IL-6 showed a significant positive correlation with IL-10 at 2 h and at 7 d after the operation, suggesting that the reduced inflammatory responses were related to the inhibition of the development of postoperative immunosuppression. Endotoxin concentration in sera was significantly lower in the EN group after the operation than in the TPN group. Perioperative EN provides better regulation of inflammatory cytokine responses and may contribute less to immunosuppression after major surgery than parenteral nutrition. The attenuated production of endotoxin induced by EN may play an important role in these phenomena.