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ESPEN Guidelines on Parenteral Nutrition: Non-surgical oncology 总被引:1,自引:0,他引:1
F. Bozzetti J. Arends K. Lundholm A. Micklewright G. Zurcher M. Muscaritoli 《Clinical nutrition (Edinburgh, Scotland)》2009,28(4):445
Parenteral nutrition offers the possibility of increasing or ensuring nutrient intake in patients in whom normal food intake is inadequate and enteral nutrition is not feasible, is contraindicated or is not accepted by the patient.These guidelines are intended to provide evidence-based recommendations for the use of parenteral nutrition in cancer patients. They were developed by an interdisciplinary expert group in accordance with accepted standards, are based on the most relevant publications of the last 30 years and share many of the conclusions of the ESPEN guidelines on enteral nutrition in oncology.Under-nutrition and cachexia occur frequently in cancer patients and are indicators of poor prognosis and, per se, responsible for excess morbidity and mortality. Many indications for parenteral nutrition parallel those for enteral nutrition (weight loss or reduction in food intake for more than 7–10 days), but only those who, for whatever reason cannot be fed orally or enterally, are candidates to receive parenteral nutrition. A standard nutritional regimen may be recommended for short-term parenteral nutrition, while in cachectic patients receiving intravenous feeding for several weeks a high fat-to-glucose ratio may be advised because these patients maintain a high capacity to metabolize fats. The limited nutritional response to the parenteral nutrition reflects more the presence of metabolic derangements which are characteristic of the cachexia syndrome (or merely the short duration of the nutritional support) rather than the inadequacy of the nutritional regimen. Perioperative parenteral nutrition is only recommended in malnourished patients if enteral nutrition is not feasible. In non-surgical well-nourished oncologic patients routine parenteral nutrition is not recommended because it has proved to offer no advantage and is associated with increased morbidity. A benefit, however, is reported in patients undergoing hematopoietic stem cell transplantation. Short-term parenteral nutrition is however commonly accepted in patients with acute gastrointestinal complications from chemotherapy and radiotherapy, and long-term (home) parenteral nutrition will sometimes be a life-saving maneuver in patients with sub acute/chronic radiation enteropathy. In incurable cancer patients home parenteral nutrition may be recommended in hypophagic/(sub)obstructed patients (if there is an acceptable performance status) if they are expected to die from starvation/under nutrition prior to tumor spread.
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Summary of statements: Non-surgical Oncology | |||
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Subject | Recommendations | Grade | Number |
Nutritional status | Nutritional assessment of all cancer patients should begin with tumor diagnosis and be repeated at every visit in order to initiate nutritional intervention early, before the general status is severely compromised and chances to restore a normal condition are few | C | 1.1 |
Total daily energy expenditure in cancer patients may be assumed to be similar to healthy subjects, or 20–25 kcal/kg/day for bedridden and 25–30 kcal/kg/day for ambulatory patients | C | 1.4 | |
The majority of cancer patients requiring PN for only a short period of time do not need a special formulation. Using a higher than usual percentage of lipid (e.g. 50% of non-protein energy), may be beneficial for those with frank cachexia needing prolonged PN (Grade C) | C | 1.5 | |
Indications | Therapeutic goals for PN in cancer patients are the improvement of function and outcome by: | C | 2.1 |
• preventing and treating under-nutrition/cachexia, | |||
• enhancing compliance with anti-tumor treatments, | |||
• controlling some adverse effects of anti-tumor therapies, | |||
• improving quality of life | |||
PN is ineffective and probably harmful in non-aphagic oncological patients in whom there is no gastrointestinal reason for intestinal failure | A | 2.1 | |
PN is recommended in patients with severe mucositis or severe radiation enteritis | C | 2.1 | |
Nutritional provision | Supplemental PN is recommended in patients if inadequate food and enteral intake (<60% of estimated energy expenditure) is anticipated for more than 10 days | C | 2.2 |
PN is not recommended if oral/enteral nutrient intake is adequate | A | 2.2 | |
In the presence of systemic inflammation it appears to be extremely difficult to achieve whole body protein anabolism in cancer patients. In this situation, in addition to nutritional interventions, pharmacological efforts are recommended to modulate the inflammatory response | C | 2.3 | |
Preliminary data suggest a potential positive role of insulin (Grade C). There are no data on n-3 fatty acids | C | 2.4 | |
Peri-operative care | Peri-operative PN is recommended in malnourished candidates for artificial nutrition, when EN is not possible | A | 3.1 |
Peri-operative PN should not be used in the well-nourished | A | 3.1 | |
During non-surgical therapy | The routine use of PN during chemotherapy, radiotherapy or combined therapy is not recommended | A | 3.2 |
If patients are malnourished or facing a period longer than one week of starvation and enteral nutritional support is not feasible, PN is recommended | C | 3.2 | |
Incurable patients | In intestinal failure, long-term PN should be offered, if (1) enteral nutrition is insufficient, (2) expected survival due to tumor progression is longer than 2–3 months),(3) it is expected that PN can stabilize or improve performance status and quality of life, and (4) the patient desires this mode of nutritional support | C | 3.3 |
There is probable benefit in supporting incurable cancer patients with weight loss and reduced nutrient intake with “supplemental” PN | B | 3.4 | |
Hematopoietic stem cell transplantation (HSCT) | In HSCT patients PN should be reserved for those with severe mucositis, ileus, or intractable vomiting | B | 3.5 |
No clear recommendation can be made as to the time of introduction of PN in HSCT patients. Its withdrawal should be considered when patients are able to tolerate approximately 50% of their requirements enterally | C | 3.6 | |
HSCT patients may benefit from glutamine-supplemented PN | B | 3.7 | |
Tumor growth | Although PN supplies nutrients to the tumor, there is no evidence that this has deleterious effects on the outcome. This consideration should therefore have no influence on the decision to feed a cancer patient when PN is clinically indicated | C | 4.1 |
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M. Braga O. Ljungqvist P. Soeters K. Fearon A. Weimann F. Bozzetti 《Clinical nutrition (Edinburgh, Scotland)》2009,28(4):378
In modern surgical practice it is advisable to manage patients within an enhanced recovery protocol and thereby have them eating normal food within 1–3 days. Consequently, there is little room for routine perioperative artificial nutrition. Only a minority of patients may benefit from such therapy. These are predominantly patients who are at risk of developing complications after surgery. The main goals of perioperative nutritional support are to minimize negative protein balance by avoiding starvation, with the purpose of maintaining muscle, immune, and cognitive function and to enhance postoperative recovery.Several studies have demonstrated that 7–10 days of preoperative parenteral nutrition improves postoperative outcome in patients with severe undernutrition who cannot be adequately orally or enterally fed. Conversely, its use in well-nourished or mildly undernourished patients is associated with either no benefit or with increased morbidity.Postoperative parenteral nutrition is recommended in patients who cannot meet their caloric requirements within 7–10 days orally or enterally. In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice.The main consideration when administering fat and carbohydrates in parenteral nutrition is not to overfeed the patient. The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weights.In those patients who are unable to be fed via the enteral route after surgery, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis.
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Summary of statements: Surgery | |||
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Subject | Recommendations | Grade | Number |
Indications | Preoperative fasting from midnight is unnecessary in most patients | A | Preliminary remarks |
Interruption of nutritional intake is unnecessary after surgery in most patients | A | Preliminary remarks | |
Application | Preoperative parenteral nutrition is indicated in severely undernourished patients who cannot be adequately orally or enterally fed | A | 1 |
Postoperative parenteral nutrition is beneficial in undernourished patients in whom enteral nutrition is not feasible or not tolerated | A | 2 | |
Postoperative parenteral nutrition is beneficial in patients with postoperative complications impairing gastrointestinal function who are unable to receive and absorb adequate amounts of oral/enteral feeding for at least 7 days | A | 2 | |
In patients who require postoperative artificial nutrition, enteral feeding or a combination of enteral and supplementary parenteral feeding is the first choice | A | 2 | |
Combinations of enteral and parenteral nutrition should be considered in patients in whom there is an indication for nutritional support and in whom >60% of energy needs cannot be met via the enteral route, e.g. in high output enterocutaneous fistulae or in patients in whom partly obstructing benign or malignant gastro-intestinal lesions do not allow enteral refeeding. In completely obstructing lesions surgery should not be postponed because of the risk of aspiration or severe bowel distension leading to peritonitis | C | 2 | |
In patients with prolonged gastrointestinal failure parenteral nutrition is life-saving | C | 2 | |
Preoperative carbohydrate loading using the oral route is recommended in most patients. In the rare patients who cannot eat or are not allowed to drink preoperatively for whatever reasons the intravenous route can be used | A | 3 | |
Type of formula | The commonly used formula of 25 kcal/kg ideal body weight furnishes an approximate estimate of daily energy expenditure and requirements. Under conditions of severe stress requirements may approach 30 kcal/kg ideal body weight | B | 4 |
In illness/stressed conditions a daily nitrogen delivery equivalent to a protein intake of 1.5 g/kg ideal body weight (or approximately 20% of total energy requirements) is generally effective to limit nitrogen losses | B | 4 | |
The Protein:Fat:Glucose caloric ratio should approximate to 20:30:50% | C | 4 | |
At present, there is a tendency to increase the glucose:fat calorie ratio from 50:50 to 60:40 or even 70:30 of the non-protein calories, due to the problems encountered regarding hyperlipidemia and fatty liver, which is sometimes accompanied by cholestasis and in some patients may progress to non-alcoholic steatohepatitis | C | 5 | |
Optimal nitrogen sparing has been shown to be achieved when all components of the parenteral nutrition mix are administered simultaneously over 24 hours | A | 6 | |
Individualized nutrition is often unnecessary in patients without serious co-morbidity | C | 7 | |
The optimal parenteral nutrition regimen for critically ill surgical patients should probably include supplemental n-3 fatty acids. The evidence-base for such recommendations requires further input from prospective randomised trials | C | 8 | |
In well-nourished patients who recover oral or enteral nutrition by postoperative day 5 there is a little evidence that intravenous supplementation of vitamins and trace elements is required | C | 9 | |
After surgery, in those patients who are unable to be fed via the enteral route, and in whom total or near total parenteral nutrition is required, a full range of vitamins and trace elements should be supplemented on a daily basis | C | 9 | |
Weaning from parenteral nutrition is not necessary | A | 10 |
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ESPEN Guidelines on Parenteral Nutrition: Hepatology 总被引:2,自引:0,他引:2
Mathias Plauth Eduard Cabr Bernard Campillo Jens Kondrup Giulio Marchesini Tatjana Schütz Alan Shenkin Julia Wendon 《Clinical nutrition (Edinburgh, Scotland)》2009,28(4):436
Parenteral nutrition (PN) offers the possibility to increase or to ensure nutrient intake in patients, in whom sufficient nutrition by oral or enteral alone is insufficient or impossible. Complementary to the ESPEN guideline on enteral nutrition of liver disease (LD) patients the present guideline is intended to give evidence-based recommendations for the use of PN in LD. For this purpose three paradigm conditions of LD were chosen: alcoholic steatohepatitis (ASH), liver cirrhosis and acute liver failure. The guideline was developed by an interdisciplinary expert group in accordance with officially accepted standards and is based on all relevant publications since 1985. The guideline was presented on the ESPEN website and visitors' criticism and suggestions were welcome and included in the final revision. PN improves nutritional state and liver function in malnourished patients with ASH. PN is safe and improves mental state in patients with cirrhosis and severe HE. Perioperative (including liver transplantation) PN is safe and reduces the rate of complications. In acute liver failure PN is a safe second-line option to adequately feed patients in whom enteral nutrition is insufficient or impossible.
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Summary of statements: Alcoholic Steatohepatitis | |||
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Subject | Recommendations | Grade | Number |
General | Use simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition. | C | 1 |
Start PN immediately in moderately or severely malnourished ASH patients, who cannot be fed sufficiently either orally or enterally. | A | 1 | |
Give i.v. glucose (2–3 g kg−1 d−1) when patients have to abstain from food for more than 12 h. | C | 1 | |
Give PN when the fasting period lasts longer than 72 h. | C | 1 | |
Energy | Provide energy to cover 1.3 × REE | C | 2 |
Give glucose to cover 50–60 % of non-protein energy requirements. | C | 3 | |
Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions. | C | 3 | |
Amino acids | Provide amino acids at 1.2–1.5 g kg−1 d−1. | C | 3 |
Micronutrients | Give water soluble vitamins and trace elements daily from the first day of PN. | C | 3 |
Administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy. | C | 3 | |
Monitoring | Employ repeat blood sugar determinations in order to detect hypoglycemia and to avoid PN related hyperglycemia. | C | 6 |
Monitor phosphate, potassium and magnesium levels when refeeding malnourished patients. | C | 3 | |
Summary of statements: Liver Cirrhosis | |||
Subject | Recommendations | Grade | Number |
General | Use simple bedside methods such as the Subjective Global Assessment (SGA) or anthropometry to identify patients at risk of undernutrition. | C | 4 |
Start PN immediately in moderately or severely malnourished cirrhotic patients, who cannot be fed sufficiently either orally or enterally. | A | 4 | |
Give i.v. glucose (2–3 g kg−1 d−1) when patients have to abstain from food for more than 12 h. | C | 4 | |
Give PN when the fasting period lasts longer than 72 h. | C | 4 | |
Consider PN in patients with unprotected airways and encephalopathy when cough and swallow reflexes are compromised. | C | 4 | |
Use early postoperative PN if patients cannot be nourished sufficiently by either oral or enteral route. | A | 4 | |
After liver transplantation, use early postoperative nutrition; PN is second choice to EN. | C | 4 | |
Energy | Provide energy to cover 1.3 x REE | C | 5 |
Give glucose to cover 50 % - 60 % of non-protein energy requirements. | C | 6 | |
Reduce glucose infusion rate to 2–3 g kg−1 d−1 in case of hyperglycemia and use consider the use of i.v. insulin. | C | 6 | |
Use lipid emulsions with a content of n-6 unsaturated fatty acids lower than in traditional pure soybean oil emulsions. | C | 6 | |
Amino acids | Provide amino acids at 1.2–1.5 g kg−1 d−1. | C | 7 |
In encephalopathy III° or IV°, consider the use of solutions rich in BCAA and low in AAA, methionine and tryptophane. | A | 7 | |
Micronutrients | Give water soluble vitamins and trace elements daily from the first day of PN. | C | 8 |
In alcoholic liver disease, administer vitamin B1 prior to starting glucose infusion to reduce the risk of Wernicke's encephalopathy. | C | 3, 8 | |
Monitoring | Employ repeat blood sugar determinations in order to avoid PN related hyperglycemia. | A | 6 |
Monitor phosphate, potassium and magnesium levels when refeeding malnourished patients. | C | 8 | |
Summary of statements: Acute Liver Failure | |||
Subject | Recommendations | Grade | Number |
General | Commence artificial nutrition when patient is unlikely to resume normal oral nutrition within the next 5–7 days. | C | 9 |
Use PN when patients cannot be fed adequately by EN. | C | 9 | |
Energy | Provide energy to cover 1.3 × REE. | C | 10 |
Consider using indirect calorimetry to measure individual energy expenditure. | C | 10 | |
Give i.v. glucose (2–3 g kg−1 d−1) for prophylaxis or treatment of hypoglycaemia. | C | 11 | |
In case of hyperglycaemia, reduce glucose infusion rate to 2–3 g kg−1 d−1 and consider the use of i.v. insulin. | C | 11, 6 | |
Consider using lipid (0.8 – 1.2 g kg−1 d−1) together with glucose to cover energy needs in the presence of insulin resistance. | C | 11 | |
Amino acids | In acute or subacute liver failure, provide amino acids at 0.8–1.2 g kg−1 d−1. | C | 11 |
Monitoring | Employ repeat blood sugar determinations in order to detect hypoglycaemia and to avoid PN related hyperglycaemia. | C | 11 |
Employ repeat blood ammonia determinations in order to adjust amino acid provision. | C | 11 |
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Andr Van Gossum Eduard Cabre Xavier Hbuterne Palle Jeppesen Zeljko Krznaric Bernard Messing Jeremy Powell-Tuck Michael Staun Jeremy Nightingale 《Clinical nutrition (Edinburgh, Scotland)》2009,28(4):415
Undernutrition as well as specific nutrient deficiencies has been described in patients with Crohn's disease (CD), ulcerative colitis (UC) and short bowel syndrome. In the latter, water and electrolytes disturbances may be a major problem.The present guidelines provide evidence-based recommendations for the indications, application and type of parenteral formula to be used in acute and chronic phases of illness.Parenteral nutrition is not recommended as a primary treatment in CD and UC. The use of parenteral nutrition is however reliable when oral/enteral feeding is not possible.There is a lack of data supporting specific nutrients in these conditions.Parenteral nutrition is mandatory in case of intestinal failure, at least in the acute period.In patients with short bowel, specific attention should be paid to water and electrolyte supplementation. Currently, the use of growth hormone, glutamine and GLP-2 cannot be recommended in patients with short bowel.
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Summary of statements: Parenteral nutrition in Crohn's disease | |||
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Subject | Recommendations | Grade | Number |
Indication | PN is indicated for patients who are malnourished or at risk of becoming malnourished and who have an inadequate or unsafe oral intake, a non (or poorly) functioning or perforated gut, or in whom the gut is inaccessible. Specific reasons in patients with CD include an obstructed gut, a short bowel, often with a high intestinal output or an enterocutaneous fistula. | B | 4.1 |
Active disease | Parenteral nutrition (PN) should not be used as a primary treatment of inflammatory luminal CD. | A | 3.5 |
Bowel rest has not been proven to be more efficacious than nutrition per se. | |||
Maintenance of remission | In case of persistent intestinal inflammation there is rarely a place for long-term PN. | B | 3.7 |
The most common indication for long-term PN is the presence of a short bowel. | |||
Perioperative | Use of PN in the perioperative period in CD patients is similar to that of other surgical procedures. | B | 3.6 |
Application | When indicated, PN improves nutritional status and reduces the consequences of undernutrition, providing there is not continuing intra-abdominal sepsis | B | 1 |
Specific deficits (trace elements, vitamins) should be corrected by appropriate supplementation. | B | 1 | |
The use of PN in patients with CD should follow general recommendations for parenteral nutrition. | B | 1 | |
Route | Parenteral nutrition is usually combined with oral/enteral food unless there is continuing intra-abdominal sepsis or perforation. Central and peripheral routes may be selected according to the expected duration of PN | C | 3.2 |
Type of formula | Although there are encouraging experimental data, the present clinical studies are insufficient to permit the recommendation of glutamine, n-3 fatty acids or other pharmaconutrients in CD. | B | 4.3 |
Undernutrition | Parenteral nutrition may improve the quality of life in undernourished CD patients. | C | 3.4 |
Summary of statements: PN in ulcerative colitis | |||
Subject | Recommendations | Grade | Number |
Indication | Parenteral nutrition should only be used in patients with UC who are malnourished or at risk of becoming malnourished before or after surgery if they cannot tolerate food or an enteral feed | B | 9 |
Active disease | There is no place for PN in acute inflammatory UC as means of enabling bowel rest. | B | 10 |
Maintenance of remission | Parenteral nutrition is not recommended. | B | 11 |
Application | Treat specific deficiencies when oral route is not possible. | C | 5 |
Type of formula | The value of specific substrates (n-3 fatty acids, glutamine) is not proven. | B | 10.2 |
Summary of statements: Short bowel syndrome (intestinal failure) | |||
Subject | Recommendations | Grade | Number |
Indication | Maintenance and/or improvement of nutritional status, correction of water and electrolyte balance, improvement in quality of life. | B | 15 |
Route | |||
Post-op period | Predictions on the route of nutritional support needed can be made from knowledge of the remaining length of small bowel and the presence or absence of the colon. PN is likely to be needed if the remaining small bowel length is very short (e.g., less than 100 cm with a jejunostomy and less than 50 cm with a remaining colon in continuity). With longer lengths parenteral nutrition, water and electrolytes may be needed until oral/enteral intake is adequate to maintain nutrition, water and electrolyte status. | B | 17.1 |
Adaptation phase | Patients with a jejunostomy have little change in their nutritional/fluid requirements with time. Patients with a colon in continuity with the small bowel have an improvement in absorption over 1–3 years and parenteral nutrition can often be reduced or stopped. | B | 17.2 |
Dietary counseling is important for those with a retained colon and may facilitate intestinal adaptation. In patients with a jejunostomy and a high output stoma advice on oral fluid intake and drug treatments are vital. | |||
Maintenance/Stabilization | Parenteral nutrition, water and electrolytes (especially sodium and magnesium should be continued when oral/enteral intake is insufficient to maintain a normal body weight/hydration or when the intestinal/stool output is so great as to severely reduce the patient's quality of life. Assuming strict compliance with dietary/water and electrolyte advice, after 2 years, dependency on PN is likely to be long-term. | B | 17.3 |
Type of formula | No specific substrate composition of PN is required per se. | B | 16 |
Specific attention should be paid to electrolyte supplementation (especially sodium and magnesium). | B | 16, 17 | |
Currently, the use of growth hormone, glutamine or GLP-2 cannot be recommended. | B | 18 |
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L. Sobotka S.M. Schneider Y.N. Berner T. Cederholm Z. Krznaric A. Shenkin Z. Stanga G. Toigo M. Vandewoude D. Volkert 《Clinical nutrition (Edinburgh, Scotland)》2009,28(4):461
Older subjects are at increased risk of partial or complete loss of independence due to acute and/or chronic disease and often of concomitant protein caloric malnutrition. Nutritional care and support should be an indispensable part of their management. Enteral nutrition is always the first choice for nutrition support. However, when patients cannot meet their nutritional requirements adequately via the enteral route, parenteral nutrition (PN) is indicated.PN is a safe and effective therapeutic procedure and age per se is not a reason to exclude patients from this treatment. The use of PN should always be balanced against a realistic chance of improvement in the general condition of the patient. Lower glucose tolerance, electrolyte and micronutrient deficiencies and lower fluid tolerance should be assumed in older patients treated by PN. Parenteral nutrition can be administered either via peripheral or central veins. Subcutaneous administration is also a possible solution for basic hydration of moderately dehydrated subjects. In the terminal, demented or dying patient the use of PN or hydration should only be given in accordance with other palliative treatments.
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Summary of statements: Geriatrics | |||
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Subject | Recommendations | Grade | Number |
Indications | Age per se is not a reason to exclude patients from PN. | C [IV] | 1.1. |
PN is indicated and may allow adequate nutrition in patients who cannot meet their nutritional requirements via the enteral route. | C [IV] | 1.1. | |
PN support should be instituted in the older person facing a period of starvation of more than 3 days or if intake is likely to be insufficient for more than 7–10 days, and when oral or enteral nutrition is impossible. | C [IV] | 1.1. | |
Pharmacological sedation or physical restraining to make PN possible is not justified. | C [IV] | 1.1. | |
PN is a useful and effective method of nutritional support in older persons but compared to EN and oral nutritional supplements are much less often justified. | B [III] | 1.2. | |
Metabolic/physiological features in older subjects | Insulin resistance and hyperglycaemia together with impairment of cardiac and renal function are the most relevant features. They may warrant the use of formulae with higher lipid content. | C [IV] | 2 |
Deficiencies in vitamins, trace elements and minerals should be suspected in older subjects. | B [IIb] | 2 | |
The effect of nutritional support on restoration of depleted body cell mass is lower in elderly patients than in younger subjects. The oxidation capacity for lipid emulsions is not negatively influenced by age. | B [IIa] | 2 | |
Peripheral PN | Both central and peripheral nutrition can be used in geriatric patients. | C [IV] | 3 |
Osmolarity of peripheral parenteral nutrition should not be higher than 850 mOsmol/l. | B [III] | 3 | |
Subcutaneous fluid administration | The subcutaneous route is possible for fluid administration in order to correct mild to moderate dehydration but not to meet other nutrient requirements. | A [Ia] | 4 |
PN and nutritional status | PN can improve nutritional status in older as well as in younger adults. However, active physical rehabilitation is essential for muscle gain. | B [IIb] | 5 |
Functional status | PN can support improvement of functional status, but the margin of improvement is lower than in younger patients. | C [IV] | 6 |
Morbidity and mortality | PN can reduce mortality and morbidity in older as well as in middle-aged subjects. | C [IV] | 7 |
Length of hospital stay | No studies have assessed length of hospital stay in older patients on PN. | 8 | |
Quality of life | Long-term parenteral nutrition does not influence quality of life of older patients more negatively than it does in younger subjects. | C [IV] | 9 |
Specific complications | There are no specific complications of PN in geriatric patients compared to other ages, but complications tend to be more frequent due to associated comorbidities. | C [IV] | 10 |
Specific situations | Indications for PN are similar in younger and older adults in the hospital and at home. | B [III] | 11 |
Ethical problems | PN or parenteral hydration should be considered as medical treatments rather than as basic care. Therefore their use should be balanced against a realistic chance of improvement in the general condition. | C [IV] | 12 |
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S.D. Anker A. Laviano G. Filippatos M. John A. Paccagnella P. Ponikowski A.M.W.J. Schols 《Clinical nutrition (Edinburgh, Scotland)》2009,28(4):455-460
Nutritional support is becoming a mainstay of the comprehensive therapeutic approach to patients with chronic diseases. Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) are frequently associated with the progressive development of malnutrition, due to reduced energy intake, increased energy expenditure and impaired anabolism. Malnutrition and eventually cachexia have been shown to have a negative influence on the clinical course of CHF and COPD, and to impinge on patients' quality of life. Nutritional support in these patients should be therefore considered, particularly to prevent progressive weight loss, since restoration of lean and fat body mass may not be achievable. In CHF and COPD patients, the gastrointestinal tract is normally accessible and functioning. Although recent reports suggest that heart failure is associated with modifications of intestinal morphology, permeability and absorption, the clinical relevance of these are still not clear. Oral supplementation and enteral nutrition should represent the first choices when cardiopulmonary patients need nutritional support, particularly given the potential complications and economic burden of parenteral nutrition. This appropriately preferential enteral approach partly explains the lack of robust clinical trials of the role of parenteral nutrition in CHF and COPD patients. Based on the available evidence collected via PubMed, Medline, and SCOPUS searches, it is recommended that parenteral nutrition is reserved for those patients in whom malabsorption has been documented and in those in whom enteral nutrition has failed.
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Summary of statements: Parenteral Nutrition in Cardiology | |||
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Subject | Recommendations | Grade | Number |
Background | The prevalence of cardiac cachexia, defined from weight loss of at least 6% in 6 months, has been estimated at about 12–15% in patients in New York Heart Association (NYHA) classes II–IV. The incidence of weight loss >6% in CHF patients with NYHA class III/IV is approximately 10% per year. CHF affects nutritional state, energy and substrate metabolism. | B | 1.1 |
The mortality in CHF patients with cardiac cachexia is 2–3 times higher than in non-cachectic CHF patients. | B | 1.2 | |
Although there is limited evidence that gut function is impaired in CHF, decreased cardiac function can reduce bowel perfusion and lead to bowel wall oedema, resulting in malabsorption. | B | 1.3 | |
Indications | Although there is no evidence available from well-designed studies, PN is recommended to stop or reverse weight loss in patients with evidence of malabsorption, on the basis that it improves outcome in other similar conditions and there is a plausible physiological argument for it. | C | 1.4 |
Currently there is no indication for PN in the prophylaxis of cardiac cachexia. Further studies are needed to assess the impact of the parenteral administration of specific substrates on cardiac function. | C | 1.5 | |
Contra-indications | There are no specific contraindications to PN in CHF patients. However, considering that cardiac function is decreased and water retention is frequently found in CHF patients, it is recommended that PN should be avoided, other than in patients with evidence of malabsorption in whom enteral nutrition has been shown, or is strongly expected, to be ineffective. | B | 1.6 |
Implementation | When feeding CHF patients, either enterally or parenterally, fluid overload must be avoided. | C | 1.6 |
Summary of statements: Parenteral Nutrition in Respiratory Medicine | |||
Subject | Recommendations | Grade | Number |
Background | Between 25% and 40% of patients with advanced COPD are malnourished. | B | 2.1 |
Being underweight and having low fat-free mass are independently associated with a poor prognosis in patients with chronic respiratory insufficiency, especially in COPD. | B | 2.2 | |
Indications | There is no evidence showing that gut function is impaired in COPD patients. Therefore, considering that enteral nutrition is less expensive and associated with fewer and less severe complications than parenteral nutrition, enteral nutrition should represent the first approach to patients with COPD in need of nutritional support. | B | 2.3 |
There is limited evidence that COPD patients intolerant of EN profit from PN. Small studies do however suggest that, in combination with exercise and anabolic pharmacotherapy, PN has the potential to improve nutritional status and function. | C | 2.4 | |
Effect of PN | Loss of body weight is correlated with increased morbidity and mortality. However, due to the lack of studies of its effects, it is not possible to be sure if prognosis is influenced by the provision of PN. | B | 2.5 |
Regimen selection | In patients with stable COPD, glucose-based PN causes an increase in the respiratory CO2 load. PN composition should accordingly be orientated towards lipids as the energy source. There is not sufficient evidence to recommend specific lipid substrates. | B | 2.6 |
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Kirsten Simmons Manoj Gambhir Juan Leon Ben Lopman 《Emerging infectious diseases》2013,19(8):1260-1267
The duration of immunity to norovirus (NoV) gastroenteritis has been believed to be from 6 months to 2 years. However, several observations are inconsistent with this short period. To gain better estimates of the duration of immunity to NoV, we developed a mathematical model of community NoV transmission. The model was parameterized from the literature and also fit to age-specific incidence data from England and Wales by using maximum likelihood. We developed several scenarios to determine the effect of unknowns regarding transmission and immunity on estimates of the duration of immunity. In the various models, duration of immunity to NoV gastroenteritis was estimated at 4.1 (95% CI 3.2–5.1) to 8.7 (95% CI 6.8–11.3) years. Moreover, we calculated that children (<5 years) are much more infectious than older children and adults. If a vaccine can achieve protection for duration of natural immunity indicated by our results, its potential health and economic benefits could be substantial.Key words: Norovirus, modeling, mathematical model, immunity, incidence, vaccination, vaccine development, viruses, enteric infections, acute gastroenteritisNoroviruses (NoVs) are the most common cause of acute gastroenteritis (AGE) in industrialized countries. In the United States, NoV causes an estimated 21 million cases of AGE (1), 1.7 million outpatient visits (2), 400,000 emergency care visits, 70,000 hospitalizations (3), and 800 deaths annually across all age groups (4). Although the highest rates of disease are in young children, infection and disease occur throughout life (5), despite an antibody seroprevalence >50%, and infection rates approach 100% in older adults (6,7).Frequently cited estimates of the duration of immunity to NoV are based on human challenge studies conducted in the 1970s. In the first, Parrino et al. challenged volunteers with Norwalk virus (the prototype NoV strain) inoculum multiple times. Results suggested that the immunity to Norwalk AGE lasts from ≈2 months to 2 years (8). A subsequent study with a shorter challenge interval suggested that immunity to Norwalk virus lasts for at least 6 months (9). In addition, the collection of volunteer studies together demonstrate that antibodies against NoV may not confer protection and that protection from infection (serologic response or viral shedding) is harder to achieve than protection from disease (defined as AGE symptoms) (10–14). That said, most recent studies have reported some protection from illness and infection in association with antibodies that block binding of virus-like particles to histo-blood group antigen (HBGA) (13,14). Other studies have also associated genetic resistance to NoV infections with mutations in the 1,2-fucosyltransferase (FUT2) gene (or “secretor” gene) (15). Persons with a nonsecretor gene (FUT2−/−) represent as much as 20% of the European population. Challenge studies have also shown that recently infected volunteers are susceptible to heterologous strains sooner than to homotypic challenge, indicating limited cross-protection (11).One of many concerns with all classic challenge studies is that the virus dose given to volunteers was several thousand–fold greater than the small amount of virus capable of causing human illness (estimated as 18–1,000 virus particles) (16). Thus, immunity to a lower challenge dose, similar to what might be encountered in the community, might be more robust and broadly protective than the protection against artificial doses encountered in these volunteer studies. Indeed, Teunis et al. have clearly demonstrated a dose-response relationship whereby persons challenged with a higher NoV dose have substantially greater illness risk (16).Furthermore, in contrast with results of early challenge studies, several observations can be made that, when taken together, are inconsistent with a duration of immunity on the scale of months. First, the incidence of NoV in the general population has been estimated in several countries as ≈5% per year, with substantially higher rates in children (5). Second, Norwalk virus (GI.1) volunteer studies conducted over 3 decades, indicate that approximately one third of genetically susceptible persons (i.e., secretor-positive persons with a functional FUT2 gene) are immune (18,20,22). The point prevalence of immunity in the population (i.e., population immunity) can be approximated by the incidence of infection (or exposure) multiplied by the duration of immunity. If duration of immunity is truly <1 year and incidence is 5%, <5% of the population should have acquired immunity at any given time. However, challenge studies show population immunity levels on the order of 30%–45%, suggesting that our understanding of the duration of immunity is incomplete (8,11,17,18). HBGA–mediated lack of susceptibility may play a key role, but given the high seroprevalence of NoV antibodies and broad diversity of human HBGAs and NoV, HBGA–mediated lack of susceptibility cannot solely explain the discrepancy between estimates of duration of immunity and observed NoV incidence. Moreover, population immunity levels may be driven through the acquisition of immunity of fully susceptible persons or through boosting of immunity among those previously exposed.
Open in a separate window*AGE, acute gastroenteritis; SM, Snow Mountain virus; NV, Norwalk virus; MC, Montgomery County virus; HI, Hawaii virus; GII.4, genogroup 2 type 4.
†Only includes initial challenge, not subsequent re-challenge.
‡Only includes placebo or control group.In this study, we aimed to gain better estimates of the duration of immunity to NoV by developing a community-based transmission model that represents the transmission process and natural history of NoV, including the waning of immunity. The model distinguishes between persons susceptible to disease and those susceptible to infection but not disease. We fit the model to age-specific incidence data from a community cohort study. However, several factors related to NoV transmission remain unknown (e.g., the role asymptomatic persons who shed virus play in transmission). Therefore, we constructed and fit a series of 6 models to represent the variety of possible infection processes to gain a more robust estimate of the duration of immunity. This approach does not consider multiple strains or the emergence of new variants, so we are effectively estimating minimum duration of immunity in the absence of major strain changes. 相似文献
Table 1
Summary of literature review of Norwalk virus volunteer challenge studies*Study | All | Secretor positive | Secretor negative | Strain | |||||||
---|---|---|---|---|---|---|---|---|---|---|---|
No. challenged | No. (%) infected | No. (%) AGE | No. challenged | No. (%) infected | No. (%) AGE | No. challenged | No. (%) infected | ||||
Dolin 1971 (10) | 12 | 9 (75) | SM | ||||||||
Wyatt 1974 (11)† | 23 | 16 (70) | NV, MC, HI | ||||||||
Parrino 1977 (8)† | 12 | 6 (50) | NV | ||||||||
Johnson 1990 (17)† | 42 | 31 (74) | 25 (60) | NV | |||||||
Graham 1994 (12) | 50 | 41 (82) | 34 (68) | NV | |||||||
Lindesmith 2003 (18) | 77 | 34 (44) | 21 (27) | 55 | 35 (64) | 21 (38) | 21 | 0 | NV | ||
Lindesmith 2005 (19) | 15 | 9 (60) | 7 (47) | 12 | 8 (67) | 3 | 1 (33) | SM | |||
Atmar 2008 (20) | 21 | 16 (76) | 11 (52) | 21 | 16 (76) | 11 (52) | NV | ||||
Leon 2011 (21)‡ | 15 | 7 (47) | 5 (33) | 15 | 7 (47) | 5 (33) | NV | ||||
Atmar 2011 (14)‡ | 41 | 34 (83) | 29 (71) | 41 | 34 (83) | 29 (71) | NV | ||||
Seitz 2011 (22) | 13 | 10 (77) | 10 (77) | 13 | 10 (77) | 10 (77) | 1 (5.6) | NV | |||
Frenck 2012 (23) | 40 | 17 (42) | 12 (30) | 23 | 16 (70) | 12 (52.1) | 17 | GII.4 |
†Only includes initial challenge, not subsequent re-challenge.
‡Only includes placebo or control group.In this study, we aimed to gain better estimates of the duration of immunity to NoV by developing a community-based transmission model that represents the transmission process and natural history of NoV, including the waning of immunity. The model distinguishes between persons susceptible to disease and those susceptible to infection but not disease. We fit the model to age-specific incidence data from a community cohort study. However, several factors related to NoV transmission remain unknown (e.g., the role asymptomatic persons who shed virus play in transmission). Therefore, we constructed and fit a series of 6 models to represent the variety of possible infection processes to gain a more robust estimate of the duration of immunity. This approach does not consider multiple strains or the emergence of new variants, so we are effectively estimating minimum duration of immunity in the absence of major strain changes. 相似文献
10.
Adebobola T. Bashorun Anthony Ahumibe Saliman Olugbon Patrick Nguku Kabir Sabitu 《Online Journal of Public Health Informatics》2013,5(1)