Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)成年危重病患者营养支持治疗的实施与评估指南：美国危重病医学会(SCCM)与美国肠外肠内营养学会(ASPEN)Taylor BE, McClave SA, Martindale RG, et al. Crit Care Med 2016; 44: 390-438翻译：清华大学长庚医院 周华 许媛F. ADJUNCTIVE THERAPY 辅助治疗Question: Should a fiber additive be used routinely in all hemodynamically stable ICU patients on standard enteral formulas? Should a soluble fiber supplement be provided as adjunctive therapy in the critically ill patient who develops diarrhea and is receiving a standard non-fiber-containing enteral formula?问题：是否血流动力学稳定的ICU患者均需在标准肠内营养配方基础上添加纤维素？合并腹泻的重症患者，是否应在标准配方基础上添加纤维素作为辅助治疗？F1. Based on expert consensus, we suggest that a fermentable soluble fiber (e.g., fructo-oligossaccharides [FOSs], inulin) additive be considered for routine use in all hemodynamically stable medical and surgical ICU patients placed on a standard enteral formulation. We suggest that 10–20 grams of a fermentable soluble fiber supplement be given in divided doses over 24 hours as adjunctive therapy if there is evidence of diarrhea. 根据专家共识，建议血流动力学稳定的内科与外科ICU患者，可考虑添加发酵性可溶性纤维（如低聚果糖[FOSs], 菊粉）。合并腹泻患者推荐添加10-20g可溶性纤维，于24小时内分次给予。 Question: Is there a role for probiotic administration in critically ill patients? Is there any harm in delivering probiotics to critically ill patients?问题：益生菌是否有益于重症患者？是否会对危重症患者造成伤害？F2. We suggest that, while the use of studied probiotics species and strains appear to be safe in general ICU patients, they should be used only for select medical and surgical patient populations for which RCTs have documented safety and outcome benefit. We cannot make a recommendation at this time for the routine use of probiotics across the general population of ICU patients. [Quality of Evidence: Low] 虽然研究所用的益生菌类别与菌种在综合ICU患者显示是安全的，但也仅限用于那些RCT研究证实安全且有益预后的内外科患者，目前尚不能推荐此范围以外ICU患者常规使用益生菌制剂。 [证据质量：低] Question: Does the provision of antioxidants and trace minerals affect outcome in critically ill adult patients?问题：补充抗氧化剂与微量元素对危重病患者的预后会有影响吗？F3. We suggest that a combination of antioxidant vitamins and trace minerals in doses reported to be safe in critically ill patients be provided to those patients who require specialized nutrition therapy [Quality of Evidence: Low] 对于需要特殊营养治疗的重症患者，我们建议依据报道的安全剂量补充抗氧化维生素与微量元素。 [证据质量：低] F4. We suggest that supplemental enteral glutamine NOT be added to an en regimen routinely in critically ill patients. [Quality of Evidence: Moderate] 我们建议肠内补充谷氨酰胺不应纳入危重症患者EN的常规处方中。 [证据质量：中]
G. WHEN TO USE PN 何时应用PNQuestion: When should PN be initiated in the adult critically ill patient at low nutrition risk?问题：低营养风险的成年危重病患者，何时应开始PN？G1. We suggest that, in the patient at low nutrition risk (for example, NRS-2002 ≤ 3 or NUTRIC score ≤ 5), exclusive PN be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible. [Quality of Evidence: Very Low] 我们建议，对于低营养风险（如：NRS-2002≤3或NUTRIC评分≤5）、不适宜早期肠内营养、且入ICU 7天仍不能保证经口摄食量的患者，7天后给予PN支持。 Question: When should PN begin in the critically ill patient at high nutrition risk?问题：高营养风险的危重病患者，何时开始PN？G2. Based on expert consensus, in the patient determined to be at high nutrition risk (for example, NRS-2002 ≥ 5 or NUTRIC score ≥ 6) or severely malnourished, when en is not feasible, we suggest initiating exclusive PN as soon as possible following ICU admission. 根据专家共识，确定存在高营养风险（如：NRS-2002≥5或NUTRIC评分 ≥6）或严重营养不良的患者，如果EN不可行，我们建议入ICU后尽早开始PN。 G3. We recommend that, in patients at either low or high nutrition risk, use of supplemental PN be considered after 7 to 10 days if unable to meet > 60% of energy and protein requirements by the enteral route alone. Initiating supplemental PN prior to this 7–10-day period in critically ill patients on some en does not improve outcomes and may be detrimental to the patient. [Quality of Evidence: Moderate] 无论低或高营养风险患者，接受肠内营养7-10天，如果经EN摄入能量与蛋白质量仍不足目标的60%，我们推荐应考虑给予补充型PN。在开始EN7天内给予补充型PN，不仅不能改善预后，甚至可能有害。 [证据质量：中]
H. WHEN INDICATED, MAXIMIZE EFFICACY OF PN 肠外营养支持最大获益的适应症Question: When PN is needed in the adult critically ill patient, what strategies can be adopted to improve efficacy?问题：成年危重病患者何时需要PN支持？提高有效性的策略是什么？H1. Based on expert consensus, we suggest the use of protocols and nutrition support teams to help incorporate strategies to maximize efficacy and reduce associated risk of PN. 根据专家共识，我们建议使用营养支持实施方案与营养支持小组，以促进营养支持策略的最大化获益并降低PN相关风险。 Question: In the appropriate candidate for PN (high risk or severely malnourished), should the dose be adjusted over the first week of hospitalization in the ICU?问题：对于具有PN适应症的患者（高风险或严重营养不良），住ICU第一周应如何调整营养供给量？H2. We suggest that hypocaloric PN dosing (≤ 20 kcal/kg/day or 80% of estimated energy needs) with adequate protein (≥ 1.2g protein/kg/day) be considered in appropriate patients (high risk or severely malnourished) requiring PN, initially over the first week of hospitalization in the ICU. [Quality of Evidence: Low] 对于高营养风险或严重营养不良、需要PN支持的患者，我们建议住ICU第一周内给予低热卡PN（≤20 kcal/kg/day 或能量需要目标的80%），以及充分的蛋白质补充（≥ 1.2 g/kg/day）。 [证据质量：低] Question: Should soy-based IV fat emulsions (IVFE) be provided in the first week of ICU stay? Is there an advantage to using alternative IVFE (i.e., medium-chain triglycerides [MCT], olive oil [OO], FO, mixture of oils) over traditional soybean oil (SO)-based lipid emulsions in critically ill adult patients?问题：成年危重症患者在收住ICU第一周内是否给予大豆油基础的静脉脂肪乳剂(IVFE)？给予新一代的静脉脂肪乳剂（含中/长链甘油三酯[MCT]，橄榄油[OO]，鱼油[FO]，混合油类），是否比传统大豆油基础的脂肪乳剂更有优势？H3a. We suggest withholding or limiting SO-based IVFE during the first week following initiation of PN in the critically ill patient to a maximum of 100 g/week (often divided into 2 doses/week) if there is concern for essential fatty acid deficiency. [Quality of Evidence: Very Low] 危重病患者开始PN的第一周，我们建议暂缓或限制大豆油基础的静脉脂肪乳剂输注，如果考虑必需脂肪酸缺乏，其最大补充剂量为100g／每周（常分2次补充）。 [证据质量：非常低] H3b. Alternative IVFE may provide outcome benefit over soy-based IVFE; however, we cannot make a recommendation at this time due to lack of availability of these products in the U.S. When these alternative IVFEs (SMOF, MCT, OO and FO) become available in the United States, based on expert opinion, we suggest that their use be considered in the critically ill patient who is an appropriate candidate for PN. 新一代的IVFE比大豆油基础的IVFE对预后具有更好影响；但是，鉴于美国这类产品的缺乏，故尚不能做出任何推荐意见。根据专家意见，一旦这类脂肪乳剂（SMOF, MCT, OO, FO）在美国上市，建议在有PN适应症的重症患者使用。 Question: Is there an advantage to using standardized commercially available PN (premixed PN) versus compounded PN admixtures?问题：标准商品化的PN（预混合的PN制剂）比配置的PN混合液更有优势吗？H4. Based on expert consensus, use of standardized commercially available PN versus compounded PN admixtures in the ICU patient has no advantage in terms of clinical outcomes. 根据专家共识，标准商品化的PN制剂（多腔袋）与配置PN液相比，未见任何影响ICU患者临床结局的优势。 Question: What is the desired target blood glucose range in adult ICU patients?问题：成年ICU患者预期的血糖控制目标是多少？H5. We recommend a target blood glucose range of 140– or 150–180 mg/dl for the general ICU population; ranges for specific patient populations (post-cardiovascular surgery, head trauma) may differ and are beyond the scope of this guideline. [Quality of Evidence: Moderate] 我们推荐综合ICU患者的血糖控制目标在：140–180 或 150–180 mg/dl；特殊患者（心血管术后，颅脑损伤）可能有超出指南的不同推荐。 [证据质量：中] Question: Should parenteral glutamine be used in the adult ICU patient?问题：成年ICU患者肠外支持是否应补充谷氨酰胺？H6. We recommend that parenteral glutamine supplementation NOT be used routinely in the critical care setting. [Quality of Evidence: Moderate] 我们推荐危重病患者肠外营养期间无需常规补充谷氨酰胺。 [证据质量：中] Question: In transition feeding, as an increasing volume of EN is tolerated by a patient already receiving PN, at what point should the PN be terminated?问题：接受PN支持的患者向EN过渡期间，如EN量逐渐增加，何时应终止PN？H7. Based on expert consensus, we suggest that, as tolerance to EN improves, the amount of PN energy should be reduced and finally discontinued when the patient is receiving > 60% of target energy requirements from EN. 根据专家共识，当EN耐受性提高，达到目标能量60%以上时，我们建议经PN途径供给的能量可逐渐减量至终止。 |
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