多发病(也称为共患病)定义为共同发生至少两种慢性病,住院患者尤其普遍。然而,临床指南主要解决单个疾病,很少考虑多发病。 2017年7月24日,欧洲肠外肠内营养学会(欧洲临床营养与代谢学会)在线发表瑞士阿劳州立医院、巴塞尔大学、伯尔尼大学医院、英国牛津大学、南安普敦大学医院、伯明翰伊丽莎白女王医院、伦敦大学国王学院盖伊和圣托马斯医院、西班牙莱昂大学附属医院、瑞典乌普萨拉大学、意大利罗马萨皮安扎大学、德国柏林大学夏里特医学院、希腊雅典莱科综合医院、葡萄牙里斯本大学、法国尼斯大学、德国斯图加特霍恩海姆大学起草的ESPEN指南:内科多发病患者营养支持,针对内科病房多发病住院患者的12个营养支持关键临床问题提供了22条推荐意见和4项声明。 该指南制定所用方法遵循ESPEN指南的标准操作规程,始于2015年1月在瑞士苏黎世召开的工作小组启动会,形成了12个关键临床问题,包括营养支持的不同方面:指征、喂养途径、能量和蛋白质的需求、微量营养素的需求、特定疾病营养素、时机、监测和干预流程,对3个不同数据库(Medline、EMBASE和Cochrane图书馆)及次要来源(如发表的指南)进行系统的文献检索,截至2016年4月。 结果共检索到4532篇摘要,对检索到的摘要进行筛选,以确定用于制定推荐意见的相关研究,从中分析了38项相关研究,产生一份指南草案,提出了22条推荐意见和4项声明,于2017年2月提交给专家,采用德尔菲法进行在线投票。第一轮在线投票结果显示68%的推荐意见和75%的声明获得高度共识(>90%同意),32%的推荐意见和25%的声明获得共识(>75%~90%同意)。2017年4月24日,在德国法兰克福召开的最后共识会议上,所有的推荐意见达成了超过89%的共识。 因此,虽然制定非特定疾病指南存在方法学困难,但是本指南对内科多发病住院患者营养支持许多重要方面的证据进行了回顾,并总结成实用的临床推荐意见。使用这些指南为内科多发病住院患者提供循证营养方案,可改善其结局(转归)。 ESPEN指南:内科多发病患者营养支持 指征 1、基于筛查和和/或评定的营养支持与不筛查和/或评定相比,能改善多发病住院患者的结局吗?
喂养途径 2、对于营养需求可经口满足的多发病住院患者,在有或无营养咨询下使用口服营养补充(ONS)与无ONS相比,能改善结局吗?
3、对于营养需求不能经口满足的患者,使用(完全或补充)肠内营养(EN)与肠外营养(PN)相比,能改善多发病住院患者的结局吗?
能量需求 4、用预测公式估计能量需求与基于体重的公式相比,能改善需要营养支持的多发病住院患者的结局吗?
蛋白质需求 5、蛋白质目标量高于1g/kg体重/d与较低的目标量相比,能改善需要营养支持的多发病住院患者的结局吗?
微量营养素需求 6、对于仅经口喂养的患者,微量营养素的补充(维生素和微量元素)与无补充相比,能改善多发病住院患者的结局吗?
特定疾病营养素 7、特定疾病的营养补充剂(如纤维素、ω-3脂肪酸、支链氨基酸、谷氨酰胺等)与标准配方相比,能改善多发病住院患者的结局?
时机 8、早期营养支持(如入院后不到48小时提供)与延迟营养支持相比,能改善多发病住院患者的结局吗?
9、出院后继续营养支持与仅住院期间进行营养支持相比,会影响多发病住院患者的结局吗?
监测 10、若可能,监测身体功能,与监测营养指标(如体重、能量和蛋白质摄入量)相比,能改善接受营养支持的多发病住院患者的其他结局吗?
11、满足超过75%的能量和蛋白质需求(作为遵循指标)与较低的比例相比,能改善接受营养支持的多发病住院患者的结局吗?
干预流程 12、营养支持的组织变化(如干预指导委员会、保证进餐时间的实施、实行不同的预算分配)与无变化相比,能改善多发病住院患者的结局吗?
非目标人群、干预、比较、结局的问题 a)基础疾病对营养支持的预期结果有影响吗?
b)为了对多发病患者的临床病程产生影响营养支持应给予多久?
c)多发病住院患者有多重用药和药物—营养素相互作用的风险吗?
翻译:肖慧娟(天津市第三中心医院) Clin Nutr. 2017 Jul 24. [Epub ahead of print] ESPEN guidelines on nutritional support for polymorbid internal medicine patients. Gomes F, Schuetz P, Bounoure L, Austin P, Ballesteros-Pomar M, Cederholm T, Fletcher J, Laviano A, Norman K, Poulia KA, Ravasco P, Schneider SM, Stanga Z, Weekes CE, Bischoff SC. Cantonal Hospital Aarau, Switzerland; University of Basel, Switzerland; Oxford and Southampton University Hospitals, United Kingdom; Complejo Asistencial Universitario de León, Spain; Uppsala University, Sweden; Queen Elizabeth Hospital, Birmingham, United Kingdom; Sapienza University of Rome, Italy; Charité University Medicine Berlin, Germany; Laiko General Hospital of Athens, Greece; University of Lisbon, Portugal; University of Nice Sophia-Antipolis, France; University Hospital and University of Bern, Switzerland; Guy's & St. Thomas' NHS Foundation Trust and King's College London, United Kingdom; University of Hohenheim, Stuttgart, Germany. BACKGROUND & AIMS: Polymorbidity (also known as multimorbidity) - defined as the co-occurrence of at least two chronic health conditions - is highly prevalent, particularly in the hospitalized population. Nonetheless, clinical guidelines largely address individual diseases and rarely account for polymorbidity. The aim of this project was to develop guidelines on nutritional support for polymorbid patients hospitalized in medical wards. METHODS: The methodology used for the development of the current project follows the standard operating procedures for ESPEN guidelines. It started with an initial meeting of the Working Group in January 2015, where twelve key clinical questions were developed that encompassed different aspects of nutritional support: indication, route of feeding, energy and protein requirements, micronutrient requirements, disease-specific nutrients, timing, monitoring and procedure of intervention. Systematic literature searches were conducted in three different databases (Medline, Embase and the Cochrane Library), as well as in secondary sources (e.g. published guidelines), until April 2016. Retrieved abstracts were screened to identify relevant studies that were used to develop recommendations, which were followed by submission to Delphi voting rounds. RESULTS: From a total of 4532 retrieved abstracts, 38 relevant studies were analyzed and used to generate a guideline draft that proposed 22 recommendations and four statements. The results of the first online voting showed a strong consensus (agreement of >90%) in 68% of recommendations and 75% of statements, and consensus (agreement of >75-90%) in 32% of recommendations and 25% of statements. At the final consensus conference, a consensus greater than 89% was reached for all of the recommendations. CONCLUSIONS: Despite the methodological difficulties in creating non-disease specific guidelines, the evidence behind several important aspects of nutritional support for polymorbid medical inpatients was reviewed and summarized into practical clinical recommendations. Use of these guidelines offer an evidence-based nutritional approach to the polymorbid medical inpatient and may improve their outcomes. KEYWORDS: Guidelines; Hospitalized patients; Multimorbidity; Nutritional support; Polymorbidity PMID: 28802519 DOI: 10.1016/j.clnu.2017.06.025 |
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