再喂养综合征的临床防治进展

Progress in clinical prevention and treatment of refeeding syndrome

再喂养综合征(refeeding syndrome,RFS)是指,长期营养不良或禁食的患者,在积极营养治疗(经肠内、肠外或口服)初期,因机体体液和电解质细胞内外转移而引发的临床综合征。2020年美国肠外肠内营养学会(American Society for Parenteral and Enteral Nutrition,ASPEN)将RFS概述为再喂养后发生的一系列代谢和电解质变化,患者既可以表现为仅存在电解质紊乱而几乎没有临床症状的轻度RFS,也可以表现为发生循环、呼吸衰竭的重度RFS。RFS的临床表现多样且无特异性,易被临床医师忽视。RFS的发病率为0~80%,随人群及RFS定义差异而不同。RFS的诊断标准一直存在很大异质性,从单纯的低磷血症,到存在严重的低血清电解质水平,并伴有体液平衡失调和(或)器官功能障碍。RFS高危因素包括神经性厌食患者、精神障碍患者、酒精与毒品滥用者等。危重症患者发生RFS与高死亡率相关,其死亡率可达52.3%~83.3%。目前,在临床开展营养治疗前,主要基于2006年英国国家卫生及医疗优化研究院(National Institute for Health and Care Excellence,NICE)标准,筛查可能发生再喂养问题的高危患者,但其筛查效力有待提高。早期筛查RFS,及时识别高危患者,避免其出现严重电解质紊乱及临床症状恶化的危重状态,可降低患者的死亡风险。

Refeeding syndrome(RFS)refers to the clinical syndrome caused by intracellular and extracellular transfer of the body fluids and electrolytes in patients with long-term malnutrition or fasting during the initial stage of active nutritional therapy(enteral,parenteral,or oral).In 2020,the American Society for Parenteral and Enteral Nutrition(ASPEN)defines RFS as a range of metabolic and electrolyte alterations that occur after refeeding.RFS can present as mild RFS only with electrolyte disturbances and few clinical symptoms,or as severe RFS with circulatory and respiratory failure.The clinical manifestations of RFS are diverse and non-specific,which are easy to be ignored by clinicians.The incidence of RFS is 0-80%,which varies with the population and the definition of RFS.The diagnostic criteria for RFS have always been highly heterogeneous,ranging from simple hypophosphatemia to severe low serum electrolyte levels accompanied by fluid imbalance and/or organ dysfunction.The high-risk factors for RFS include patients with anorexia nervosa,patients with mental disorders,and alcohol or drug abusers.The occurrence of RFS in critically ill patients is associated with high mortality rates,ranging from 52.3%to 83.3%.At present,before nutritional treatment,the screening of patients with high risk to develop refeeding problem is mainly based on the National Institute for Health and Care Excellence(NICE)criteria in 2006,but its effectiveness needs to be improved.Therefore,it is necessary to screen and identify high-risk patients early to avoid severe electrolyte disturbance and deterioration of clinical symptoms,thus reduce the risk of death.