从欧洲肠外肠内营养学会外科营养指南更新探讨围术期营养支持

Discussion on perioperative nutrition support from the update of ESPEN surgical nutritional guidelines

外科疾病和手术创伤应激会引起机体分解代谢,导致炎症、蛋白质分解、氮丢失等;与营养不良相关的肌肉减少症、恶液质、肌肉脂肪浸润等均会导致不良临床结局。营养支持的首要步骤是营养风险筛查和评估,欧洲肠外肠内营养学会(ESPEN)相关指南推荐的营养风险筛查工具有营养风险筛查2002、微型营养评定简表和营养不良通用筛查工具等,评定工具有主观全面评定和全球(营养)领导人发起的营养不良诊断标准共识等。由于与临床结局的密切关系,瘦肉体的变化在营养评定中日益受到重视。患者术前存在营养不良,建议术前施行10~14 d的营养支持,方式首选肠内营养,尤其是口服肠内营养;术后营养支持亦首选肠内营养,如肠内营养不达标或不能进行肠内营养时,则应给予补充性肠外营养或全肠外营养。围术期药理营养素的应用仍有不同意见,相关指南共识推荐在大手术后、外科重症肠外营养酌情应用。笔者将结合ESPEN更新的外科指南和围术期营养支持推荐意见,深入阐述围术期营养管理策略。

Surgical diseases and traumatic stress can cause body catabolism,which result in inflammation,protein decomposition and nitrogen loss.In surgical patients,sarcope⁃nia,cachexia and muscle fat infiltration,which are related to nutrition deficiencies,lead to adverse clinical outcomes.The first step of nutrition support is nutrition risk screening and as⁃sessment.The nutrition risk screening tools recommended by rel⁃evant guidelines of European Society for Parenteral and Enteral Nutrition(ESPEN)include Nutrition Risk Screening 2002,short⁃form Mini Nutritional Assessment,Malnutrition Universal Screening Tool,etc.Evaluation tools include Subjective Global Assessment and Global Leadership Initiative on Malnutrition.Due to the close relationship with clinical outcomes,the change of lean body mass has received increasing attention in nutritional assessment.If the patient has malnutrition before surgery,it is recommended to perform 10-14 days of preoperative nutrition support.Enteral nutrition is the first choice,especially oral en⁃teral nutrition.Enteral nutrition is also preferred for postoperative nutrition support,however,supplementary parenteral nutrition or total parenteral nutrition should be performed if enteral nutri⁃tion is non⁃compliant or infeasible.There are still controversies on the application of pharmacological nutrients in the periopera⁃tive period,which are recommended for parenteral nutrition in critically ill patients after major surgery by relevant guidelines and consensus.Combined with the update of ESPEN surgical nu⁃tritional guidelines and perioperative nutrition support recom⁃mendations,the authors elaborate on perioperative nutritional management strategies.