腹部外科术后重症患者肠外营养治疗的时机与策略

Strategies of parenteral nutrition in critically ill patients after abdominal surgery

随着肠内营养治疗理念和实践经验的不断深入和强化,外科术后肠内营养的实施占据主导地位,肠外营养往往占于次要地位,常用于肠内喂养不足,或者无法进行肠内营养的患者。临床应避免将肠内营养的禁忌证或肠外营养的适应证扩大。相当一部分术后需要肠外营养治疗的患者存在复杂的并发症,且病程延长,往往需要重症监护治疗。由于重症患者的病理生理及代谢特点存在一定特殊性,需动态评估患者的能量及蛋白需求,并适时添加肠外营养。补充性肠外营养的启动时机应根据患者的营养风险个体化实施,高营养风险患者可能需更早实施。肠外营养时可考虑静脉补充谷氨酰胺,并注意脂肪乳剂的选择,新型脂肪乳剂可能对外科重症患者有一定益处。本文就腹部外科术后重症患者肠外营养治疗的对象、目标、时机与策略,及近年来相关进展与理念作一评述,以期对临床实践有一定裨益。

With the development of clinical and basic research,as well as practical experience of nutrition therapy,enteral nutrition occupies the dominant route of therapy after abdominal surgery compared with parenteral nutrition.Currently,parenteral nutrition is often used supplementarily for patients with insufficient enteral feeding,or totally for whom unable to carry out enteral nutrition.Cautions should be paid according to the indications and contraindications of parenteral nutrition,avoiding the misuse of parenteral nutrition.A considerable percent of postoperative patients who need parenteral nutrition have complex complications with prolonged courses of disease,thus often need intensive care treatment.Nutrition therapy including energy and protein needs should be individualized based on the pathophysiological and metabolic characteristics of critically ill patients.Timing of adding supplemental parenteral nutrition should be based on patient′s nutrition risk,early supplemental parenteral nutrition is indicated to those with high nutrition risk.Glutamine can be added to parenteral nutrition,while attention should also be paid to the choice of lipids.New lipids including structured lipids,omega⁃3 fatty acids,and lipid emulsion formulas of soybean oil,medium⁃chain triglycerides,olive oil,and fish oil(SMOF)might be beneficial to surgical critically ill patients.This article reviews the indications,targets of energy and proteins,time to initiation and formula of parenteral nutrition for critically ill patients after abdominal surgery,as well as the related progress and concepts in recent years,with the aim to provide new information for clinical practice.