1、ESPEN Guidelines on Enteral Nutrition:Intensive care 程俊峰程俊峰 普外科普外科 Geriatrics Liver disease Surgery including organ transplantation Wasting in HIV and other chronic infectious diseases Adult renal failure Gastroenterology Pancreas Cardiology and pulmonology Non-surgical oncology Intensive care ESPEN
2、 Guidelines on EN:ESPEN Guidelines on PN:Geriatrics Hepatology surgery Cardiology and pneumology Adult renal failure Gastroenterology Pancreas home parenteral nutrition(HPN)in adult patients SummarySummary Enteral nutrition(EN)的定义及目的：的定义及目的：1、EN is the preferred way of feeding the critically ill pat
3、ient and counteracting for the catabolic state induced by severe diseases.2、Intended to give evidence-based recommendations for the ICU patient,focusing particularly on those who develop a severe inflammatory response,i.e.patients who have failure of at least one organ during their ICU stay.EN的的 时机及
4、要求：时机及要求：1、EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days.2、the first 24 h using a standard high-protein formula.the acute and initial phases 2025 kcal/kg/d（exogenous energy）.Recovery,2530 kcal/kg/d.3、Glutamine should be supplemented in pa
5、tients suffering from burns or trauma.Subject Recommendations Grade indication All patients who are not expected to be on a full oral diet within 3 days C Application There are no data support using early EN can improve their Prognosis，but the committee still recommend the early（24h）appropriate amou
6、nt of feeding,once the patient have a haemo-dynamically stable and a functioning gastrointestinal tract.C Exogenous energy supply:the acute and initial phase:25kcal/kg/d less favourable Recovery：25kcal/kg/d C severe under-nutrition：the EN energy supply should up to 25kcal/kg/d，if not reached，please
7、add PN C If the patient intolerance(such as high gastric residuals)to EN,metoclopramide（胃复安）or Erythromycin（红霉素）should be considered.C Route Use EN in patients who can be fed via the enteral route.C Via jejunal versus gastric feeding,there is no significant difference.C If the patients tolerate EN a
8、nd can reach the target energy value,PN should be avoid.A Via EN can not be fed sufficiently,PN Should supplement C Type of formula Whole protein formulae are superior to the peptide-based formulae C Immune-modulating formulae(formulae enriched with arginine(精氨酸),nucleotides（核苷酸）and w-3 fatty acids)
9、are superior to standard enteral formulae:In elective upper GI surgical patients;in patients with a mild sepsis(APACHE 15);in patients with severe sepsis,may be harmful and are not Recommended;in patients with trauma;in patients with ARDS(formulae containing o-3 fatty acids and antioxidants).A B B A
10、 B Due to insufficient data,no recommendation support the Immune-modulating formulae apply to the burned patients,but the trace elements(Cu,Se and Zn)should be supplemented in a higher than standard dose A the severe illness ICU patients,should not receive an immune-modulating formula enriched with
11、arginine,nucleotides and w-3 fatty acids if the EN700ml/d.B Glutamine should be added to standard enteral formula in burned patients and trauma patients A 1.1 EN1.1 EN-when?when?All patients（can not be on a full oral diet within 3 days）should receive EN（C）a.It is unethical to investigate the maximum
12、 time of ICU patient can survive without nutritional support.b.Due to increased substrate metabolism（基础代谢）,the critical illness is more likely to develop under-nutrition.c.Scandinavian showed that the mortality rate of patient treat with glucose only 250-300g/d over 14 days is 10 times higher on ade
13、quate TPN.d.so inadequate oral intake,the surgical patient is likely to develop within 812 days of post-operation.e.Most trials focusing the early EN or late EN after 46 days,have proved the positive effect of early EN,so we come to the title conclusion.1.2 EN1.2 EN-Is early EN superior to delayed E
14、N?There are no data support using early EN can improve their prognosis，but the committee still recommend the early(24h）appropriate amount of feeding(C).a.meta analysis and systematic review A meta analysis of 15 RCTs(surgery,trauma,head injury,burns or suffering from acute medical conditions),showed
15、 early EN can reduce the infectious complications and length of stay.systematic review of 19 studies can show early EN play a positive effect on the survival rate、length of treatment,the rate of septic.and other complications，the conclusion provide 1 level evidence for using the early EN.b.Individua
16、l studies:(recommendation level C)Moore and Jones Graham和coworkers Chiarelli et al Eyer et al Hasse et al Singh et al No general amount recommend to be adjust EN therapy according to course of disease.But exogenous energy supply of the acute and initial phase:25kcal/kg/d and recovery：25kcal/kg/d may be favourable(C)a.Prospective observational cohort study b.Ibrahim c.A recent trial 1.3 EN1.3 EN-how much?how much?1.4 which route?1.4 which route?Jejunal versus gastric feeding in critically illness