创伤患者的营养支持指南【原文编译】
2012年版，目前尚未更新，网址：http://www.east.org/。由于内容太多，这里就不翻译啦，如有个别单词不认识的可借助翻译工具。
1. 目标
a. To define an approach to optimal nutritional support in the critically ill or injuredpatient.
b. To establish meaningful goals for implementing enteral nutrition.
c. To providean understanding of the various formulations for enteral nutrition and their use.
d. To establish the indications for total parenteral nutrition (TPN).
2. 定义
•肠内营养 (EN)—the use of the stomach, duodenum, or jejunum to provide thenutrition targets to optimize healing and normal physiologic function.
•全肠外营养 (TPN)—formulated nutritional substrate provided intravenously to optimize healing and normal physiologic function.
3. 指南
a. Consult Medical Nutrition Therapy on all ICU patients for nutritional assessment and cooperative guidance on nutritional support.
b. 患者不能自主进食时肠内营养应作为首选Enteral nutrition should be the first choice over total parenteral nutrition for the patients unable to consume food on their own. 因为Enteral nutrition maintains gut mucosal integrity and immuno-competence.
c. 肠内营养的绝对禁忌症:
1) High risk fornon-occlusive bowel necrosis: a) Active shock or ongoing resuscitation; b)Persistent mean arterial pressure (MAP) < 60mmHg
2) Generalized peritonitis
3) Intestinalobstruction
4) Surgicaldiscontinuity of bowel
5) Paralytic ileus
6) Intractablevomiting/diarrhea refractory to medical management
7) Mesentericischemia
8) Majorgastrointestinal bleed
9) Increasingrequirement for vasoactive support to maintain MAP > 60mmHg
10) High outputuncontrolled fistula
d. 肠内营养的相对禁忌症:
1) Bodytemperature < 96 F
2) Requirement forcontinuous neuromuscular blockage
3) Concern forabdominal compartment syndrome as evidenced by bladder pressuretrending higherand/or > 25mmHg
e. 肠内营养的适应症:
1) Any patient onthe trauma service who is anticipated to remain unable to take full oralintakeon their own.
2) Any patient whohas oral intake with supplementation that is inadequate to meetcurrent nutritionalneeds (i.e., < 50% of estimated required calories for >3 days.)
f. 肠外营养(TPN)的适应症:
1) Unable to meet> 50% caloric needs enterally by day 5 from time of injury and hasacontraindication to enteral nutrition.
2) Any of thecontraindications for enteral nutrition listed in 3.c above thatpersist andpatient without nutritional support for 3 days.
3) Massive smallbowel resection refractory to enteral feeds.
4) High outputfistula after failure of elemental diet.
g. Enteral accesswill be established ideally within 24 hours of admission to the Role 3MTF.
1) If thepatient will be taken to the operating room (OR) within 24-48 hours of arrivalfor a laparotomy procedure, a naso-jejunal feeding tube (NJFT) should beplaced while the patient is in the OR.
2) If the patientis not a candidate for operative placement, use whatever means availabletoplace a feeding tube. (i.e., placement of an endoscopicNJFT/fluouroscopicallyguided, magnet guided, etc.)
3) If unable to placeNJFT, consider use of orogastric (OG) or nasogastric (NG) tubeduring stay withintent to discontinue enteral feeds 6 hours prior to aeromedicalevacuation (AE)flight and selected procedures (e.g., surgery). Due to the intermittentnatureof gastric feedings and the need for frequent holdings for patientevacuationand/or procedures, it is emphasized that this is NOT the preferredmethod of feedingthese patients.
4. 配方选择
a.Immune modulating diet
(e.g., IMPACT with glutamine or equivalent) with soluble fiber—high protein, isotonic, polymeric feed supplemented withadditional glutamine. Use for:
1) Major trauma patients for the first 7 days ofnutrition support
2) Moderately malnourished patients (pre-albumin < 15gm/dl)undergoing majorelective procedures of the esophagus, stomach, pancreas,hepatobiliary tree orabdominal-perineal resection
3) Severely malnourishedpatients (pre-albumin < 10gm/dl) undergoing large bowelresection
4) Prolongedstarvation > 6 days
5) High output distal small bowel fistula
b.Immune modulating elemental formula
(Optimental)with small amount of solublefiber—moderate protein, isotonic feed supplementedwith Omega-3 fatty acids,probiotics and arginine. Elemental formulas are easilyabsorbed. Use for:
1) Proven intolerance to the first formula used
2) Persistent,severe diarrhea > 48hrs
3) Burn patients
4) Pancreatic or duodenal injury
5)Moderate distention > 24hrs
6) Short bowel syndrome
7) At discretion ofattending physician
c.Polymeric high protein, fiber free formula
(Osmolite1.2)—isotonicenteral feed withlong-chain proteins, carbohydrates and a normal fat content.Use for:1) Patients with a moderate protein need, normal digestive andabsorptive capacity ofthe GI tract.
d. Polymeric with mixed fiber formula
(Jevity1.0)—addedfiber content to promote moreformed stool. Use for:1) Stable, long termpatients and those requiring a bowel regimen (i.e., paraplegics.)
e. Other formulas
include:
1) Isosource1.5—high protein, high calorie, soluble fiber containing formula with 1.5kcal/mlto limit volume.
2)Nepro—therapeutic nutrition with mixed fiber for patients on dialysis needingfluidand electrolyte restrictions (may require protein supplementation.)
f.Additional fiber source: If additional fiber is needed forstool management, use the soluble variety (e.g.,Benefiber® or equivalent.)
5. 营养能量/蛋白需求
Nutritionalenergy/protein requirements are based on the patient’s current nutritionalstatusand severity/type of trauma suffered.Below are some basic guidelines:
a. 热卡
1) 25–35kcal/kg/day dry weight for high stress trauma/burn patients
2) 20–25kcal/kg/day dry weight for ventilated patients
3) 15–20kcal/kg/day adjusted weight for obese patients：
a) Obesity is defined as a Body Mass Index(BMI) > 30：
b) BMI (kg/m2) =(lbs. x 703)/(inches2)
b. 蛋白质
1) 1.0–1.5grams/kg/day
2) 1.5–2.0 grams/kg/day in major trauma/ burn / head injured/obese patients
c. 脂肪—30% of calories (may be less in burn patients 15–20%)
d. 游离水—1 ml/kcal
e. Please be careful in your evaluation of this patient population. Many are young, healthy, and very muscular. If they are muscular with a BMI >30, you should use their estimated actual weight pre-injury. Those with aBMI > 30 due to obesity should use the adjusted weight as stated above.Pick any formula you like as they are all 70–80% accurate compared to ametabolic cart study. These are not available until the patient reaches a CONUS facility and should be used as soon as possible to get the gold standardforcaloric and macronutrient requirements.
6. 肠内营养的启动与实施
a. Start enteraltube feed with full strength formula at 20 ml/hour.
b. Increase rateby 20 ml/hour every 6-8 hours to goal rate
c. For BURN andHEAD injured patients with no abdominal trauma or othercontraindications,advance 20 ml every 4 hours to goal rate
7. 谷氨酰胺 (when available)
Glutamineadministration, separate from enteral formula, should be started upon patient’sarrival in the ICU.
a. Glutasolve® isa powder supplement that provides 90 kcals and 15 grams of L-glutamineperpacket.
b. AdministerGlutasolve to all patients requiring vasoactive pressor support, mechanicalventilation,trauma resuscitation, TPN, CVVHD, or HD.
Note: Do notadminister for liver failure patients, those with acute renal failurewith Cr> 3.0 mg/dl who are not on dialysis, or patients with totalbilirubin > 10mg/dl
c. Doseglutamine:1) 0.5 grams/kg/day dry weight daily for 7 days after admission tothe ICUa) For patients < 81 kg, start with 1 packet twice a dayb) Forpatients > 80 kg, start with 1 packet three times a day2) Continuesupplementation when enteral nutrition is initiated unless using IMPACT©withglutamine. If this product is used, the supplemental glutamine shouldbediscontinued once goal rate is achieved.
d. Glutasolvemust be dissolved in 60–120 ml of WARM water and infused immediately viathe OGtube.
Note: If the dissolvedGlutasolve® sits for more than 15 minutes prior toadministration, it mustbe wasted and a new packet used. It may beadministered via the NJFT if nogastric tube and the NJFT is larger than8F. Be sure to flushtube with an additional 20 ml water afterwards tomaintain patency.
8. 耐受饮食患者的营养补充
Many traumaticallyinjured patients can tolerate a regular diet. For various reasons, however, patientsmay be subjected to frequent holding of oral intake for procedures, recoveryperiods after procedures, decreased appetite due to medications, etc.
a. Supplementationdrinks when patient is eating can help bridge some of the caloric deficitsand provide nutritional therapeutic benefits missed during thetime-limitedperiods of inadequate intake.
b. Recommendationsare for high-protein drinks (i.e., Ensure Plus®, Impact© AdvancedRecovery™,or equivalent) at 0.5–1.0 L per day (3–4 drinks) in addition to meals.
c. If thepatient is on less than a regular diet (e.g., clear or full liquid) considerthe use ofGlutasolve (15 gm glutamine/packet) 2–3 times a day, as this productis easily dissolved in other drinks and is best if consumed immediatelyafter mixing. Of note, glutamine is already included in the ImpactAdvanced Recovery™ supplement, if that particular product is used.
9. 肠内营养耐受性
处理：
a. Vomiting
1) If no OG tubein position, place one and initiate low wall suction.2) Check existing OG tubefunction and placement location.3) If OGT is in proper position and functional,decrease tube feed rate by 50% andnotify physician for further evaluation andwork up.4) Ensure patient is having normal bowel elimination.
b. Abdominal Distention
1) Mild—Obtain history if possible and physical exam; maintaincurrent tube feed rate.Continue to monitor.
2) Moderate—Perform history and physical exam.
a) Maintaincurrent tube feed rate and do not advance.
b) Obtain portableabdominal x-ray to assess for small bowel obstruction or ileus.
c) If distentionpersists >24hrs with no contraindication for continued tube feeds,switch toelemental formula.
d) If feedingwhile the patient is on low-dose vasopressors, any increase in distentionshouldprompt holding tube feeds.
3) Severe—Perform history and physical exam
a) Stop tube feedinfusion.
b) Monitor fluidstatus.
c) Considerworkup—CBC, lactate, ABG, Chem7, CT scan abdomen.
d) Check bladderpressure.
c. Diarrhea
1) Mild—1–2 times/24hrs or 200–400ml/24hrs：No change – continue tube feeds andadvance per protocol.
2) Moderate—3–4 times/24 hrs or 400–600ml/24hrs：
a) Maintain tubefeeds at current rate, do not advance rate.
b) Reviewmedication record for possible causes of new onset diarrhea.
c) Considersending stool for Clostridium difficile (C. diff.)
3) Severe— > 4 times/24hrs or > 600ml/24hrs
a) Decrease tube feedrate by 50%.
b) Reviewmedication record for possible causes of new onset diarrhea.
c) Send stoolspecimen for C. diff.
d) Obtainabdominal x-ray to evaluate feeding tube location.
e) Considerswitching to an elemental, non-fiber formula. This is highly recommendedif diarrhea persists for >48hrs after treatment. If C. diff positive,treatwith oral Flagyl. Only start anti-diarrheals after 48 hrs of antibiotictreatmentif diarrhea persists.
f) If C. diffnegative, give 2 mg loperamide after each loose stool, alternative is 15mgcodeine.
g) Monitor fluidand electrolyte status.
Note: May consideraddition of probiotics in patient without pancreatitis.
d. High OG output (> 1200 ml/24 hrs) with OGT to continuous suction andfeeding viaNJFT.
1) Stop tubefeeds.
2) Obtainabdominal x-ray to evaluate location of OGT and NJFT.
a) Verify OGT isin the stomach. If OGT is past pylorus, pull it back into stomachand resumetube feeds at previous rate.
b) Verify NJFT isin correct position. If NJFT is in the stomach take appropriateaction to movethe tube to the appropriate position. If NJFT is in the correctposition,decrease tube feeds by 50% and assess patient’s overall condition.
3) Check OGaspirate for glucose testing in lab.
a) If glucose >110, hold tube feeds for 12 hours and re-evaluate.
b) If glucosenegative, resume tube feeds at 50% previous rate.
e. Increased gastric residual volumes (GRV) with OG feeding.
1) If feedingthrough OGT, check gastric residuals every 4 hours.
2) Re-infusethe entire gastric aspirate or administer an equivalent volume of ½ NS.
3) If GRV > 300ml on two consecutive checks, notify physician.
4) StartErythromycin 250 mg IV or oral every 6 hours or Reglan 10 mg IV every 6hoursand continue every 4 hour residual checks.
5) Hold enteralfeeds only when ordered by physician.
10. 药物考虑
a. Inotropicagents (Dobutamine, Milrinone) – No change to feeding plan recommended.Advanceper feeding protocol.
b. Paralytics,vasoactive agents (i.e., vasopressin > 0.04 units/min, dopamine > 10mcg/kg/min,norepinepherine > 5 mcg/min, phenylepherine > 50mcg/min, anyepinephrine).
1) ContinueGlutasolve.
2) Elementalformula at 20 ml/hr – do not advance.
3) Consider TPNstarting day #5 from time of injury.
4) Hold tubefeeding if adding vasopressor, increasing dosages or MAPS < 60.
11. 一般考虑（空肠营养）
Generalconsiderations for patients receiving enteral nutrition into the jejunum:
1) Maintainhead of bed > 30 degrees at all times or in reverse Trendelenburg positionifspine not cleared.
2) Obtainportable abdominal X-ray within12 hours of CCATT or AE movement toconfirm feedingtube location is within jejunum.
3) Enteralnutrition administered into the jejunum (past the ligament of Treitz) doesNOTneed to be stopped prior to going to the operating room, diagnostictests,CCATT/AE transport, lying flat for procedures, etc.
4) Keep OGT onintermittent low wall suction while initiating and advancing tube feedsviaNJFT.
5) TPN is onlyused when enteral nutrition is not possible and patient meets therequirementslisted under 3.f above.
6) See attachedsheet for ordering TPN.
7) Ensurepatient has a clean, dedicated central intravenous line for administration of TPN.
12. 一般考虑（经胃营养）
Generalconsiderations for patients receiving gastric feeds:
a. Gastric feeds maybe necessary to initiate early enteral nutrition but are highlydiscouraged inthis trauma patient population during the period of rapid transport toCONUS.
b. If theclinical scenario warrants consideration of gastric feeding, it must bediscussedwith the attending trauma surgeon and coordinated among the entiremultidisciplinaryteam.
13. 实验室评估
a. Obtain apre-albumin and CRP every Monday for those with ICU stays greater than 7days.
b. Obtain liverfunction tests (LFTs) and lipid panels at baseline and every Monday for thoseon TPN.
14. 肠道清洁
Those patients athigh risk for acute constipation should be started on a bowel regimen. If a patientis receiving tube feeds and has less than 1 bowel movement (BM) every 2 days,they should be started on the bowel care protocol. A bowel careprotocol also may be started empirically with initiation of enteralnutrition in patients know to be at risk for constipation.
a. Inclusion criteriaincludes patients at high risk for acute constipation:1) opioids 2)immobility 3) altered diet and fluid intake 4) stress 5) historyof constipation
b. Relative exclusion criteria includes:1) rectal surgery 2) abdominal pain 3)allergy to medications 4) neutropenia (ANC < 1000/mm3) 5)thrombocytopenia (platelets < 30,000)
c. Absoluteexclusion criteria is suspected or confirmed bowel obstruction
d. If patienthas had one BM every 2 days, pt is at Stage One or under observation only
e. Stage One
if no BM for 48hours:
Patient assessmentand rectal exam
1)Impacted—manually dis-impact; give soap suds enema once OR Bisacodyl 10 mg suppositoryonce daily
2) Not impacted—Docusate 100 mgPO or NJFT q 8 hours and Senna 1 tab PO or 5ml via NJFT every am
3) If no BM orvery small amounts in 24 hours following initiation of Stage One,proceed toStage Two.
f. Stage Two
1) Add Bisacodyl10 mg supp once daily, hold if stooling and continue with Stage Oneregimen.
2) If no BM orvery small amounts within 24 hours, proceed to Stage Three.
3) If patientdevelops loose stools or diarrhea, return to Stage One.
g. StageThree
1) Add Milk ofMagnesia 30 ml PO every 6 hours or Miralax 17 grams PO/NJFT twice dailyfor renal disorders until BM, then stop. Return to Stage Two.
2) If no BM in 24hours or very small amounts, proceed to Stage Four.
3) If patientdevelops loose stools or diarrhea, return to Stage One.
h.Stage Four 1) Call and notifyMD. Obtain a KUB. Clarify continued therapy for bowel care.
15. 肠道管理系统 (Zassi OrEquivalent.)
For patients requiring the use of the BMS for wound care and/or stool management, please referto those separate guidelines for specific product recommendations.
16. 维生素与微量元素
Continue for 7days and then re-assess patient’s clinical and nutritional condition. Evaluate closely dosing in renal and liver failure patients.
a. Vitamin C1000 mg IV every 8 hours
b. Zinc sulfate220 mg tab PO once a day
c. Vitamin E1000-1200 IU PO/OGT/NJFT every 8 hours
d. Selenium 200mcg IV or PO/OGT every 24 hourse. Multivitamintab, elixir, or IV once a day
1) Prenatal vitamins are often an excellent choice for supplementation if iron isalsoneeded.
2) For those unable to swallow a large pill or for whom the iron causes GI upset,children’schewable vitamins (e.g., Flintstone’s™ Complete or equivalent) are well tolerated.
17. 鼻空肠营养管的维护
a. Due to thesize (8-12F) of the NJFTs, meticulous care is needed to prevent clogging of tubes.This is easily managed by flushing the tubes every 2 hours, and BEFORE and AFTERall medications given.
b. Clogging isdue to either lining of the NJFT with a build-up of tube feeds or inappropriate medicationsgiven down the tube.
c. The volumeof the tube is so small that no amount of pancreatic enzymes, bicarbonate, cola,etc. is effective to maintain patency for any extended period of time.Prevention of the buildup is essential to ensure a functioning tube.
d. Recommendationis for 20 ml water (may use pre-filled NS syringes if labs allow) to be flusheddown tube every two hours. An additional 20 ml BEFORE and AFTER all medicationsgiven. The volume may be increased as patient’s condition and fluid requirementsdictate.
18. 操作改进（PI）监测
a. Intent(Expected Outcomes).
b. All patientsundergoing laparotomy within 24-48 hours of admission to a Role 3 facility whomeet criteria for enteral feeding will have a NJFT placed at the time ofsurgery
c. Performance/Adherence Measures.1)All patients requiring laparotomy within 24-48 hours of admission to a Role 3facility who also met criteria for enteral feeding had the NJFT placed atthe time of surgery.
d. Data Source.2) Patient Record 3)Joint Theater Trauma Registry (JTTR)
e. System Reporting & Frequency.
The above constitutes the minimum criteria for PI monitoring of this CPG. System reporting will be performed annually; additional PI monitoring and system reporting maybeperformed as needed.
The system review and data analysis will be performed by the Joint Theater Trauma System (JTTS)Director, JTTS Program Manager, and the Joint Trauma System (JTS) Performance ImprovementBranch.
19. 责任.
It is the trauma team leader’s responsibility to ensure familiarity, appropriate compliance and PI monitoring at the local level with this CPG.