【时隔七年，重装上阵】美国肠外肠内营养学会和重症医学会联合更新《成人重症患者营养支持疗法提供与评定指南》
营养在医疗机构中起着显著的作用，尤其对于重症监护病房（ICU）危重状态的患者，营养不良可以产生致命的影响。
2016年1月15日，美国肠外肠内营养学会（ASPEN ）和重症医学会（SCCM）联合发表了2016年版《成人重症患者营养支持疗法提供与评定指南》，分别刊登于2016年2月第2期的《肠外肠内营养杂志》（JPEN）和《重症医学》（CCM）。
该指南面向医师、护士、营养师和药师，针对重症成人（18岁以上）患者，提供了最佳营养疗法的最新建议，协助医疗团队提供适当的营养疗法，可以减少并发症、缩短住院时间、降低疾病严重程度、改善患者结局。
2016年版指南基于2009年版的12个章节：
肠内营养的时机（Initiate EN）
肠外营养的时机（When to Use PN）
肠内营养的用法（Dosing of EN）
肠内营养的用量和耐受性监测（Monitoring Tolerance and Adequacy of EN）
肠内营养配方的合理选择（Selection of Appropriate Enteral Formulation）
辅助疗法（Adjunctive Therapy）
肠外营养的指征和疗效最大化（When Indicated, Maximize Efficacy of PN）
肺衰竭（Pulmonary Failure）
肾衰竭（Renal Failure）
肝衰竭（Hepatic Failure）
急性胰腺炎（Acute Pancreatitis）
生命终末期的营养疗法（Nutrition Therapy in End-of-Life Situations）
调整顺序、扩充并更新为18个章节：
营养评定（Nutrition Assessment）
肠内营养的时机（Initiate EN）
肠内营养的用法（Dosing of EN）
肠内营养的用量和耐受性监测（Monitoring Tolerance and Adequacy of EN）
肠内营养配方的合理选择（Selection of Appropriate Enteral Formulation）
辅助疗法（Adjunctive Therapy）
肠外营养的时机（When to Use PN）
肠外营养的指征和疗效最大化（When Indicated, Maximize Efficacy of PN）
肺衰竭（Pulmonary Failure）
肾衰竭（Renal Failure）
肝衰竭（Hepatic Failure）
急性胰腺炎（Acute Pancreatitis）
外科各论（Surgical Subsets）：包括创伤性脑损伤（Traumatic Brain Injury）、腹部开放疗法（Open Abdomen）、烧伤（Burns）等外科特殊情况
脓毒症（Sepsis）
外科大手术后（Postoperative Major Surgery）：外科ICU患者除外（SICU Admission Expected）
慢性重症患者（Chronically Critically Ill）
肥胖重症患者（Obesity in Critical Illness）
生命终末期的营养疗法（Nutrition Therapy in End-of-Life Situations）
该指南基于对文献、国际于国家指南、专家意见、临床实用性的分析，参考文献由2009年的307篇更新到2016年的480篇，JPEN版正文页数由2009年的40页增加到2016年的53页，附录更多达140页。
2016年版指南的主要推荐意见包括：
早期评估患者入住ICU时的营养风险（推荐NRS2002或NUTRIC评分），并计算能量和蛋白质需求量，以确定营养疗法的目标量；Assess patients on admission to the intensive care unit (ICU) for nutrition risk, and calculate both energy and protein requirements to determine goals of nutrition therapy.
重症发病并入住ICU后24～48小时内启动肠内营养，并增加入住ICU第1周的目标量；Initiate enteral nutrition (EN) within 24−48 hours following the onset of critical illness and admission to the ICU, and increase to goals over the first week of ICU stay.
循序渐进以减少误吸风险并提高胃饲耐受性（使用促动力药、连续输注、洗必泰漱口、抬高床头、适当调整胃肠道喂养量）；Take steps as needed to reduce risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed, and divert level of feeding in the gastrointestinal tract).
根据医疗机构具体情况制定肠内喂养方案，以促进肠内营养的实施；Implement enteral feeding protocols with institution-specific strategies to promote delivery of EN.
不要使用胃残留量作为常规诊疗监控接受EN的ICU患者；Do not use gastric residual volumes as part of routine care to monitor ICU patients receiving EN.
对于高风险或重度营养不良的患者，当肠内营养不可行或不足够时，早期启动肠外营养。Start parenteral nutrition early when EN is not feasible or sufficient in high-risk or poorly nourished patients.
2016年版指南在ASPEN《JPEN》官方网站（pen.sagepub.com）和CSPEN官方微博（weibo.com/cspen）提供全文免费下载，您也可直接点击本微信左下角“阅读全文”。
以下为2016年JPEN版指南首页：
JPEN J Parenter Enteral Nutr. 2016 Feb;40(2):159-211.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
McClave SA, Taylor BE, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C; Society of Critical Care Medicine; American Society for Parenteral and Enteral Nutrition.
Department of Medicine, University of Louisville, Louisville, Kentucky.
Nutrition Support Specialist, Barnes Jewish Hospital, St Louis, Missouri.
Chief Division of General Surgery, Oregon Health and Science University, Portland, Oregon.
Critical Care Dietitian, Portland VA Medical Center, Portland, Oregon.
Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital and Clinics, Madison, Wisconsin.
Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, Illinois.
Senior Nurse Scientist, Center for Nursing Science and Clinical Inquiry, Madigan Healthcare System, Tacoma, Washington.
Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, New York.
Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee.
Project Research Staff, Digestive Disease Institute, Gastroenterology and Pathobiology, Cleveland, Ohio.
Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, Indiana.
Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, Alabama.
Professor and Vice Chair, Division Chief of Critical Care Medicine, Director of Research John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, Oklahoma.
Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania.
KEYWORDS: Grading of Recommendations, Assessment, Development, and Evaluation criteria; critical care; enteral; evidence-based medicine; guidelines; intensive care unit; nutrition; parenteral
PMID: 26773077
DOI: 10.1177/0148607115621863
以下为2016年CCM版指南首页：
Crit Care Med. 2016 Feb;44(2):390-438.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).
Taylor BE, McClave SA, Martindale RG, Warren MM, Johnson DR, Braunschweig C, McCarthy MS, Davanos E, Rice TW, Cresci GA, Gervasio JM, Sacks GS, Roberts PR, Compher C; and the Society of Critical Care Medicine and the American Society of Parenteral and Enteral Nutrition.
Nutrition Support Specialist, Barnes Jewish Hospital, St. Louis, MO.
Department of Medicine, University of Louisville, Louisville, KY.
Chief Division of General Surgery, Oregon Health and Science University, Portland, OR.
Critical Care Dietitian, Portland VA Medical Center, Portland, OR.
Clinical Nurse Specialist: Wound, Skin, Ostomy, UW Health University of Wisconsin Hospital & Clinics, Madison, WI.
Professor, Department of Kinesiology and Nutrition and Division of Epidemiology and Biostatistics, University of Illinois at Chicago, Chicago, IL.
Senior Nurse Scientist, Center for Nursing Science & Clinical Inquiry, Madigan Healthcare System, Tacoma, WA.
Pharmacotherapy Specialist, Nutrition Support, The Brooklyn Hospital Center, Brooklyn, NY.
Assistant Professor of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine Vanderbilt University School of Medicine, Nashville, TN.
Project Research Staff, Digestive Disease Institute, Gastroenterology & Pathobiology, Cleveland, OH.
Chair and Professor of Pharmacy Practice, Butler University College of Pharmacy and Health Science, Indianapolis, IN.
Professor and Head, Department of Pharmacy Practice, Harrison School of Pharmacy, Auburn University, Auburn, AL.
Professor & Vice Chair, Division Chief of Critical Care Medicine, Director of Research, John A. Moffitt Endowed Chair, Department of Anesthesiology, Oklahoma City, OK.
Professor of Nutrition Science, University of Pennsylvania School of Nursing, Philadelphia, PA.
PMID: 26771786
DOI: 10.1097/CCM.0000000000001525