美国肠外肠内营养学会和重症医学会：儿科重症患者营养支持疗法提供与评定指南
2017年7月27日，美国肠外肠内营养学会《肠外肠内营养杂志》和重症医学会《儿科重症医学》正式发表哈佛医学院、波士顿儿童医院、科罗拉多儿童医院、宾夕法尼亚大学、费城儿童医院、贝勒医学院、德克萨斯儿童医院、辛辛那提儿童医院、新汉诺威地区医疗中心贝蒂卡梅伦妇女儿童医院、伊利诺伊大学芝加哥分校、威斯康星医学院起草的儿科重症患者营养支持疗法提供与评定指南。
本文是美国肠外肠内营养学会和重症医学会首次合作共同描述重症儿童营养疗法的最佳实践。本指南的目标人群是针对住PICU时间预计长于2～3天的内科、外科、心脏疾病的重症儿童（＞1月龄，＜18岁）。共检索到2032篇相关文献。PubMed/MEDLINE检索到960篇临床研究文献和925篇队列研究文献。EMBASE检索到临床研究1661文献。最终，临床研究共检索获得1107篇文献，而队列研究检索到925篇文献。经过仔细审核后，16个随机对照研究和37项队列研究似乎可回答本指南预先确认的八组问题中的一组。采用证据推荐分级的评定、制定与评价标准（GRADE），根据研究设计和实施质量评价对证据等级进行调整。该指南不适用于新生儿或成人患者。指南重申了营养评估的重要性，尤其是针对最易发生营养不良、因而有可能从及时干预中获益患者的检查。有必要重新关注能量需求的精确估计，并注意优化蛋白质的摄入。若可行，采用间接能量测定法，谨慎使用估计方程，建议加强监测非故意能量喂养不足和过量。最佳蛋白质摄入量及其与临床结局的关系是人们非常感兴趣的领域。营养供给的最佳途径和时机是争论激烈和研究较多的领域。肠内营养仍是营养供给的首选途径。已有多种优化重症疾病状态下肠内营养的策略。补充肠外营养的作用已被突出，延迟方案似乎有益。免疫营养目前不推荐。总之，儿科重症管理人群多种多样，有必要采取有细微差别的个体化营养支持方案以改善临床结局。
重症儿童营养支持临床指南推荐意见
Q1A、营养状态对重症儿童的临床结局有什么影响？
R1A、根据观察研究，营养不良包括肥胖，与不良临床结局有关，包括机械通气时间延长、医院获得性感染风险升高、住PICU和住院时间延长、死亡率增加。推荐PICU患者在入住48小时内进行详细的营养评定。
另外，由于患者在住院期间存在营养恶化风险，会带来不良临床结局，建议在住院期间至少每周评估一次营养状态。
证据质量：非常低
GRADE推荐强度：强
Q1B、筛查并确定PICU中有营养不良或营养状况恶化风险患者的最好做法是什么？
R1B、根据观察研究和专家共识，推荐收入PICU时测量体重和身高/身长，用年龄别体重指数（身长别体重＜2岁）或年龄别体重（若体重准确，不知道身高）Z评分筛查处于这些指标极值的患者。36月龄以下的儿童，应记录头围。
应开发针对PICU人群的有效筛查方法来识别有营养不良风险的患者。筛查方法可使有限的资源针对最有可能从早期营养评定和干预中获益的高危患者。
证据质量：非常低
GRADE推荐强度：强
Q2A、重症儿童的能量推荐需要量是多少？
R2A、根据观察队列研究，建议用间接热量测定法（IC）测得的能量消耗确定能量需求，指导每日处方达能量目标。
证据质量：低
GRADE推荐强度：弱
Q2B、在无IC时应如何确定能量需求？
R2B、如果用IC测得静息能量消耗（REE）不可行，建议可用斯科菲尔德公式或联合国粮食及农业组织/世界卫生组织/联合国大学公式“不加”应激因子来估算能量消耗。许多队列研究已证实，大多数已发表的预测公式不准确，会导致非故意过度喂养或喂养不足。HB公式和RDA，即膳食营养素参考摄入量，不应被用来确定重症儿童的能量需求。
证据质量：非常低
GRADE推荐强度：弱
Q2C、重症儿童的目标能量摄入量是多少？
R2C、根据观察队列研究，建议在PICU第一周结束时能量供给至少达到既定的每日能量需要量的2/3。重症疾病第一周累积能量不足可能与不良临床和营养结局有关。根据专家共识，建议关注个体化的能量需求，及时启动并达到目标能量和能量平衡，防止非故意累积能量不足或过量。
证据质量：低
GRADE推荐强度：弱
Q3A、重症儿童的最低蛋白质推荐需要量是多少？
R3A、根据来自随机对照研究和观察队列研究支持的证据，推荐最低蛋白质摄入量为1.5g/kg/d。随机对照研究显示超过这个限值的蛋白质摄入可防止累积的蛋白质负平衡。在重症婴幼儿中，达到蛋白质正平衡所需的最佳蛋白质摄入量可能远高于这个最低限值。蛋白质负平衡可能导致瘦体重的丢失，这与重症患者的不良结局有关。根据一项大型观察研究，较高的蛋白质摄入量可能与机械通气儿童60天死亡率降低有关。
证据质量：中等
GRADE推荐强度：强
Q3B、在PICU最佳蛋白质供给策略是什么？
R3B、根据随机研究的结果，建议在重症疾病早期蛋白质的供给达到目标量，促进正氮平衡。在观察研究中较高比例的蛋白质供给目标量与积极的临床结局相关。
证据质量：中等
GRADE推荐强度：弱
Q3C、重症儿童蛋白质供给目标量应如何确定？
R3C、使临床结局改善的最佳蛋白质剂量还不清楚。不推荐用RDA值来指导重症儿童处方中蛋白质的供给。这些值是为健康儿童制定的，往往低估了重症儿童的蛋白质需求。
证据质量：中等
GRADE推荐强度：强
Q4A、重症儿童肠内营养可行吗？
R4A、根据观察研究，推荐肠内营养作为重症儿童营养供给的首选方式。观察研究支持用肠内营养，它可安全地为内科和外科疾病诊断明确以及接受血管活性药物治疗的重症儿童提供营养。在PICU实施肠内营养常见的障碍包括启动延迟、由于感觉不耐受而中断、长时间禁食。根据观察研究，建议应努力减少肠内营养中断，以期通过肠内途径达到营养素供给目标量。
证据质量：低
GRADE推荐强度：强
Q4B、肠内营养对这些患者有什么益处？
R4B、尽管宏量营养素的最佳剂量尚不清楚，但通过肠内营养供给一定量的营养素仍有利于胃肠道黏膜的完整性和运动性。根据大型队列研究，早期启动肠内营养（在入PICU的24～48小时内），且在重症疾病第一周达到营养目标量的2/3可改善临床结局。
证据质量：低
GRADE推荐强度：弱
Q5A、对于PICU患者推进肠内营养的最佳方法是什么？
R5A、根据观察研究，建议采用循序渐进策略推进PICU儿童的肠内营养。循序渐进原则必须包括床旁支持，以便发现和管理肠内营养不耐受及指导肠内营养输注的最佳增加速率。
证据质量：低
GRADE推荐强度：弱
Q5B、营养支持小组或专业营养师在优化营养治疗方面能发挥什么作用？
R5B、根据观察研究，建议PICU团队应有营养支持小组，包括专业营养师，以便对患者及时进行营养评定、最佳营养素供给及调整。
证据质量：低
GRADE推荐强度：弱
Q6A、肠内营养输注的最佳部位在哪里，胃或小肠？
R6A、现有的资料不足以就重症儿童肠内营养输注的最佳部位提出普遍建议。根据观察研究，建议经胃途径是PICU患者肠内营养输注的首选部位。经幽门后或小肠输注肠内营养可用于无法耐受经胃喂养或误吸风险高的患者。现有的资料不足以就采用连续或间歇经胃喂养提出建议。
证据质量：低
GRADE推荐强度：弱
Q6B、肠内营养应何时启动？
R6B、根据专家意见，建议所有重症儿童应启动肠内营养，除非有禁忌证。根据观察研究，建议早期启动肠内营养，对适合的患者在收入PICU后第一个24～48小时内启动。建议用医疗机构肠内营养指南和循序渐进原则，包括肠内营养适应证、启动时机和增加速率，来指导发现和管理肠内营养不耐受。
证据质量：低
GRADE推荐强度：弱
Q7A、重症儿童使用肠外营养的最佳时机是什么时候？
R7A、根据单个随机对照研究，不推荐在入PICU后24小时内启动肠外营养。
证据质量：中等
GRADE推荐强度：强
Q7B、肠外营养作为肠内营养不足的补充有什么作用？
R7B、对于耐受肠内营养的儿童，建议通过肠内途径逐步增加营养供给，延迟启动肠外营养。根据当前的证据，补充肠外营养对达到特定能量供给目标量的作用尚不清楚。应启动肠外营养以补充肠内营养不足的时机也不清楚。肠外营养起始供给量和启动时机应个体化。
根据单个随机对照研究，对基础营养状态正常和营养恶化风险低的患者实施补充肠外营养应延迟到入PICU后1周。根据专家共识，建议对在PICU第一周不能接受任何肠内营养的儿童予以肠外营养补充。对严重营养不良或营养恶化患者，如果他们不能在低剂量肠内营养基础上加量，可在第一周用肠外营养补充。
证据质量：低
GRADE推荐强度：弱
Q8、免疫营养对重症儿童有什么作用？
R8、根据现有的证据，不推荐重症儿童使用免疫营养。
证据质量：中等
GRADE推荐强度：弱
翻译：肖慧娟（天津市第三中心医院）
JPEN J Parenter Enteral Nutr. 2017;41(5):706-742.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.
Mehta NM, Skillman HE, Irving SY, Coss-Bu JA, Vermilyea S, Farrington EA, McKeever L, Hall AM, Goday PS, Braunschweig C.
Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Children's Hospital Colorado, Aurora, Colorado, USA; Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, Pennsylvania, USA; Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA; Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA; Betty H. Cameron Women's and Children's Hospital, New Hanover Regional Medical Center, Wilmington, North Carolina, USA; University of Illinois at Chicago, Chicago, Illinois, USA; Medical College of Wisconsin, Milwaukee, Wisconsin, USA; University of Illinois, Chicago, Illinois, USA.
This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and <18 years) expected to require a length of stay >2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.
KEYWORDS: adolescent; algorithm; child; critical illness; energy; enteral nutrition; guidelines; immunonutrition; indirect calorimetry; infant; intensive care unit; malnutrition; nutrition team; obesity; parenteral nutrition; pediatric; pediatric nutrition assessment; protein; protein balance; resting energy expenditure
PMID: 28686844
DOI: 10.1177/0148607117711387
Pediatr Crit Care Med. 2017 Jul;18(7):675-715.
Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Pediatric Critically Ill Patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition.
Mehta NM, Skillman HE, Irving SY, Coss-Bu JA, Vermilyea S, Farrington EA, McKeever L, Hall AM, Goday PS, Braunschweig C.
Boston Children's Hospital, Harvard Medical School, Boston, MA; Children's Hospital Colorado, Aurora, CO; The Children's Hospital of Philadelphia, University of Pennsylvania School of Nursing, Philadelphia, PA; Baylor College of Medicine, Texas Children's Hospital, Houston, TX; Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Betty H. Cameron Women's and Children's Hospital, New Hanover Regional Medical Center, Wilmington, NC; University of Illinois at Chicago, Chicago, IL; Medical College of Wisconsin, Milwaukee, WI; University of Illinois, Chicago, IL.
This document represents the first collaboration between two organizations, American Society of Parenteral and Enteral Nutrition and the Society of Critical Care Medicine, to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric (> 1 mo and < 18 yr) critically ill patient expected to require a length of stay greater than 2 or 3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2,032 citations were scanned for relevance. The PubMed/Medline search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1,661 citations. In total, the search for clinical trials yielded 1,107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer one of the eight preidentified question groups for this guideline. We used the Grading of Recommendations, Assessment, Development and Evaluation criteria to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutritional assessment, particularly the detection of malnourished patients who are most vulnerable and therefore potentially may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery is an area of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.
PMID: 28691958
DOI: 10.1097/PCC.0000000000001134