胰腺炎的营养治疗课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,Nutrition in Acute Pancreatitis,“An Evidence Based Approach”,Nutrition in Acute Pancreat,Which patients benefits from nutritional support in acute pancreatitis?,All patients with acute pancreatitis?,(Mild pancreatitis is different from severe,pancreatitis),Enteral or parenteral?,Where is the evidence?,Which patients benefits from n,Severity,(Clinical, laboratory and radiological signs),Nutritional status,Outcome predictors,- Mild form (,80%),- Severe form (,20%),Outcome predictors- Mild form,Severity assesment,Mild form (,80%)- Ranson signs,3- CRP 3- CRP 120 mg/l- APACHE II score 8- Balthazars-CT-score 3,Severity assesment,1068 patients, mean age 52.8 yrs,589 edematous AP, 479 severe AP,MORTALITY: total 7.8%,mild,a,P 1%, severe,a,P 16.1%,Severity and outcome,Mortality can increase to up to 40% if sepsis and MOF occur,1068 patients, mean age 52.8 y,ESPEN Guidelines,Enteral Nutrition:,Clinical Nutrition Vol 25 (2), April 2006,Parenteral Nutrition:,Clinical Nutrition Vol 28, July 2009,www.espen.org/education/,guidelines.htm,ESPEN GuidelinesEnteral Nutri,Severity of acute pancreatitis can be assessed adequately,For artificial nutritional interventions,mild pancreatitis has to be separated from,severe pancreatitis,Nutritional status has to be assessed on admission and during the course of the disease,Recommentation I,Recommentation I,Main goals for nutrition in acute pancreatitis,To provide calories with EN or PN to reverse protein catabolism without stimulation of the exocrine pancreatic secretion,To improve or to avoid nutritional depletion,To reduce morbidity and mortality,Main goals for nutrition in ac,How should nutritional support be done?,Parenteral or enteral?,Gastral or jejunal?,How should nutritional support,EN vs PN and acute pancreatitis,Mild to moderate pancreatitis,Early EN (ED, NJ) vs PN,PRCT,N=32,EN PN,n = 16 n = 16,Caloric goal (day 4) 72% 86%,Days to normal amylase 4.8, 0.6,6.8, 1.5,Days to diet by mouth 5.6 0. 7.1 1.1,LOH (days) 9.7 1.3 11.9 2.6,Lengh of ICU stay (days) 1.3 0.9 2.8 1.3,% Nosocomial infection 12.5 8.5 12.5 8.5,Mortality (%) 0.0 0.0,Cost (US$) 761 50.3 3294 551.9*,McClave et al, JPEN, 1997,* p 0.05,EN vs PN and acute pancreatiti,Is the situation differentin mild to moderate or severe pancreatitis?,Is the situation differentin,EN vs PN and acute pancreatitis,Severe pancreatitis,EN (SED, NJ) vs PNPRCTN=38,EN PN n = 18 n = 20,LOH (d) 40 (25-83) 39(22-73),LOICU (d) 10 (5-21) 12 (5-24),Complication,-septic (Tot.nb) 5 (6) 10 (15)*,- Hyperglycaemia 4 9,- Pancr. necrosis 1 4,Pneumonia 2 4,Costs 3 times higher,Kalfarentzos et al, B J Surg, 1997,EN vs PN and acute pancreatiti,EN vs PN and acute pancreatitis,Severe pancreatitis,EN (NJ Hypocaloric) vs PNPRCTN=156,Enroled patients,87% mild,10% moderate,3% severe,75% improved on 48h bowel rest and iv. fluids,discharged within 4 days,Rest randomized to jejunal EN or PN,Abou-Assi, et al, Am J Gastroenterology, 2002,EN vs PN and acute pancreatiti,Results of the randomized patients,n = 27 n = 26,Ransons Criteria 2.5 (0.5) 3.1 (0.6),Nutr. Goal 88%* 54%,Hyperglycemia (MOF) 14 pt.* (8) 4 pt.(7),Catheter Sepsis 9 pt.* 1 pt.,Death 6 pt. 8 pt.,Duration of feeding (d) 10.8* 6.7,Hosp. Days 18.4 (2.9)* 15.2 (2.6),Hosp. Costs (US dollar) lower in EN (saving 2360.-),*p 195 mg/L,107 Patients,54 TPN, 115 kJ/KG/d 1,2 g N 250 ml 20% Intralipid,53 TEN, 115 kJ/KG/d 1,5 g N Survimed jejunal,APACHE II 16 4CRP 218 8,APACHE II 14 2CRP 211 9,Wu et al, Pancreas 2010,EN vs PN and severe acute panc,EN vs PN and severe acute pancreatitis,Wu et al, Pancreas 2010,EN vs PN and severe acute panc,EN vs PN and severe acute pancreatitis,Enteral nutrition (N= 25),TPN,(N=25),P value,Infection,16 (64.0%),15 (60.0%),1.000,ICU stay (days; median and range),10 (0-44),15 (0-60),0.625,Hospital stay (days; median and range),42 (15-108),36 (20-77),0.755,Mortality,5 (20.0%),4 (16.0%),1.000,Doley et al, J Pancreas 2009,EN vs PN and severe acute panc,EN vs PN in acute pancreatitis,Olah et al, Langenbecks Arch Surg 2010,847 patients,16 RCT,EN vs PN in acute pancreatitis,Recommendation II,There is no evidence that neither EN or,PN has a clinical beneficial effect on,clinical outcome in patients with mild,pancreatitis, if you can predict that the patient can consume normal food in between 5 days (A),If oral nutrition is not possible in 5 days,enteral nutrition should be started immetiately (C),If this is true in patients with malnutrition,is not known,Recommendation IIThere is no e,ESPEN, Guidelines 2006/2009,Treatment mild,pancreatitis,Assessment of severity of acute pancreatitis,mild to moderate,fasting (2-5 days),analgesics,i.v. fluid/electrolytes,no pain, enzymes,refeeding (3-7 days),diet rich in CH,diet moderate in protein/fat,normal diet,ESPEN, Guidelines 2006/2009Tr,Recommendation III,Nutritional support in essential in patients with severe disease and nutritional risk factors (A),The route of nutrient delivery (parenteral/enteral) should be determined by the patient tolerance,EN should be attempted in all patients first (C),Intakes should be monitored carefully to ensure adequate nutritional support,When enteral nutrition is not sufficient combine it with PN (C),Recommendation IIINutritional,ESPEN, Guidelines 2006/2009Treatment severe pancreatitis,Assessment of severity of acute pancreatitis,severe,early continuous enteral nutrition (naso-jejunal tube),elemental diet or,polymeric diet or,immune-enhancing diet?,enteral nutrition is not possible,add parenteral nutrition,- all in one,- or single component solutions (CH, protein (AS), fat),TPN and,continuous small,amount of an,enteral diet,(10-30 ml/h) perfused to,the jejunum,nutritional goal not reached,ESPEN, Guidelines 2006/2009Tr,Recommendation IV,Patients with severe disease, complications or the,need for surgery require early nutritional support to,prevent the adverse effects of nutrient deprivation,C,ontinous early enteral jejunal feeding over,24h is recommended (A),When side effects occur or the caloric goal can not be achieved, PN should be combined,with EN (C),Recommendation IVPatients with,How nutrients should be applied?,4 trials showed that jejunal tubes are well tolerated,there was no exacerbation of pancreatitis-related symptoms,McClave, JPEN, 1997,Cravo, Clin Nutr, 1989,Kudsk, Nutr Clin Pract, 1990,Nakad, Pancreas, 1998,How nutrients should be appli,Nasogastric or nasojejunal feeding in patients with severe pancreatitis?,Nasogastric or nasojejunal fee,Nasogastric vs nasojejunal feeding in patients with acute pancreatitis,Petrow et al, JOP 2008,Nasogastric vs nasojejunal fee,Nutritional intolerance,Pain exazerbation,Nasogastric vs nasojejunal feeding in patients with acute pancreatitis,Petrow et al, JOP 2008,Nutritional intolerancePain ex,Diarrhea,Mortality,Nasogastric vs nasojejunal feeding in patients with acute pancreatitis,Petrow et al, JOP 2008; 9(4):440-448.,DiarrheaMortalityNasogastric v,Recommendation V,Jejunal tube placement is safe and well tolerated (C),If nasogastric tube feeding is a useful and practical approach can not be answered up to now!,Recommendation VJejunal tube p,Which formula should be used?,Elemental, semielemental, polymeric, or,immunenhancing (Arg, RNA, n-3-FA, Glu),Enteral diet with pre- or probiotics,TPN and glutamine and or n-3-FA,There is no clear consensus about the preferred formula but most trials were performed with semielemental diets,Which formula should be used?,Tiengou et al, JPEN, 2006,Semielemental vs polymeric,diet in acute pancreatitis,Tiengou et al, JPEN, 2006 Semi,EN (immunmodulating) vs EN (standard),HospitalICUMortalityN,StayStay,EN (Arg/Glu)27.2 d* 8.6 d* 22.2%,vs,1),16,EN (STD)38.4 d34.8 d 28.6%,EN (n-3-FA)13.1 d * 7.1%,vs,2),28,EN (STD)19.3 d 14.2%,* p 0.05,1) Hallay et al, Hepatogastroenterol, 2001,2) Lasztity et al, Clin Nutr, 2005,EN (immunmodulating) vs EN (s,Algorythm for using enteral formula,Severe acute pancreatitis,GI-function,Normal,GI-function,Impaired,Polymeric diet,Elemental- or semielemental diet,GI-function,Impaired,Elemental- or semielemental diat,GI-function,Normal,Polymeric diet,Algorythm for using enteral fo,Synbiotics* in severe pancreatitis,Incidence of infected,necrosis and abscess 4.5 30.4% (p 0.02),LOHS 13.7 21.4 d (ns),Need for re-surgery 1 7 (p 0.02),Olah et al, Br J Surg 2002,Enteral nutrition with 10g oat fibre,(,-glucan),and Lactobacillus plantarum 299, 10,9,Rand, db, controlled trial (N = 45), 1 week,*Probio,Probiotics Control p,Synbiotics* in severe pancreat,Synbiotics* in severe pancreatitis,Probiotics Control p,MOF 15% 31% sig,Septic complicatios 27% 52% ns,LOHS (d) 15 20 ns,Need for surgery 12% 24% ns,Mortality 6% 21% ns,Olah et al, Hepatogastroenterol 2007,Enteral nutrition with 10g,-glucan, inulin, pectin, resistant starch,and Lb plantarum 299, pediacoccus, leuconostoc, paracasei, 10,10,Rand, db, controlled trial (N = 62), 1 week,*,Synbiotic 2000,Synbiotics* in severe pancreat,Synbiotics* in severe acute pancreatitis,Probiotics Placebo,N=152 N=144,Infectious compl. 30% 28%,Bowel ischaemia (N) 9* 0,Mortality 24 (16%)* 9 (6%),Multifibre diet plus and cornstarch, maltodextrin,Besselink et al, Lancet 2008,and 4 Lactobacilli, 2 Bifidobacteria 10,10,twice daily,Rand, db, placebo-controled trial, N= 298, 4 weeks,*Ecolocgic 641,(*/* sig),Synbiotics* in severe acute pa,Comparison of the 3 studies using probiotics in acute pancreatitis,Olah 2002,Olah 2007,Besselink 2008,Probio,Control,Synbiotic,Control,Ecologic,Control,(n = 22),(n = 23),(n = 33),(n = 29),(n = 152),(n = 144),Baseline,APACHE II,8.9,9.4,11.7,10.4,8.6,8.4,Imrie Scores,2.5,2.8,2.9,3.1,3.3,3.4,Mean CRP,206,188,216,191,268,270,% Alcohol,59%,70%,60%,62%,18%,19%,% Necrosis,41%,48%,60%,62%,30%,24%,Age,44.1,46.5,47.5,46.0,60.4,59.9,Comparison of the 3 studies us,What went wrong?,Aggressive enteral Nutrition (30kcal/Tag),Patients with vasoactive treatment,Multifibre diet plus prebiotics,(30g fibre/day),6 probiotic strains (2x/day 10,10,),- For the first time Bifidobacteria),Fermentation distension ischaemia,?,What went wrong?Aggressive ent,PN (immunmodulating) vs PN (standard),Glutamine,N- 3 fatty acids,PN (immunmodulating) vs PN (,McClave et al, JPEN, 2006,Acute pancreatitis,Glutamine vs standard PN,Complications,RR 0.68,CI: 0.42-1.09,p= 0.11,McClave et al, JPEN, 2006Acute,Acute pancreatitis,Glutamine vs standard PN,3 further randomized controlled trials,Significant reduction of complications (N=40),Significant reduction of mortality,Sahin et al, Eur J Cin Nutr 2007,Significant reduction of complications (N= 44,),Fuentes-Orozco et al, JEPN 2008,Significant reduction in the length of,organ failure N=76),Reduction of infection (early vs late) 8 vs 23%,Reduction of surgery (early vs late) 13 vs 43%,Reduction of mortality (early vs late) 5 vs 21%,Xue et al, W J Gastroenterol 2008,Acute pancreatitis3 further ra,N-3-FA in TPN in patients with severe acute pancreatitis,N=40,Control,N-3-FA,SIRS ratio,9/20,4/20,ARDS ratio,5/20,4/20,Infectious complication, n,5/20,3/20,Renal dysfunction, n,2/20,1/20,CRRT, days,26,3.4,18,2.3,ICU, days,27.5,5.6,21.4,4.2,Length of hospital stay, days,70.5,9.1,65.2,7.3,Wang et al, JPEN 2008,Prospective, randomized, double-blind study, PN over 5 days,N-3-FA in TPN in patients with,N-3-FA in TPN in patients with severe acute pancreatitis,Patients supplemented with fish oil,had significantly lower CRP levels,after 5 days of parenteral nutrition,Wang et al, JPEN 2008,N-3-FA in TPN in patients with,N-3-FA in TPN in patients with severe acute pancreatitis,N=60,Control,N-3-FA,Apache II, 7th day,13,2.3,8,1.9*,Fluid equilibrium, days,8.4,2.3,5.1,2.2,SIRS score, 7th day,2.5,0.7,1.7,0.5*,Xiong et al, JPEN 2008,Prospective, randomized, double-blind study,*P 0.05,During the initial stage of acute pancreatitis n-3 FA efficiently reduce,the magnitude and persistence time of SIRS and retrieve the,unbalance of the pro/anti-inflammatory cytokines,N-3-FA in TPN in patients with,Recommendation VI,Elemental and semielemental formulas can be used safely in acute pancreatitis (A),Standard polymeric formulas can be tried if they are tolerated (C),There is no evidence for using immunomodulating formulas or probiotics,If TPN has to be used, glutamine,could have a beneficial effect (B), for n-3 FA we need further trials,Recommendation VIElemental and,Conclusion,Nutritional support is essential in severe acute pancreatitis,Starting with early enteral nutrition is recommended,The combination of EN and PE make sense if enteral nutrition is inadaequate,Probiotics can not be recommended yet,More studies in this field are necessary,In PE glutamine ca be helpful,Conclusion Nutritional support,后面内容直接删除就行,资料可以编辑修改使用,资料可以编辑修改使用,后面内容直接删除就行,主要经营：网络软件设计、图文设计制作、发布广告等,公司秉着以优质的服务对待每一位客户，做到让客户满意！,主要经营：网络软件设计、图文设计制作、发布广告等,致力于数据挖掘，合同简历、论文写作、,PPT,设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求,致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划,感谢您的观看和下载,The user can demonstrate on a projector or computer, or print the presentation and make it into a film to be used in a wider field,感谢您的观看和下载The user can demonstr,