神经系统疾病营养支持课件

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,2021/2/3,#,背景,共识草稿（,2008/8,）,神经系统疾病营养支持适应症,2006,神经系统疾病营养支持指南,中华医学会肠外肠内营养学分会,神经系统疾病营养支持操作规范,2006,神经系统疾病营养支持操作规范,首都医科大学宣武医院神经内科重症监护病房,背景共识草稿（2008/8）,1,背景,共识初稿（,2008/9,）,神经疾病营养支持工作组,宿英英（首都医科大学宣武医院）,黄旭升（中国人民解放军总医院）,彭斌（北京协和医院）,潘速跃（广州南方医院）,张运周（首都医科大学宣武医院）,背景共识初稿（2008/9）,2,共识背景,共识讨论稿（,2008/11,）,共识推广稿撰写者,国内部分神经内科专家（按姓氏笔划）,牛小媛、牛俊英、王少石、毕齐、吕佩源、陈玲、杜继臣、狄晴、张旭、胡文立、胡颖红、黄旭 升、宿英英、程焱、彭斌、潘速跃、魏东宁,共识背景共识讨论稿（2008/11）,3,第一部分,神经系统疾病营养支持适应症,第一部分神经系统疾病营养支持适应症,4,撰写方法,文献检索,（脑卒中、痴呆、持续神经性吞咽障碍、昏迷）,确认证据,（,OCEBM,）,推荐意见,撰写方法文献检索确认证据（OCEBM）推荐意见,5,牛津循证医学中心,分级,（,Oxford Centre for Evidence-based Medicine,，,OCEBM,）,推荐意见,证据级别,描述,A,1a,基于,RCTs,（,具有同质性）,1b,单个,RCT,研究,1c,“,全或无,”,证据,有治疗以前,所有患者,全都,死亡，有治疗之后,有,患者存活,有治疗以前,有,些,患者死亡，有治疗以后,无,患者死亡,B,2a,基于队列研究,（,具有同质性）,2b,单个队列研究,(,如,80%,随访,),;,包括低质量,RCT,3a,基于病例对照研究,（,具有同质性）,3b,单个病例对照研究,C,4,病例报道,(,低质量队列研究,),D,5,专家意见或评论,牛津循证医学中心分级（Oxford Centre for,6,年限,文献,方法,结论,证据,级别,1996,Effect of malnutrition after acute stroke on clinical outcome.,Stroke, 1996, 27(6):1028-1032.,病例对照,脑卒中患者营养不足与,不良预后,（死亡率、并发症、住院时间和功能残疾程度）相关,3b,104,例,1998,Nutritional status of hospitalized acute stroke patients.,Br J Nutr, 1998, 79(6):481-487.,病例对照,3b,201,例,2004,Impact of premorbid undernutrition on outcome in stroke patients.,Stroke, 2004, 35(8):1930-1934.,病例对照,3b,185,例,2005,Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients.,Clin Nutr, 2005, 24(6):1073-1077.,队列研究,脑卒中患者入院时营养不足的发生率为,19.2%,营养不足患者住院时间延长（,13d,vs 8d,）并发症增加（,50%,vs 14%,）。,2b,73,例,脑卒中伴吞咽困难患者,年限文献方法结论证据1996Effect of malnut,7,Observational Data From the FOOD Trial.,痴呆早期患者推荐加强经口营养支持（B级推荐）。,9) and an increased risk of death or poor outcome of 7.,恢复期卒中（4周）神经性吞咽障碍患者PEG喂养的体重增加多于NGT,3mmol/L，注意避免低血糖发生（D级推荐）,重症（GCS12分或APACHE16分）患者急性应激期,血脂正常患者每周检测血脂1次。,Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia.,胰岛素输注初始每1小时2小时检测血糖1次，血糖稳定后每4小时检测血糖1次。,Nutritional and cognitive relationships and long-term mortality in patients with various dementia disorders .,急性脑卒中患者血糖控制目标：10mmol/L。,大豆等膳食纤维耐受性良好，可以促进胃肠道运动。,Eur J Clin Nutr 2002;56:24551.,减慢输注速度或/和减少输注总量,(Short Peptide),Clin Nutr,2003,22(4):415-421.,第二部分神经系统疾病营养支持操作规范共识,结果：强化胰岛素治疗未降低患者死亡率，但有助于减少住院时间、提前撤机和减少急性肾损害,急性脑卒中伴吞咽障碍患者应尽早（7天内）给予肠内喂养。,Hans Basun ,et al.,年限,文献,方法,结论,证据,级别,1992,Park RH, Allison MC, Lang J, et al.,Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia.,Br Med J 1992;304:1406,9.,多中心,随机,对照,恢复期卒中,（,4,周）,神经性吞咽障碍患者,PEG,喂养的体重增加多于,NGT,1b,40,例,2006,Hamidon BB,Abdullah SA,Zawawi MF.,A prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with acute dysphagic stroke.,Med J Malaysia. 2006 Mar;61(1):59-66.,随机,对照,恢复期卒中（,4,周）,吞咽障碍患者应用,PEG,比,NGT,改善营养状况（血清白蛋白水平）更有效。,1b,22,例,脑卒中伴吞咽困难患者,Observational Data From the FO,8,年限,文献,方法,结论,证据级别,1996,Norton B, Homer-Ward M, Donnelly MT, Long RG, Holmes GK.,A randomised prospective comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding after acute dysphagic stroke.,Br Med J 1996;312:13,6.,多中心,随机,对照,恢复期卒中（发病,2,周后）伴吞咽困难患者,PEG,喂养的病死率低，治疗成功率高，营养状况改善好于,NGT,1b,30,例,脑卒中伴吞咽困难患者,年限文献方法结论证据级别1996Norton B, Home,9,2003,2005,FOOD Trial Collaboration.,Poor Nutritional Status on Admission Predicts Poor Outcomes After Stroke. Observational Data From the FOOD Trial.,Stroke June 2003,，,1450-1456.,The FOOD Trial,Collaboration.Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomized controlled trial .,Lancet 2005; 365: 764,72.,多中心,随机,对照,急性脑卒中,患者早期营养不良是长期预后不良的独立危险因素。,急性脑卒中,伴吞咽障碍患者应尽早（,7,天内）给予肠内喂养。如果肠内喂养需要持续,23,周则最好选择,NGT,途径（除非具有很强的,PEG,指征）,1b,2955,例,脑卒中伴吞咽困难患者,2003FOOD Trial Collaboration.多,10,2005,2006,FOOD : Routine oral nutritional supplementation for stroke patients in hospital (FOOD): a multicentre randomised controlled trial. Lancet, 2005, 365(9461):755-763.,FOOD : a multicentre randomised trial evaluating feeding policies in patients admitted to hospital with a recent stroke. Health Technol Assess, 2006, 10(2):1-120.,多中心,随机,对照,Supplemented diet was associated with,an absolute reduction in risk of death,of 0.7% (95% CI -1.4 to 2.7，p0.5) and an,increased risk of death or poor outcome,of 0.7% (-2.3 to 3.8，p0.6,).,1b,4012例,脑卒中伴吞咽困难患者,2005FOOD : Routine oral nutrit,11,Stroke. 2003;34:1450-1456.,Poor Nutritional Status on Admission Predicts Poor Outcomes After Stroke,Observational Data From the,FOOD Trial,FOOD Trial Collaboration,Stroke. 2003;34:1450-1456.Poor,12,分类,人数,死亡率,并发症,总人数,2955 /3012,547/2955,（,18.5%,）,营养正常,2194/2955,445/2194,（,20%,）,营养不良,275/2955,（,9%,）,102/275,（,37%,）,肺炎,其他感染,消化道出血,统计,OR=1.82,95%CI=1.34-2.47,分类人数死亡率并发症总人数2955 /3012547/295,13,神经系统疾病营养支持课件,14,神经系统疾病营养支持课件,15,神经系统疾病营养支持课件,16,Conclusions,These data provide reliable evidence that,nutritional status early after stroke is independently associated with long-term outcome.,It,supports,the rationale for the,FOOD trial, which continues to recruit and aims to estimate the effect of different feeding regimes on outcome after stroke and thus determine whether the association observed in this study is likely to be causal.,ConclusionsThese data provide,17,Effect of timing and method of enteral tube feeding for dysphagic stroke patients (FOOD): a multicentre randomised controlled trial,The FOOD Trial Collaboration,Available online 25,February,2005.,Effect of timing and method of,18,潘速跃（广州南方医院）,2006年CSPEN指南,结果发现，NRS 2002 评分3分患者，临床营养支持后良性临床结局比例增高。,MRC/BHF Heart Protection Study of cholesterol lowering with simvastatin in 20,536 high-risk individuals: a randomised placebo-controlled trial.,单次应用红霉素有助于小肠喂养管放置（2项研究中）,Malnutrition determined by the patient-generated subjective global assessment is associated with poor outcomes in acute stroke patients.,ESPEN guidelines for nutrition screening 2002.,20536例患者RCT,基于病例对照研究（具有同质性）,血糖是糖尿病患者和危重症患者重要的监测指标，在营养支持过程中必须对血糖进行密切监测，并合理使用胰岛素。,Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature.,脑卒中患者入院时营养不足的发生率为19.,痴呆晚期患者推荐管饲喂养，有条件情况下采用经皮内镜下胃造口。,Eur J Clin Nutr 2002;56:24551.,整蛋白型(Intact Protein),平衡型（balanced/standard）/,蒋朱明等 研究：中国NRS 2002 多中心营养风险筛查调查涉及13座城市19所三甲医院15098例住院患者，结果显示呼吸科、肾脏科、消化科、神经内科、普外科、普胸外科六个专科患者的总营养不良发生率35.,Stroke June 2003，1450-1456.,监测血清电解质和肾功能,Dwolatzky T, Berezovski S, Friedmann R, et al.,64,95%CI=0.,Undernutrition is common in patients admitted with stroke. we aimed to establish whether the,timing and route of enteral tube feeding,after stroke affected patients outcomes at 6 months.,Background,潘速跃（广州南方医院）Undernutrition is c,19,The FOOD trials consist of three pragmatic multicentre randomised controlled trials, two of which include,dysphagic stroke patients.,In the other, patients were allocated percutaneous endoscopic gastrostomy,(PEG),or,nasogastric feeding,.,In one trial, patients entrolled,within 7 days,of admission were randomly allocated to early enteral tube feeding or no tube feeding for,more than 7 days,(early versus avoid).,Methods,The primary outcome was,death or poor outcome at 6 mouths,.,Analysis was by intention to treat,The FOOD trials consist of thr,20,Finding,Between Nov 1,1996, and July 31, 2003,859,patients were enrolled by 83 hospitals in 15 countries into the early versus avoid trial.,Early tube feeding,was associated with,an absolute reduction in risk of,death,of,5.8%,(95% CI -0.8 to 12.5, P=0.09) and,reduction in,death or poor,outcome,of,1.2,%,(-4.2 to 6.6, P=0.7).,FindingBetween Nov 1,1996, an,21,神经系统疾病营养支持课件,22,神经系统疾病营养支持课件,23,In the PEG versus nasogastric tube trial,321,patients were entrolled by 47 hospitals in 11 countries.,PEG,feeding was associated with,an absolute,increase,in risk of death of 1.0,%,(,-,10.0 to 11.9, P=0.9,),and,an,increased,risk of death or poor outcome of 7.8%,(0.0 to 15.5, P=0.05),.,In the PEG versus nasogastric,24,神经系统疾病营养支持课件,25,神经系统疾病营养支持课件,26,神经系统疾病营养支持课件,27,Early tube feeding might,reduce case fatality, but at the,expense of increasing,the proportion surviving with poor outcome.,Our data do,not support,a policy of early initiation of,PEG,feeding in dysphagic stroke patients,Interpretation,Early tube feeding might redu,28,血脂正常患者每周检测血脂1次。,整蛋白型(Intact Protein),低胆固醇血症患者的肺部疾病和精神障碍的发生率显著高于胆固醇正常和高胆固醇血症患者（P0.,Dwolatzky T, Berezovski S, Friedmann R, et al.,J Am Geriatr Soc 1990;38:11958.,发病7天高蛋白肠内营养制剂组血清蛋白下降低于对照组，前白蛋白为著（P0.,神经系统疾病患者，尤其是伴有吞咽困难患者或危重神经疾病患者进行营养风险筛查（Nutrition risk screening , NRS）,Nutritional status of hospitalized acute stroke patients.,痴呆晚期患者推荐管饲喂养，有条件情况下采用经皮内镜下胃造口。,Clin Nutr, 2001, 20:535-540.,增加短链脂肪酸产生，刺激益生菌生长，有助于维持结肠粘膜结构和功能完整，并减少腹泻,Gerd Faxn-Irving,需要肠内营养支持的糖尿病患者，有条件时，可选用糖尿病适用性肠内营养制剂。,3mmol/L，注意避免低血糖发生（D级推荐）,发病14天内 APACHE19分患者，高蛋白肠内营养制剂组低蛋白血症发生率明显低于对照组（P0.,2006年SPARCL研究,营养不良发生与痴呆严重程度相关,有条件情况下，可用营养输注泵控制输注速度。,3mmol/L，注意避免低血糖发生（D级推荐）,痴呆早期患者推荐加强经口营养支持（B级推荐）。,Park RH, Allison MC, Lang J, et al.,60例重症（GCS12分）脑卒中患者,Long-term enteral feeding of aged demented nursing home patients.,胃肠动力药物能改善危重症患者胃肠动力,血清前白蛋白（prealbumin, PA ）,Scand J Gastroenterol, 1992, 194:95-98.,胃肠道功能正常（最好是含有膳食纤维的整蛋白标准配方，A级推荐）,Usefulness of soluble dietary fiber for the treatment of diarrhea during enteral nutrition in elderly patients,首都医科大学宣武医院神经内科重症监护病房,9种情况的营养制剂选择,2003 Oct; 24 Suppl 3:314s-318s.,2003 Oct; 24 Suppl 3:314s-318s.,J Am Diet Assoc.,添加膳食纤维能够改善长期管饲患者胃肠道的耐受性，改善胃肠道功能，减少缓泻剂的应用。,基于病例对照研究（具有同质性）,营养不良发生与痴呆严重程度相关,Stroke, 1996, 27(6):1028-1032.,2002年MRC/BHF Heart Protection研究,洼田饮水试验评分2分时可停止管饲喂养,超过24小时仍不能改善时，改为鼻肠管或肠外营养（D级推荐）。,2003年，Krishnan等,外科ICU的1548例患者,推荐意见,脑卒中伴吞咽困难患者推荐肠内营养支持，发病,7,天内尽早开始喂养，短期（,4,周内）采用鼻胃管（,NGT,）喂养，长期（,4,周后）在有条件情况下采用经皮内镜下胃造口（,PEG,）喂养。,（,A,级推荐）,血脂正常患者每周检测血脂1次。60例重症（GCS12分）脑,29,年限,文献,研究,方法,结论,证据级别,2003,Brocker P, Benhamidat, et,al.,Nutritional status and Alzheimers disease: preliminary results of the REAL.FR study. Rev Med Interne. 2003 Oct; 24 Suppl 3:314s-318s.,病例,对照,营养不良,发生与痴呆严重程度相关,3a,479,例,2004,Gerd Faxn-Irving,Hans Basun ,et al.Nutritional and cognitive relationships and long-term mortality in patients with various dementia disorders . AgeAgeing. 2005 Mar;34(2):136-41. Epub 2005 Jan 11.,病例,对照,BMI,23,（,52%,）痴呆患者与,7,年死亡风险增加有关,3a,231,例,老年痴呆患者,年限文献研究结论证据级别2003Brocker P, Ben,30,年限,文献,研究,方法,结论,证据级别,2006,Munoz AM, Agudelo GM,et al.,Nutritional condition in,patients with Alzheimer-type,dementia from the,neurosciences group,Medellin 2004. Biomedica. 2006 Mar;26(1):113-25,病例,对照,AD,早期,患者营养状况已受到影响,3a,77,例,2007,Poor nutrient intakes during 1-year follow-up with community-dwelling older adults with early-stage Alzheimer dementia compared to cognitively intact matched controls.,J Am Diet Assoc.,2007,107(12):2091-2099.,病例,对照,认知功能正常的老年居民（,58,例）饮食中各种营养成分摄入好于,早期痴呆患者,（,36,例）,3a,94例,老年痴呆患者,年限文献研究结论证据级别2006Munoz AM, Agud,31,年限,文献,研究方法,结论,证据级别,1990,Peck A, Cohen CE, Mulvihill MN.,Long-term enteral feeding of aged demented nursing home patients.,J Am Geriatr Soc 1990;38:1195,8.,非随机,对照,1,年的,管饲喂养,使老年休养所痴呆患者体重增加。,3,52,例,2000,Rudberg MA, Egleston BL, Grant MD, Brody JA.,Effectiveness of feeding tubes in nursing home residents with swallowing disorders.,J Parenter Enteral Nutr 2000;24:97,102.,队列,管饲喂养,使老年休养所严重认知功能损伤患者死亡率降低。,2b,150,例,老年痴呆患者,年限文献研究方法结论证据级别1990Peck A, Cohe,32,年限,文献,研究,方法,结论,证据级别,2002,Faxen-Irving G.,The effect of nutritional intervention in elderly subjects residing in group-living for the demented.,Eur J Clin Nutr 2002;56:221,7.,非随机,对照,6,个月,经口,营养补充使老年人居住地痴呆患者体重增加,2a,38,例,2002,Wouters-Wesseling W.,Study of the effect of a liquid nutrition supplement on the nutritional status of,psycho-geriatric,nursing home patients.,Eur J Clin Nutr 2002;56:245,51.,随机,双盲,对照,3,个月,经口,营养液补充易于接受，并使老年休养所痴呆患者体重增加，营养状况改善,1b,42,例,老年痴呆患者,年限文献研究结论证据级别2002Faxen-Irving G,33,年限,文献,研究,方法,结论,证据级别,2001,Dwolatzky T, Berezovski S, Friedmann R, et al.,A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people.,Clin Nutr 2001;20:535,40.,多中心,队列,6,个月,PEG,或,NGT,喂养不能使急性衰老老人院（,Acute geriatric units,）和敬老院（,long-term care hospitals,）老年人或痴呆患者体重增加，但,PEG,喂养,4,周末白蛋白高、生存率高、拔管率低、误吸率低,2b,122,例,2005,Percutaneous endoscopic gastrostomy; evidence of different prognosis in various patient subgroups.,Age Ageing, 2005, 34(4):353-7.,前瞻,观察,PEG,患者中生存时间最短的是年龄大于80岁痴呆患者。生存时间最长的是年龄80岁的严重痴呆患者,3a,674,例,老年痴呆患者,年限文献研究结论证据级别2001Dwolatzky T, B,34,推荐意见,痴呆早期患者推荐加强经口营养支持,（,B,级推荐）,。痴呆晚期患者推荐管饲喂养，有条件情况下采用经皮内镜下胃造口。,（,B,级推荐）,推荐意见痴呆早期患者推荐加强经口营养支持（B级推荐）。痴呆,35,持续神经性吞咽障碍,年限,文献,研究,方法,结论,证据,级别,1992,Park RH, Allison MC, Lang J, et al.,Randomised comparison of percutaneous endoscopic gastrostomy and nasogastric tube feeding in patients with persisting neurological dysphagia.,Br Med J 1992;304:14069.,随机,对照,PEG,可保证持续神经性吞咽障碍患者营养与能量充足摄入，治疗失败率低。,NGT,胃管移位发生率高。,1 b,40,例,1992,Feeding via nasogastric tube or percutaneous endoscopic gastrostomy. A comparison. Scand J Gastroenterol, 1992, 194:95-98.,前瞻,随机,对照,PEG,比,NGT,患者中断喂养发生率低，护理方便,1,b,90,例,持续神经性吞咽障碍年限文献研究结论证据1992Park RH,36,持续神经性吞咽障碍,年限,文献,研究,方法,结论,证据,级别,2001,A prospective comparison of the use of nasogastric and percutaneous endoscopic gastrostomy tubes for long-term enteral feeding in older people. Clin Nutr, 2001, 20:535-540.,多中心前瞻,PEG,比,NGT,组生存率、误吸率及脱管率低,1 b,122例,持续神经性吞咽障碍年限文献研究结论证据2001A prosp,37,推荐意见,其他神经系统疾病伴持续吞咽困难患者，短期（,4,周内）推荐鼻胃管喂养，长期（,4,周后）推荐经皮内镜下胃造口喂养。,（,A,级推荐）,推荐意见其他神经系统疾病伴持续吞咽困难患者，短期（4周内）,38,昏迷患者的推荐意见,任何原因引起的昏迷患者，短期（,4,周内）昏迷推荐鼻胃管喂养，长期（,4,周以后）昏迷（如持续植物状态）推荐经皮内镜下胃造口喂养,（,D,级推荐）,。,昏迷患者的推荐意见任何原因引起的昏迷患者，短期（4周内）昏,39,第二部分,神经系统疾病营养支持操作规范共识,第二部分神经系统疾病营养支持操作规范共识,40,文献检索,（指南推荐、文献证据）,确认证据,（,OCEBM,）,推荐意见,撰写方法,文献检索确认证据（OCEBM）推荐意见撰写方法,41,1.,营养风险筛查,神经系统疾病患者，尤其是伴有吞咽困难患者或危重神经疾病患者进行营养风险筛查（,Nutrition risk screening , NRS,）,A,级推荐,1.营养风险筛查神经系统疾病患者，尤其是伴有吞咽困难患者或危,42,2002,年,ASPEN,指南（,B,级推荐）,2006,年,ESPEN,指南 （,A,级推荐）,2006,年,CSPEN,指南 （,A,级推荐）,Kondrup,等系统分析：,128,个临床,RCT,研究，,8944,例患者，评估营养支持对疾病临床结局的影响，包括病死率和死亡率，严重并发症，住院日，经济耗费等。结果发现，,NRS 2002,评分,3,分患者，临床营养支持后良性临床结局比例增高。,（,Kondrup J, et al. ESPEN guidelines for nutrition screening 2002.J. Clin Nutr,2003,22(4):415-421.,）,蒋朱明等 研究：中国,NRS 2002,多中心营养风险筛查调查涉及,13,座城市,19,所三甲医院,15098,例住院患者，结果显示呼吸科、肾脏科、消化科、神经内科、普外科、普胸外科六个专科患者的总营养不良发生率,35.5%,。神经内科患者营养风险比例,36.6%,，而实际得到营养支持的很少，肠内营养,2.8%,，肠外营养,6.4%,。,（,蒋朱明,陈伟,朱赛楠,等,.,中国东、中、西部大城市三甲医院营养不良,(,营养不足,),、营养风险发生率及营养支持应用状况调查,.,中国临床营养杂志, 2008, 16(6): 335-338.,）,2002年ASPEN指南（B级推荐）,43,单个队列研究 (如 0.,营养不良发生与痴呆严重程度相关,Eur J Clin Nutr 2002;56:24551.,血糖正常患者，每周检测血糖1次3次。,500ml时暂停肠内营养，并对患者胃肠耐受性进行再评价,有治疗以前有些患者死亡，有治疗以后无患者死亡,单个队列研究 (如 3,(%),955,(33.9),751,(35.2),937,(36.4),1130,(44.7),590,(25.5),1004,(36.6),NRS0.05),（高金霞,宿英英,.,等热量不同糖成分营养制剂对急性脑卒中患者血糖影响的随机对照研究,J.,中国临床营养杂志,2008,16(4):209-210.,(,2b,级证据，,B,级推荐,),2006年CSPEN指南：血糖监测和血糖控制稳定的情况下，一,59,2008,年,RCT,研究,60,例重症（,GCS12,分）脑卒中患者,高蛋白肠内营养制剂和糖尿病专用型肠内营养制剂比较,持续泵入两种肠内营养制剂对血糖影响无明显差异，高蛋白肠内营养制剂的血清蛋白支持作用更强。,2008年RCT研究,60,重症神经系统疾病并发低蛋白血症患者约占,10.7,19%,，其既可增加感染率和死亡率，又可加重脑损伤程度,近期多项小样本,RCT,研究发现，危重患者选用高蛋白肠内营养配方能够改善氮平衡、减轻低蛋白血症程度，推测与高蛋白肠内营养配方提供的高氮源量有关。,重症神经系统疾病并发低蛋白血症患者约占10.719%，其既,61,RCT,研究,51,例重症（,GCS,平均,78,分）脑卒中患者,发病,7,天高蛋白肠内营养制剂组血清蛋白下降低于对照组，前白蛋白为著（,P,0.05,）,发病,14,天内,APACHE,19,分患者，高蛋白肠内营养制剂组低蛋白血症发生率明显低于对照组（,P,0.05,）,2006,RCT研究2006,62,血清蛋白,血清白蛋白（,albumin,）,肝脏合成,12g/d,，以前白蛋白的形式合成,是血浆中最主要的蛋白质，浓度,38%48%,，血浆总蛋白的,50%,半衰期,20,天,血清前白蛋白（,prealbumin, PA,）,结合甲状腺素,半衰期,2,天，监测饥饿和营养治疗反应的敏感指标,血清蛋白血清白蛋白（albumin）,63,白蛋白生理作用,维持血浆胶体渗透压,维持血浆胶体渗透压（,80%,）,决定水在血管内外的分布,运转（血浆中最主要载体）小分子物质,亲脂性结合位点，运输多种物质,营养,血浆中约,200g,，用于组织蛋白合成和供能,白蛋白生理作用维持血浆胶体渗透压,64,6.,营养输注管道选择,短期（,4,周）,首选鼻胃管喂养。,（,A,级推荐）,不耐受鼻胃管喂养或有反流和误吸高风险患者选择鼻肠管喂养。,（,B,级推荐）,。,长期（,4,周）,有条件情况下,选择经皮内镜下胃造瘘术（,PEG,）喂养。,（,A,级推荐）,6.营养输注管道选择 短期（4周）,65,The FOOD Trial,血糖水平与不良结局相关,Clin Nutr, 2005, 24(6):1073-1077.,监测血清电解质和肾功能,腹泻（稀便3次/d或稀便200g/d）,增加粪便体积和水分，促进肠道运动,上消化道出血（隐血试验证实）,9种情况的营养制剂选择,血糖正常患者，每周检测血糖1次3次。,Poor Nutritional Status on