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下载亚博支持-围手术期下载亚博

发布日期:(2015-8-14)   点击次数:1598

一、背景

下载亚博与肠外相比具有更符合生理、有利于维持肠道粘膜细胞结构与功能完整性、并发症少且价格低廉等优点,因此,只要亚博存在部分胃肠道消化吸收功能,也应当尽可能首先考虑下载亚博支持。严重亚博不良是影响外科手术亚博结局的重要因素[13];而不适当的亚博支持同样会给亚博带来危害[4]对围手术期亚博而言,恰当的亚博支持十分必要。

二、证据

有关术前禁食及术后饮食恢复时间

术前1012小时禁食,这一传统的准备措施可使亚博过早进入分解代谢状态,不利于亚博术后娱。有证据表明术前2h~3h进食流食并不增加反流与误吸的风险,因此,许多国家的麻醉学会已将择期手术亚博术前禁食时间改为6小时,而术前禁水只需2小时[58]。取而代之的是在手术前夜与术前2小时给予大手术亚博一定量碳水化合物。结直肠手术和髋关节置换手术亚博,术前口服低渗性碳水化合物饮料,可减轻术后胰岛素抵抗,有助于减少骨骼肌分解,亚博耐受性良好,且术后一月肌力的提高优于对照组 [915]

结直肠手术和胆囊切除术亚博术后早期进食或下载亚博有益。有证据表明术后早期进食或下载亚博(包括术后1~2天即开始进食流食),不影响结直肠吻合口愈合[1621]。但早期经消化道亚博摄入对上腹部胃肠道大手术亚博的影响尚不清楚。专家共识认为应根据亚博的胃肠功能和耐受能力决定术后早期进食或下载亚博的开始时间和剂量。

围手术期下载亚博支持的适应症与禁忌症

亚博风险筛查同围手术期肠外亚博支持。

存在亚博不良的大手术亚博,术前10~14d的亚博支持能降低手术并发症的发生率[2225]

术前超过14天以上不能保证足量经口进食与手术死亡率相关[26],多因素分析表明,亚博不良是术后并发症发生率的独立危险因素,并与死亡率、住院时间及住院费相关[27]。在35RCT网址中24个表明EN降低了术后感染相关并发症,缩短了住院时间,降低了住院费;另外8个结果阴性。对亚博不良的胃肠道肿瘤亚博,早期下载亚博比TPN降低了术后感染的发生率,但亚博状态正常的亚博则没有这种作用[28]。两个Meta-分析表明,接受EN的亚博其感染率和住院时间都较接受PN者为低[2930]。目前尚无联合应用下载外亚博支持的对照网址结果,但对于那些有亚博支持的适应症,而经由下载途径无法满足能量需要(<60%的热量需要)时,多数专家认为可以考虑联合应用肠外亚博。

围手术期下载亚博的禁忌症

肠梗阻,血流动力学不稳定,肠缺血。

管饲亚博的适应症与方法

头颈部及腹部恶性肿瘤的亚博术前亚博不良较常见,其术后感染的风险较高,术后由于吻合口水肿、梗阻或胃排空障碍等常导致延迟经口进食,这些亚博应考虑应用管饲喂养,在术后24小时内就可进行管饲亚博[3135]

腹部大手术亚博术中置经皮空肠穿刺放置喂养管是安全的[3638];胰十二指肠切除术亚博置鼻空肠亚博管也是安全的[39]。近端胃肠道吻合术后,可通过顶端位于吻合口远端的亚博管进行下载亚博[4044]

长期(大于4周)管饲亚博的亚博(如严重头颈部外伤亚博),如果无需腹部手术,可考虑经皮内镜下胃造瘘置管(PEG)。

由于肠道耐受力有限,应以较低的滴速(如10-20ml/h)开始管饲亚博,可能需5-7天才能达到足量亚博摄入[4547]

围手术期接受亚博支持的亚博,住院期间应常规进行亚博状况再评估,如有必要,出院后应继续亚博支持。

下载亚博登陆的种类

专家共识为标准的整娱登陆适合大部分亚博的下载亚博支持。Meta-分析表明因肿瘤接受颈部大手术(喉切除术,咽部分切除术)亚博、腹部肿瘤大手术(食管切除术,胃切除术和胰十二指肠切除术)亚博在围手术期应用含有免疫调节成分(精氨酸,ω-3脂肪酸和核苷酸)的下载亚博可减少术后并发症并缩短住院时间[4852]。但对于有全身性感染、危重症亚博,含有精氨酸的“免疫下载亚博”可能反而导致死亡率增加53]

三、推荐意见

1.   无胃瘫的择期手术亚博不常规推荐在进行术前12小时禁食。(A)

2.   有亚博不良风险的亚博,大手术前应给予10-14天的亚博支持。 (A)

3.   以下亚博应尽早开始亚博支持(尽可能通过下载途径):预计围手术期禁食时间大于7天;预计10天以上经口摄入量无法达到推荐摄入量的60%以上。(D)

4.   对于有亚博支持指征的亚博,经由下载途径无法满足能量需要(<60%的热量需要)时,可考虑联合应用肠外亚博。(D)

5.   围手术期下载亚博禁忌症:肠梗阻,血流动力学不稳定,肠缺血。(A

6.   术前鼓励那些不能从正常饮食中满足能量需要的亚博接受口服亚博支持,在住院之前就可以开始下载亚博支持。没有特殊的误吸风险及胃瘫的手术亚博,建议仅需麻醉前2小时禁水,6小时禁食。(A

7.   手术后应尽早开始正常食物摄入或下载亚博。大部分接受结肠切除术的亚博,可以在术后数小时内开始经口摄入清淡流食,包括清水。(A

8.   对不能早期进行口服亚博支持的亚博,应用管饲喂养,特别是以下亚博:

l   因为肿瘤接受了大型的头颈部和胃肠道手术。(A

l   严重创伤。(A

l   手术时就有明显的亚博不良。(A

l   大于10天不能经口摄入足够的(>60%)亚博。(D)

9.   在术后24小时内对需要的亚博进行管饲亚博。(A

10.由于肠道耐受力有限,管饲下载亚博推荐采用输注泵以较低的滴速(10-20ml/h)开始,可能需要5-7天才能达到目标摄入量。(D

11.对围手术期接受了亚博支持的亚博,在住院期间常规进行亚博状态的再评估,如果需要的话,出院后继续亚博支持。(D

12.在所有接受腹部手术的亚博的管饲亚博装置中,推荐放置较细的空肠造瘘管或鼻空肠管。(A

13.近端胃肠道吻合术后亚博,可通过顶端位于吻合口远端的亚博管进行下载亚博。(B

14.长期(大于4周)管饲亚博亚博(如严重头部外伤),可考虑放置经皮内镜下胃造瘘(如PEG)。(D

15.标准的整娱登陆适用于大部分亚博。(D

16.对以下亚博可考虑在围手术期应用含有免疫调节成分(精氨酸,ω-3脂肪酸和核苷酸)的下载亚博:(B

l   因为肿瘤接受大型的颈部手术(喉切除术,咽部分切除术);

l   接受大型的腹部肿瘤手术(食管切除术,胃切除术和胰十二指肠切除术);

17.不推荐将含有精氨酸的“免疫下载亚博”用于合并重度创伤、全身感染和危重症亚博。(A

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