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积极评估与干预:胃肠加速康复外科指南中的营养问题

于健春 薛志刚

于健春, 薛志刚. 积极评估与干预:胃肠加速康复外科指南中的营养问题[J]. 协和医学杂志, 2018, 9(6): 490-495. doi: 10.3969/j.issn.1674-9081.2018.06.003
引用本文: 于健春, 薛志刚. 积极评估与干预:胃肠加速康复外科指南中的营养问题[J]. 协和医学杂志, 2018, 9(6): 490-495. doi: 10.3969/j.issn.1674-9081.2018.06.003
Jian-chun YU, Zhi-gang XUE. Active Assessment and Intervention:Issues of Clinical Nutrition in Guidelines for Enhanced Recovery after Gastrointestinal Surgery[J]. Medical Journal of Peking Union Medical College Hospital, 2018, 9(6): 490-495. doi: 10.3969/j.issn.1674-9081.2018.06.003
Citation: Jian-chun YU, Zhi-gang XUE. Active Assessment and Intervention:Issues of Clinical Nutrition in Guidelines for Enhanced Recovery after Gastrointestinal Surgery[J]. Medical Journal of Peking Union Medical College Hospital, 2018, 9(6): 490-495. doi: 10.3969/j.issn.1674-9081.2018.06.003

积极评估与干预:胃肠加速康复外科指南中的营养问题

doi: 10.3969/j.issn.1674-9081.2018.06.003
基金项目: 

国家卫生计生委公益性行业科研专项基金 201502022

北京市科技计划项目 D141100000414002

详细信息
    通讯作者:

    于健春  电话: 010-69152629, E-mail: yu-jch@163.com

  • 中图分类号: R656

Active Assessment and Intervention:Issues of Clinical Nutrition in Guidelines for Enhanced Recovery after Gastrointestinal Surgery

More Information
    Corresponding author: YU Jian-chun  Tel: 010-69152629, E-mail: yu-jch@163.com
  • 摘要: 加速康复外科(enhanced recovery after surgery, ERAS)在胃肠外科领域开展已有20余年, 尤其在结直肠外科中应用较为广泛。胃肠外科领域已有多部ERAS指南发表, 近年来国内外对胃肠外科ERAS指南又作了多次修订与更新, 有助于进一步规范围手术期胃肠外科管理。临床营养是ERAS中必不可少的重要组成部分, 包括术前营养评估、口服营养补充预康复、术后早期肠内营养等内容, 在指南更新中得到越来越多的关注与重视, 本文就国内外最新更新的ERAS指南中的临床营养部分进行重点解读。
  • 表  1  胃肠加速康复外科基本环节及核心内容

    基本环节 内容 证据质量/推荐强度
    预康复 ·包括生活方式干预、运动建议、饮食指导等[9] 低/强
    ·生活方式干预:戒烟戒酒至少4周,以减少术后并发症[15-16] 戒烟:高/强;戒酒:低/强
    ·健康宣教:门诊及住院个体化病情咨询与解答[17-18] 低/强
    术前准备 ·不常规行机械性肠道准备,以减少脱水等发生[19] 中/强
    ·术前6 h内禁食固体食物,术前2~3 h口服糖盐(不超过400 ml)以改善术后胰岛素抵抗 低/强
    ·不推荐术前麻醉用药(镇静类或抗焦虑药物),宣教、心理干预和口服糖盐有助于改善 高/强
    术前紧张焦虑[20]
    术中管理 ·切开皮肤前30~60 min,预防性使用抗生素 高/强
    ·全麻或联合硬膜外阻滞等多模式麻醉镇痛,检测麻醉深度 中/强
    ·采用加温床垫、加热液体等方式维护体温 高/强
    ·胃肠外科微创手术(腹腔镜、机器人系统)可减少手术创伤、缩短术后住院天数 结直肠外科:高/强;胃外科:中/强
    ·限制性容量治疗,监测补液量和心输出量 结直肠外科:高/强;胃外科:中/强
    ·不常规使用鼻胃管,若必须使用,建议术中留置,术后24 h内拔除[21] 高/强
    ·避免或减少腹腔引流[22] 高/强
    术后措施 ·导尿管建议术后1~2 d拔除 结直肠外科:低/强;胃外科:高/强
    ·积极预防和控制术后恶心呕吐,术前缩短禁食禁饮时间、口服糖盐、减少使用阿片类药物、预防性应用止吐药等多模式 低/强
    ·术后多模式镇痛:推荐使用非甾体类抗炎药为基础用药,减少使用阿片类药物,切开和缝合皮肤前局麻浸润等 中/强
    ·术后血糖控制 低/强
    ·预防术后肠梗阻:硬膜外麻醉、减少阿片类药物使用、避免过量体液输注、早期经口进食、咀嚼口香糖等促进肠蠕动 结直肠外科:高/强;胃外科:低/弱
    ·早期下床活动,制定每天活动量计划 结直肠外科:低/强;胃外科:极低/强
    ·出院后随访 低/强
    下载: 导出CSV

    表  2  营养风险筛查2002评分表

    评估项目 赋分 标准
    营养损害程度 0分(无) 营养状态正常
    1分(轻度) 3个月内体重下降>5%,进食量约为正常需求量50%~75%
    2分(中度) 2个月内体重下降>5%,或进食量约为正常需求量25%~50%,或BMI在18.5~20.5 kg/m2之间
    3分(重度) 1个月内体重下降>5%(或3个月内体重下降>15%),进食量约为正常需求量0~25%,或BMI<18.5 kg/m2
    疾病严重程度 0分(无)
    1分(轻度) 盆骨骨折,慢性病合并急性并发症,如肝硬化、慢性阻塞性肺病、慢性血液透析、糖尿病、肿瘤等
    2分(中度) 腹部大手术*、卒中、重症肺炎、血液透析、血液恶性肿瘤
    3分(重度) 颅脑损伤、骨髓移植、重症监护患者(急性生理学和慢性健康状况评分>10分)
    年龄 0分 <70岁
    1分 ≥70岁
    *包括未来1周内计划手术者; BMI:体质量指数
    下载: 导出CSV
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  • 收稿日期:  2018-08-27
  • 刊出日期:  2018-11-30

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