核酸及核苷酸用于营养及免疫调节治疗的早期卫生技术评估

目的：评价核酸或核苷酸用于临床营养支持和免疫调节治疗的安全性，有效性和经济学价值。方法：检索中国生物医学献数据库，Cochrane图书馆，MEDLINE光盘数据库，EMBASE光盘数据库，并联机检索SCI数据库，鉴定有关随机对照试验（RCTs)，采用RevMan4.1进行Meta-分析。结果：纳入46个随机对照试验，涉及核酸／核苷酸用于肠内营养支持，婴儿营养，免疫调节治疗。18个研究报告了含核苷酸组分的免疫增强型肠内营养对外科术后和危重症患预后的影响，合并分析发现免疫营养对患感染率，住院时间和费用有肯定意义。发现1个报告在母乳代用品中加入核苷酸对婴儿免疫功能影响的研究，但报告对临床结局无明显影响。27个对“免疫核酸”用于免疫调节治疗的随机对照试验均为低质量研究，合并分析无法肯定iRNA的临床价值。结论：在外科术扣患应用免疫肠内营养制剂可降低感染率，缩短住院时间并可能减少住院费用，但不能确定作为组分之一的核苷酸的作用。尚无证据支持在母乳代用品中添加核苷酸具有临床意义。不能肯定免疫核酸是否具有免疫调节作用，亦未发现核酸在延缓衰老，改善老年人健康状况方面的可用证据。建议对核酸，核苷酸用于营养支持治疗和免疫调节治疗进行进一步研究，严格规范“核酸营养品”的宣传和应用。     

ICU肠内营养患者喂养不耐受预防及管理的最佳证据总结

目的总结ICU肠内营养患者喂养不耐受(FI)预防和管理的相关证据, 为临床实践提供依据。方法系统检索中英文数据库、指南网及专业协会网站中有关ICU肠内营养患者FI预防和管理的文献, 包括临床实践指南、系统评价、证据总结、专家共识、随机对照试验, 检索时限为2013年1月1日—2023年3月29日。2名研究者对纳入文献进行质量评价、证据提取与汇总。结果共纳入25篇文献, 其中临床实践指南5篇、证据总结3篇、系统评价11篇、专家共识1篇和随机对照试验5篇。从风险评估、预防措施、干预措施和评价4个方面总结了37条证据。结论本研究总结了ICU肠内营养患者FI预防及管理最佳证据, 建议医护人员结合临床情境及患者意愿应用证据。     

直肠癌术后早期肠内营养患者误吸预防的循证护理

目的通过查找筛选高质量临床文献证据,为直肠癌术后患者早期肠内营养误吸合理治疗和预防方案的制订提供依据;并把证据应用于临床,指导临床护理实践,促进护理质量提升。方法由专业人员进行检索,检索词为肠内营养、误吸、tube feeding、aspiration等,数据库为Cochrane图书馆中Cochrane Database of Systematic Reviews、Cochrane Central Register of Controlled Trials、Database of Abstracts of Review s of Effects及MEDLINE、中国知网原始文献数据库。检索范围:肠内营养误吸的预防和治疗相关的系统评价、Meta分析、随机对照试验等。结果共检索出相关文献22篇,其中符合条件者13篇。结论在科学方法的指导下寻找证据指导临床营养护理,可以有效预防误吸,提高患者生存质量。     

肠内免疫营养治疗急性胰腺炎疗效的系统评价

目的系统评价肠内免疫营养对急性胰腺炎患者的治疗效果。方法计算机检索PubMed（1966—2012．8）、MEDLINE（Ovid,1946～2012．8）、CENTRAL（2012年第3期）、CBM（1978～2012．8）、CNKI（1979--2012．8）、VIP（1989～2012．8）、WanFangData（1977—2012．8）,查找有关采用肠内免疫营养治疗急性胰腺炎的随机对照试验（RCT）,并手工检索相关资料追溯参考文献。由2位评价者根据纳入和排除标准独立筛选文献、提取资料并评价质量后,采用RevMan5．0软件进行Meta分析。结果最终纳入6个RCT,共197例患者。Meta分析结果显示,肠内免疫营养与常规肠内营养比较,在急性胰腺炎患者感染并发症的发生率、病死率、住院时间、治疗后c反应蛋白水平和白细胞计数、急性生理学及慢性健康状况评分Ⅱ方面,两者差异均无统计学意义。结论目前尚无急性胰腺炎患者使用肠内免疫营养优于普通肠内营养的证据。受纳入研究的数量与质量所限,上述结论尚待今后开展更多高质量、大样本的RCT验证,以探寻适宜于急性胰腺炎患者的肠内免疫营养剂的成分和剂量。     

胃手术后肠内营养相关性腹泻患者的循证护理

目的运用循证方法,为胃手术后患者肠内营养相关腹泻制定合理的预防和治疗方案。方法根据患者病情,提出临床问题：营养液最佳输注设备;营养液的输注方式和温度;是否需要在营养液中添加治疗性物质或更换营养液。计算机检索Cochrane 图书馆、Cochrane Central Register of Controlled Trials (CCRT)、Database of Abstracts of Reviews of Effects(DARE)、MEDLINE及中国生物医学文献数据库,查找筛选高质量临床文献证据,制定合理护理方案。结果共检索出针对肠内营养相关的腹泻问题方案相关的2篇系统评价、1篇Meta分析证据水平Ia级,证据分级A级;3篇随机对照研究证据水平Ib级,证据分级 A级,2篇随机对照研究证据水平为IIb级,证据分级B级。将提取的证据应用于292例胃手术后患者,19例发生肠内营养相关腹泻（6.5%）,低于同期研究的腹泻发生率;2例改为肠外营养,其他在进行有效护理后继续行肠内营养至恢复。结论肠内营养患者均使用营养泵进行输注,从小剂量、低浓度、低速度开始,逐步增加剂量,同时营养液需要加温;营养液可添加益生菌、膳食纤维免疫物质、抗氧化剂或使用含有这些物质的营养液,可以有效预防患者腹泻发生。     

消化道肿瘤病人术后早期肠内免疫营养支持的护理现状

从常用的免疫营养制剂、免疫营养物质作用机制及临床免疫营养支持护理方面对术后肠内免疫营养支持的应用及护理做一综述。提出肠内免疫营养的护理是否与普通肠内营养护理有所区别,这类研究尚未发现,需要通过比较严谨的随机对照试验研究进行证实。     

消化道肿瘤病人术后早期肠内免疫营养支持的护理现状

从常用的免疫营养制剂、免疫营养物质作用机制及临床免疫营养支持护理方面对术后肠内免疫营养支持的应用及护理做一综述。提出肠内免疫营养的护理是否与普通肠内营养护理有所区别,这类研究尚未发现,需要通过比较严谨的随机对照试验研究进行证实。     

基于加速康复外科的早期肠内营养支持对结直肠癌手术患者营养及免疫指标的影响

目的 探讨基于加速康复外科的早期肠内营养支持对结直肠癌手术患者营养及免疫指标的影响。方法 选取2019年1～12月我院收治的83例结直肠癌患者,根据不同治疗方案分为对照组41例和观察组42例。对照组行传统围手术期治疗措施,观察组进行基于加速康复外科的早期肠内营养支持治疗,观察两组患者营养指标及免疫指标水平。结果 术后7天,观察组患者营养指标水平及免疫指标水平均高于对照组,差异有统计学意义(P0.05)。结论 基于加速康复外科的早期肠内营养支持可显著改善结直肠癌手术患者营养及免疫指标水平,具有较好临床疗效,值得推广。     

ICU俯卧位通气患者肠内营养管理的最佳证据总结

目的 提取、评价和综合俯卧位通气患者肠内营养的相关证据,为制订科学、有效的俯卧位通气患者肠内营养管理方案提供循证依据。方法 按照证据金字塔“6S”模型检索Best Practice,Up To Date,Joanna Briggs Institute循证卫生保健中心数据库、美国肠外肠内营养学会、Cochrane Library,PubMed,中国知网、Embase,万方、维普和中国生物医学文献数据库等数据库关于重症病房俯卧位通气患者肠内营养的相关证据,检索时间为建库至2022年12月1日;研究小组结合临床专业判断,对符合质量标准的文献进行证据提取及综合。结果 纳入文献16篇,归纳提取肠内营养前评估、肠内营养目标、途径、制剂的选择、启用时机及中断后启用时机、肠内营养体位、营养方案、监测指标、人员配置及培训、并发症预防及处理10个方面共25条最佳证据,其中11条A级推荐、14条B级推荐。结论 本研究提取的25条最佳证据质量较高,可用于俯卧位通气患者肠内营养的实施。     

新生儿肠内营养胃管留置管理的最佳证据总结

目的 检索、评价并整合国内外新生儿肠内营养胃管留置管理的相关证据。方法系统检索英国医学杂志最佳临床实践网、Up To Date、CINAHL、加拿大医学会临床实践指南网、国际指南网、WHO指南网、美国国立指南库、医脉通、Cochrane图书馆、PubMed、中国知网、中国生物医学文献数据库、万方数据库、维普等数据库等网站和数据库中关于新生儿肠内营养胃管留置管理的临床决策、推荐实践、证据总结、临床实践指南、技术报告、专家共识、系统评价,由2名研究者独立进行方法学质量评价后,根据主题对证据进行提取与汇总,检索时限为建库至2023年5月。结果 共纳入14篇文献,包括指南2篇、证据总结1篇、系统评价5篇、专家共识3篇、最佳实践2篇、随机对照研究1篇。最后总结包括适应与禁忌、置管前的准备与评估、胃管位置验证、胃管固定、胃管维护5个方面的22条证据。结论 本研究通过系统检索国内外高级别的循证资源,对新生儿肠内营养胃管留置的管理进行证据总结,所总结的新生儿肠内营养胃管留置管理证据全面、实用,可为规范新生儿胃管留置管理管理提供循证依据,保证新生儿肠内营养安全,提高新生儿护理质量。     

Arginine immunonutrition in critically ill patients: a clinical dilemma.

Commercial enteral nutritional formulas for enhancement of the immune system are widely used in critical care. Immunonutrition with arginine can enhance inflammatory and immunologic responses in animal models and in humans. Although clinical improvements in surgical patients have been reported, benefits in critically ill patients with systemic inflammatory response syndrome, sepsis, or organ failure are less clear. Recent meta-analyses on the use of immunonutrition with arginine in critically ill and surgical patients revealed methodological weaknesses in most published studies. Specifically, a meta-analysis indicated that critically ill patients with preexisting severe sepsis may have an increased mortality rate when fed an immunonutritional enteral formula that contains arginine. These findings brought about confusion and controversy over the use of immunonutritional formulas in subsets of critically ill patients. A review of the literature on the function of arginine, its effect on the immune system, its roles in immunonutrition and in the clinical outcomes of critically ill patients, and the implications for nursing practice indicated that the benefits of immunonutrition with arginine in critically ill patients are unproven and warrant further study. Until more information is available, nutritional support should focus primarily on preventing nutritional deficiencies rather than on immunomodulation.     

围手术期应用肠内免疫营养对胃癌术后患者免疫功能和营养状况的药理作用

目的探讨围手术期强化免疫营养素肠内营养支持对胃癌患者免疫功能和营养状况的影响。方法将2007年3月-2012年12月间24例胃癌术后患者随机分为肠内免疫营养组（研究组）和常规肠内营养组（对照组）,每组12例,进行等氮等热量营养支持,术前5d至术后7d。测定营养支持前后的血清白蛋白、前白蛋白、转铁蛋白、T淋巴细胞亚群及血清免疫球蛋白等指标变化。临床观察胃肠功能恢复时间。结果术后两组患者血清蛋白水平和免疫指标多有下降,但研究组术后8d的血清前白蛋白水平和IgG、CD4／CD8比值较对照组明显增加,研究组胃肠功能恢复时间早于对照组。结论围手术期应用强化免疫肠内营养支持可改善胃癌患者术后营养和免疫状况,促进肠道功能恢复。     

Immunologically enhanced enteral nutrition: current status

With increasing interest in enteral feeding and the role of the gut in the development of infection and multiple organ failure in critically ill patients, the use of enteral feedings enriched with immune-enhancing ingredients is attracting considerable interest. This approach to modulating the immune and inflammatory responses has become known as immunonutrition, and many products are now available for clinical use. Several have been subjected to clinical study in various patient groups, with encouraging results in terms of reducing infection rates and length of hospital stay. They appear to benefit both critically ill patients and patients undergoing major surgery, particularly when feeding is started preoperatively. Two systematic reviews have been published, both with positive results. Nevertheless, as new products become available they should be subjected to controlled clinical trials, especially because several of the mechanisms involved are not yet fully understood.     

Are there any real differences between enteral feed formulations used in the critically ill?

PURPOSE OF REVIEW: We know that adequate nutritional support is essential in the treatment of critically ill patients, because it can, if applied appropriately, improve the clinical outcome. Increasing evidence seems to suggest that malnutrition itself is a predictor of poor outcome in intensive care, and significant underfeeding during intensive care stay increases the risk of bloodstream infections. The purpose of this review is to highlight recent advances in enteral nutrition in the critically ill adult patient. RECENT FINDINGS: Recent studies suggest that tight glycaemic control is associated with improved outcome. Enteral feeding should be encouraged, using simple feeding protocols, and started early if safe to do so. Gastric residual volumes do not correlate with the risk of aspiration, and therefore should be used with caution in feeding protocols. Conflicting evidence exists for supplementation with antioxidant and immunonutrition in the critically ill. Glutamine and fish oil/borage oil should be considered for burns patients and patients with adult respiratory distress syndrome, respectively. SUMMARY: This review offers information regarding the latest developments in nutritional support via the enteral route. Further research is needed to clarify the role of enteral supplements such as antioxidants and 'immune modulating substances'.     

Lipids in the nutritional support of the critically ill patients

PURPOSE OF REVIEW: This review reports recent findings on lipid use in artificial nutrition in patients with acute respiratory failure or severe sepsis or undergoing major surgery. It examines current knowledge of fatty acid safety, biologic effects, and the impact on patients' morbidity and mortality. The newly emerging area of genotypic influence and timing of immunonutrition is also discussed. RECENT FINDINGS: In acute respiratory distress syndrome, the debate concerning the use of long-chain fatty acids as opposed to physical mixtures of medium- and long-chain fatty acids, specifically regarding their effects on gas exchange and pulmonary hemodynamics, still remains unresolved. By contrast, providing fish oil fatty acids (mainly eicosapentaenoic and docosahexaenoic acids) and/or gamma-linolenic acid, seems to decrease harmful excessive inflammatory/immune activation and to improve clinical outcome. Similar effects, although not conclusively demonstrated, have been reported for n-3 fatty acid-enriched lipid emulsions in patients with sepsis. Few recent studies examined the impact of n-3 fatty acid-enriched enteral formulas on patients undergoing major surgery. Most studies focused on intravenous fish oil and suggest beneficial effects both on inflammatory/immune parameters and patient outcome. Studies suggest that lipid use in critically ill patients may be improved by increased knowledge of genetic determinants of severity of injury and response to therapeutic agents as well as by the development of tools that allow better timing of immunonutritional intervention. SUMMARY: Overall, lipids, in particular n-3 fatty acids, emerge as powerful nutrients with pharmacologic properties potentially improving prognosis in critically ill patients. However, heterogeneity in study design makes the interpretation of available studies difficult. Consequently, larger prospective, randomized, double-blind trials with comparable methodologies are necessary for detailed evaluation of the pharmacologic impact of lipids. In addition, a better knowledge of the influence of genotypic variation and postinjury inflammatory/immune temporal patterns may improve our current therapeutic use of various fatty acids.     

Closer to the gold standard: an appraisal of formulae available in Italy for use in formula-fed infants

Infant formulae are the only alternatives to breast milk for infants who are unable to continue breastfeeding through the first year of life. They aim to provide formula-fed infants with the same structural and functional benefits observed in breastfed infants. To achieve this, bioactive nutrients have been added to infant formulae in recent years: long-chain polyunsaturated fatty acids for neurodevelopment; probiotics and prebiotics for local gastrointestinal defence; and nucleotides for promoting the immune response. Changes in protein quantity and quality allow infant formulae to achieve a balance between providing the correct plasma amino acid profile and reducing the protein intake, which could prevent obesity in later life. Hydrolysed proteins may help prevent atopic disorders. Many short-term trials have been published but long-term follow-up data are needed in infants who have been fed the newer infant formulae, to fully understand the role of bioactive nutrients.     

Ten steps for promoting and protecting breastfeeding for vulnerable infants

Human milk is the preferred food for infants, including ill and preterm infants. Ensuring skilled and comprehensive breastfeeding support for these vulnerable infants requires a specialized approach. The author outlines 10 steps for promoting and protecting breastfeeding in vulnerable infants. The steps include providing the parents with information necessary to make an informed decision to breastfeed; assisting the mother with the establishment and maintenance of a milk supply; ensuring correct breast milk management (storage and handling) techniques; developing procedures and approaches to feeding the infant breast milk; providing skin-to-skin care (kangaroo care) and opportunities for non-nutritive sucking at the breast; managing the transition to the breast; measuring milk transfer; preparing the infant and the family for infant hospital discharge; and providing appropriate follow-up care. Material and examples are drawn from the author's research and clinical work at the Children's Hospital of Philadelphia. Current research is utilized, and the role of the nurse is emphasized throughout.     

How to feed patients with sepsis

Sepsis is associated with profound catabolism and hypermetabolism that complicate provision of nutritional support. These metabolic changes are caused by inflammatory mediators involved in the septic process and cannot be reversed by nutritional means. High protein isocaloric nutritional regimens are recommended if possible, in association with aggressive measures to control the sepsis. However, nutritional therapy and its complications may also affect the incidence and course of sepsis. Hyperglycemia and conventional intravenous fat emulsions have been shown to increase susceptibility to infection. Enteral nutrition is associated with fewer infectious complications than parenteral nutrition, at least in severely injured patients. Recently nutritional formulations have been introduced that contain novel substrates that enhance various aspects of immunity. Several studies have suggested that this immunonutrition reduces infection risk in the critically ill, and preliminary findings suggest it may even have an effect on survival in sepsis.