神经系统疾病营养支持

神经系统疾病营养支持共识2009宣武医院背景•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）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、魏东宁第一部分神经系统疾病营养支持适应症撰写方法文献检索（脑卒中、痴呆、持续神经性吞咽障碍、昏迷）确认证据（OCEBM）推荐意见牛津循证医学中心分级（OxfordCentreforEvidence-basedMedicine，OCEBM）推荐意见证据级别描述A1a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B2a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RCT3a基于病例对照研究（具有同质性）3b单个病例对照研究C4病例报道(低质量队列研究)D5专家意见或评论年限文献方法结论证据级别1996Effectofmalnutritionafteracutestrokeonclinicaloutcome.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3b104例1998Nutritionalstatusofhospitalizedacutestrokepatients.BrJNutr,1998,79(6):481-487.病例对照3b201例2004Impactofpremorbidundernutritiononoutcomeinstrokepatients.Stroke,2004,35(8):1930-1934.病例对照3b185例2005Malnutritiondeterminedbythepatient-generatedsubjectiveglobalassessmentisassociatedwithpooroutcomesinacutestrokepatients.ClinNutr,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（13dvs8d）并发症增加（50%vs14%）。2b73例脑卒中伴吞咽困难患者年限文献方法结论证据级别1992ParkRH,AllisonMC,LangJ,etal.Randomisedcomparisonofpercutaneousendoscopicgastrostomyandnasogastrictubefeedinginpatientswithpersistingneurologicaldysphagia.BrMedJ1992;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NGT1b40例2006HamidonBB,AbdullahSA,ZawawiMF.Aprospectivecomparisonofpercutaneousendoscopicgastrostomyandnasogastrictubefeedinginpatientswithacutedysphagicstroke.MedJMalaysia.2006Mar;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。1b22例脑卒中伴吞咽困难患者年限文献方法结论证据级别1996NortonB,Homer-WardM,DonnellyMT,LongRG,HolmesGK.Arandomisedprospectivecomparisonofpercutaneousendoscopicgastrostomyandnasogastrictubefeedingafteracutedysphagicstroke.BrMedJ1996;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NGT1b30例脑卒中伴吞咽困难患者20032005FOODTrialCollaboration.PoorNutritionalStatusonAdmissionPredictsPoorOutcomesAfterStroke.ObservationalDataFromtheFOODTrial.StrokeJune2003，1450-1456.TheFOODTrialCollaboration.Effectoftimingandmethodofenteraltubefeedingfordysphagicstrokepatients(FOOD):amulticentrerandomizedcontrolledtrial.Lancet2005;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2~3周则最好选择NGT途径（除非具有很强的PEG指征）1b2955例脑卒中伴吞咽困难患者20052006FOOD:Routineoralnutritionalsupplementationforstrokepatientsinhospital(FOOD):amulticentrerandomisedcontrolledtrial.Lancet,2005,365(9461):755-763.FOOD:amulticentrerandomisedtrialevaluatingfeedingpoliciesinpatientsadmittedtohospitalwitharecentstroke.HealthTechnolAssess,2006,10(2):1-120.多中心随机对照Supplementeddietwasassociatedwithanabsolutereductioninriskofdeathof0.7%(95%CI-1.4to2.7，p＝0.5)andanincreasedriskofdeathorpooroutcomeof0.7%(-2.3to3.8，p＝0.6).1b4012例脑卒中伴吞咽困难患者Stroke.2003;34:1450-1456.PoorNutritionalStatusonAdmissionPredictsPoorOutcomesAfterStrokeObservationalDataFromtheFOODTrialFOODTrialCollaboration分类人数死亡率并发症总人数2955/3012547/2955（18.5%）营养正常2194/2955445/2194（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=1.8295%CI=1.34-2.47Conclusions•Thesedataprovidereliableevidencethatnutritionalstatusearlyafterstrokeisindependentlyassociatedwithlong-termoutcome.•ItsupportstherationalefortheFOODtrial,whichcontinuestorecruitandaimstoestimatetheeffectofdifferentfeedingregimesonoutcomeafterstrokeandthusdeterminewhethertheassociationobservedinthisstudyislikelytobecausal.Effectoftimingandmethodofenteraltubefeedingfordysphagicstrokepatients(FOOD):amulticentrerandomisedcontrolledtrialTheFOODTrialCollaborationAvailableonline25February2005.Undernutritioniscommoninpatientsadmittedwithstroke.weaimedtoestablishwhetherthetimingandrouteofenteraltubefeedingafterstrokeaffectedpatients’outcomesat6months..BackgroundTheFOODtrialsconsistofthreepragmaticmulticentrerandomisedcontrolledtrials,twoofwhichincludedysphagicstrokepatients.Intheother,patientswereallocatedpercutaneousendoscopicgastrostomy(PEG)ornasogastricfeeding.Inonetrial,patientsentrolledwithin7daysofadmissionwererandomlyallocatedtoearlyenteraltubefeedingornotubefeedingformorethan7days(earlyversusavoid).MethodsTheprimaryoutcomewasdeathorpooroutcomeat6mouths.AnalysiswasbyintentiontotreatFindingBetweenNov1,1996,andJuly31,2003,859patientswereenrolledby83hospitalsin15countriesintotheearlyversusavoidtrial.Earlytubefeedingwasassociatedwithanabsolutereductioninriskofdeathof5.8%(95%CI-0.8to12.5,P=0.09)andreductionindeathorpooroutcomeof1.2%(-4.2to6.6,P=0.7).InthePEGversusnasogastrictubetrial,321patientswereentrolledby47hospitalsin11countries.PEGfeedingwasassociatedwithanabsoluteincreaseinriskofdeathof1.0%(-10.0to11.9,P=0.9)andanincreasedriskofdeathorpooroutcomeof7.8%(0.0to15.5,P=0.05).•Earlytubefeedingmightreducecasefatality,butattheexpenseofincreasingtheproportionsurvivingwithpooroutcome.•OurdatadonotsupportapolicyofearlyinitiationofPEGfeedingindysphagicstrokepatientsInterpretation推荐意见⑴•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