1995肠内营养的使用指南英文AGA.docx
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1995肠内营养的使用指南英文AGA.docx
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1995肠内营养的使用指南英文AGA
AMERICANGASTROENTEROLOGICALASSOCIATION
AmericanGastroenterologicalAssociationMedicalPositionStatement:
GuidelinesfortheUseofEnteralNutrition
ThisdocumentpresentstheofficialrecommendationsoftheAmericanGastroenterologicalAssociation(AGA)ontheuseofenteralnutrition.ItwasapprovedbytheAGAPatientCareCommitteeonSeptember17,1994,andbytheAGAGoverningBoardonNovember11,1994.
Theneedtoavoidprolongedstarvationinpatientsiswellrecognized.Morerecently,ithasbeenrealizedthatwithoutintraluminalfuels,intestinalintegritymaydeteriorateandallowtranslocationofgutbacteria.Onemeanstocombatnutrientdeprivationandsimultaneouslytokeepthelocaldefensebarrieroftheintestineintactistubefeeding,i.e.,enteralnutrition.Thistechniquehasbeenpracticedinvaryingformsforhundredsofyears.Today,technicalinnovationshavemadeitamoreacceptableproceduretopatientsandalesscostlyalternativetoparenteralnutrition.Itisimportantforphysicianstounderstandtheindicationsforenteralnutrition,itscontraindications,itsrisks,sitesfornutrientdelivery,andalternativetubeplacementtechniques.
Thisdocumentprovidesgastroenterologistswithrecommendationsforprovidingsafeandeffectiveenteralnutritiontoadultpatients.ItisbasedontheAmericanGastroenterologicalAssociationTechnicalReviewonTubeFeedingforEnteralNutrition,1whichshouldbeconsultedforadditionalinformation.
IndicationsforTubeFeeding
Tubefeedingshouldbeconsideredforpatientswhocannotorwillnoteat,forpatientswhohaveafunctionalgut,andforwhomasafemethodofaccessispossible.
1. Inmostpatients,nutritionsupportshouldbeinitiatedafter1-2weekswithoutnutrientintake.Enteralfeedingispreferabletoparenteraltherapyprovidedtherearenocontraindications,accesscanbeattainedsafely,andoralintakeisnotpossible.Insomepatients,combinationsofenteralandparenteralnutritionmaybenecessarytomeettheirnutritionalneeds.
2. Mechanicalobstructionistheonlyabsolutecontraindicationtoenteralfeeding.
MethodsofFeeding
Alternativemethodsofdeliveringtubefeedingsexist,andthephysicianmustbefamiliarwiththeadvantagesandlimitationsrelativetoaspecificpatient.
1. Fortheshort-term(<30days),nasogastricornasoenterictubesarepreferredovergastrostomyorjejunostomytubes.
2. Tubesplacedpastthethirdportionoftheduodenum,andespeciallypasttheligamentofTreitz,areassociatedwithadecreasedriskofaspiration.
3. Variousmethodsoftubeplacementmaybeusedatthebedside.Endoscopicallyorfluoroscopicallyguidedtubeplacementshouldbereservedforpatientsinwhombedsidetechniqueshavebeenunsuccessful.Prokineticdrugsgivenbeforeplacementmaybebeneficialinpositioningsmallernasoenterictubes(8Fand10F)beyondthepylorus.
4. Intermittentgravityfeedingissufficientformostpatientswithnasogastricorgastrostomytubes.Pump-controlledinfusionsarerecommendedforjejunalfeedingsandforgastrostomyfeedingsgivenbycontinuousinfusiontodecreasegastroesophagealreflux.
5. Withnasogastrictubefeeding,asingleelevatedresidualvolumeisanindicationtorechecktheresidualvolumein1hour;however,thefeedingshouldnotautomaticallybestopped.
6. Jejunalaccessisappropriateinpatientswithahistoryoftubefeeding-relatedaspirationpneumoniaorrefluxesophagitis.
PercutaneousGastrostomyPlacement
Whereasplacementofgastrostomyandjejunostomytubeshastraditionallybeenthepurviewofsurgeons,severaltechniqueshavebeendevelopedthathaveledtotheseproceduresbeingperformedbygastroenterologistsorradiologists.Eachhasitsownrisksandbenefitsand,sometimes,uniquecomplications.
1. Gastrostomytubesarejustifiedforpatientswhoneedtubefeedingformorethan30days.Thepatient'sunderlyingdiseaseandavailableexpertisemustbeconsideredwhendecidingbetweentypesofplacement(operativeorpercutaneousendoscopicorradiologicalgastrostomy).Thephysicianmustbefamiliarwithalternativeplacementmethodsandtubetypes,particularlywhentreatingpatientswithesophagealdiseasethatmaycomplicatestandardinsertiontechniques.
2. Forgastricaccessusingconscioussedation,percutaneousendoscopicgastrostomyisusuallypreferabletooperativegastrostomy.Thelatterrequiresmorerecoverytimeandismoreexpensive.Radiologicalgastrostomyplacement,dependingonanatomicindications,mayobviatetheneedforendoscopicprocedures.
3. Carefulattentiontotechniqueduringplacementandmonitoringofthepatientafterplacementareessentialtominimizecomplications.
ComplicationsofTubeFeeding
Tubefeedingisarelativelysafeprocedurewhosecomplicationsusuallycanbeavoidedormanaged.Inadditiontothecomplicationsofpercutaneoustubeplacement(e.g.,infection),patientsmayexperienceaspiration,diarrhea,alterationsindrugabsorptionandmetabolism,andvariousmetabolicdisturbances.
1. Tolimittheriskofaspirationwithgastricfeeding,thefollowingprecautionsshouldbetaken:
raisetheheadofthepatient'sbed30°-45°duringfeedingandfor1hourafter,useintermittentorcontinuousfeedingregimensratherthantherapidbolusmethod,gastricresidualsshouldbecheckedregularly,andallpatientsshouldbewatchedforsignsoffeedingintolerance.
2. Jejunalaccessishelpfulinpatientswithrecurrenttubefeedingaspiration(notoropharyngeal)orincriticallyillpatientsatriskforgastricmotilitydysfunction(e.g.,patientswithheadtrauma).
3. Tolimittheriskofaspirationwithsmallbowelfeeding,thefeedingportofthenasoenterictubeorpercutaneousendoscopicjejunostomyshouldbeclosetoorbeyondtheligamentofTreitz.Severevomitingorcoughingmaydisplacesomenonsurgicaltubes,andradiographsmaybeneededtoverifythetubeposition.
4. Diarrheaisacommon,albeitpoorlydefinedcomplicationofenteralfeedingthathasmanypotentialcauses.Theseincludemedicationssuchasantibioticsorsorbitol-containingproducts,alteredbacterialflora,formulacomposition(includingosmolality),infusionrate,hypoalbuminemia,bacterialcontaminationoftheenteralfluid,andphysiologicaldisturbancesrelatedtothepatient'soverallphysicalcondition.However,studiesoftherelationshipofeachofthesefactorstodiarrheaandtubefeedingareinconclusive.Therefore,itisn'tpossibletoprovideanyuniversalrecommendationsforpreventingoreliminatingthiscomplication.Byconsideringallpotentialetiologies,itmaybepossibletotakestepsthatwillreducediarrheainselectedsituations.
5. Carefulattentionmustbepaidtofluidandelectrolytemanagementtominimizeanymetaboliccomplications.
SpecializedEnteralFormulations
Althoughoneortwoenteralformulationscanmeetmostpatients'needs,specialtyproductsmaybeusefulincertaindiseasestates.Theseincludeblenderized,lactose-containingandlactose-free,fiber-containing,elemental,andmodularproductsandspecializedfeedingssuchaspulmonaryformulas.Althoughsomeformulationshaveclearclinicalindications(e.g.,lactose-freemixturesforpatientswithlactasedeficiency),theadvantagesofothersarelessclear.
1. Isotonicpolymericformulationscanmeetmostpatients'nutritionalneeds.
2. Theuseofelementalformulationsshouldbereservedforpatientswithseveresmallbowelabsorptivedysfunction.
3. Specialtyformulationsgenerallyaremoreexpensivethanstandardformulasandhavealimitedclinicalrole;moredataareneededtojustifytheirpracticalityandeffectiveness.
NutritionSupportTeams
Multidisciplinarynutritionsupportteamsareavaluableadjunctinthemanagementoftube-fedpatients.Thecombinedexpertiseofsuchateamlikelywillresultinbettercare,decreasedcomplications,andincreasedcost-effectivenessofenteralnutrition.
References
1.KirbyDF,DeLeggeMH,FlemingCR.AmericanGastroenterologicalAssociationtechnicalreviewontubefeedingforenteralnutrition.Gastroenterology1995;108:
1282-1301.
AmericanGastroenterologicalAssociationTechnicalReviewonTubeFeedingforEnteralNutrition
ThisliteraturereviewandtherecommendationsthereinwerepreparedfortheAmericanGastroenterologicalAssociationPatientCareCommittee.Followingexternalreview,thepaperwasapprovedbytheCommitteeonSeptember17,1994.ItservesasthefoundationfortheAssociation'sofficialrecommendationsasgiveninthepreviousstatement.
Nodiseaseprocessimprovessignificantlywithprolongedstarvation.Whereasshortperiods(<7days)ofnutrientdeprivationmaybewelltoleratedbymostpatientsdependingontheirstartingpointandpresentdegreeofcatabolism,longerperiodscanbedetrimental.Duringstarvation,fatisthemajorsourceofcaloriesstoredinthebodyandismobilizedtomeetthebody'sneeds.However,glycogenhasasmallstorageform(∼900kcal)andproteinhasnostorageformsothatduringstarvation,slowturnoverproteinssuchasmusclemustbecannibalizedforenergyandvisceralproteinsupport,whichultimatelyleadstoorganfunctioncompromise.1
Whereastubefeedinghasbeenpracticedinvaryingformsformorethan400years,technicalinnovationsduringthepast2decadeshavemadetheproceduremoreacceptabletopatientsandalesscostlyalternativetoparenteralnutrition.Recentdataontheoccurrenceofbacterialtranslocationfromanenterallydeprivedgastrointestinaltracthavefocusedrenewedattentiontousethegastrointestinaltractassoonasissafelypossible.2Gastroenterologistswithvaryingamountsoftraininginnutritionsupportareaskedtomanagepatientsreceivingenteralnutri
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