胰腺炎的营养治疗课件.ppt

1、Which patients benefits from nutritional support in acute pancreatitis?lSeverity (Clinical,laboratory and radiological signs)lNutritional status Severity assesmentl Mild form (80%)-Ranson signs 3-CRP 3-CRP 120 mg/l-APACHE II score 8-Balthazars-CT-score 3 ESPEN GuidelineslEnteral Nutrition:Clinical N

2、utrition Vol 25(2),April 2006lParenteral Nutrition:Clinical Nutrition Vol 28,July 2009l Severity of acute pancreatitis can be assessed adequatelyFor artificial nutritional interventions mild pancreatitis has to be separated from severe pancreatitisl Nutritional status has to be assessed on admission

3、 and during the course of the diseaseMain goals for nutrition in acute pancreatitisl To provide calories with EN or PN to reverse protein catabolism without stimulation of the exocrine pancreatic secretionl To improve or to avoid nutritional depletionl To reduce morbidity and mortality How should nu

4、tritional support be done?Parenteral or enteral?Gastral or jejunal?Is the situation differentin mild to moderate or severe pancreatitis?Kalfarentzos et al,B J Surg,1997McClave et al,JPEN,2006McClave et al,JPEN,2006McClave et al,JPEN,2006Early EN vs PN in severe acute pancreatitis(Meta-Analysis)Outco

5、mel Mortality RR 0.40(CI:0.2-0.8)l Infected necrosis RR 0.43(CI:0.2-0.9)l Total infections RR 0.48(CI:0.3-0.8)l MOF RR 0.44(CI:0.3-0.7)l Need for surgery RR 0.37(CI:0.2-0.6)Jafri et al,Gastroenterology 2008,A 141Petrov et al,Dig Surg,2006EN vs PN and severe acute pancreatitisFirst 48 h:CT Necrosis C

6、RP 195 mg/L107 Patients 115 kJ/KG/d 1,2 g N 250 ml 20%Intralipid 115 kJ/KG/d 1,5 g N Survimed jejunalAPACHE II 16 4CRP 218 8 APACHE II 14 2CRP 211 9 Wu et al,Pancreas 2010EN vs PN and severe acute pancreatitisWu et al,Pancreas 2010EN vs PN and severe acute pancreatitis Doley et al,J Pancreas 2009EN

7、vs PN in acute pancreatitisOlah et al,Langenbecks Arch Surg 2010Recommendation IIl There is no evidence that neither EN or PN has a clinical beneficial effect on clinical outcome in patients with mild pancreatitis,if you can predict that the patient can consume normal food in between 5 days(A)l If o

8、ral nutrition is not possible in 5 days enteral nutrition should be started immetiately(C)If this is true in patients with malnutrition is not known ESPEN,Guidelines 2006/2009Treatment mild pancreatitisRecommendation IIIl Nutritional support in essential in patients with severe disease and nutrition

9、al risk factors(A)l The route of nutrient delivery(parenteral/enteral)should be determined by the patient tolerancel EN should be attempted in all patients first(C)l Intakes should be monitored carefully to ensure adequate nutritional supportl When enteral nutrition is not sufficient combine it with

10、 PN(C)ESPEN,Guidelines 2006/2009Treatment severe pancreatitisearly continuous enteral nutrition(naso-jejunal tube)elemental diet or polymeric diet or immune-enhancing diet?Recommendation IVPatients with severe disease,complications or theneed for surgery require early nutritional support toprevent t

11、he adverse effects of nutrient deprivationContinous early enteral jejunal feeding over 24h is recommended(A)When side effects occur or the caloric goal can not be achieved,PN should be combined with EN(C)How nutrients should be applied?l 4 trials showed that jejunal tubes are well toleratedl there w

12、as no exacerbation of pancreatitis-related symptomsMcClave,JPEN,1997Cravo,Clin Nutr,1989Kudsk,Nutr Clin Pract,1990Nakad,Pancreas,1998Nasogastric or nasojejunal feeding in patients with severe pancreatitis?Petrow et al,JOP 2008Nutritional intolerancePain exazerbationPetrow et al,JOP 2008DiarrheaMorta

13、lityPetrow et al,JOP 2008;9(4):440-448.Recommendation Vl Jejunal tube placement is safe and well tolerated(C)l If nasogastric tube feeding is a useful and practical approach can not be answered up to now!Which formula should be used?l Elemental,semielemental,polymeric,or immunenhancing(Arg,RNA,n-3-F

14、A,Glu)l Enteral diet with pre-or probioticsl TPN and glutamine and or n-3-FATiengou et al,JPEN,2006 EN(immunmodulating)vs EN(standard)HospitalICUMortalityNStayStayEN(Arg/Glu)27.2 d*8.6 d*22.2%vs 1)16EN(STD)38.4 d34.8 d 28.6%EN(n-3-FA)13.1 d*7.1%vs 2)28EN(STD)19.3 d 14.2%*p 0.051)Hallay et al,Hepatog

15、astroenterol,20012)Lasztity et al,Clin Nutr,2005Algorythm for using enteral formulaSynbiotics*in severe pancreatitis-Incidence of infected necrosis and abscess 4.5 30.4%(p 0.02)-LOHS 13.7 21.4 d (ns)-Need for re-surgery 1 7 (p 0.02)Olah et al,Br J Surg 2002 Synbiotics*in severe pancreatitis Probioti

16、cs Control p MOF 15%31%sig Septic complicatios 27%52%ns LOHS(d)15 20 ns Need for surgery 12%24%ns Mortality 6%21%nsOlah et al,Hepatogastroenterol 2007 Synbiotics*in severe acute pancreatitis Probiotics Placebo N=152 N=144 Infectious compl.30%28%Bowel ischaemia(N)9*0 Mortality 24(16%)*9(6%)Besselink

17、et al,Lancet 2008 Comparison of the 3 studies using probiotics in acute pancreatitisl Aggressive enteral Nutrition(30kcal/Tag)l Patients with vasoactive treatmentl Multifibre diet plus prebiotics(30g fibre/day)l 6 probiotic strains(2x/day 1010)-For the first time Bifidobacteria)Fermentation distensi

18、on ischaemia?PN(immunmodulating)vs PN(standard)lGlutaminelN-3 fatty acidsMcClave et al,JPEN,2006Sahin et al,Eur J Cin Nutr 2007Fuentes-Orozco et al,JEPN 2008 Xue et al,W J Gastroenterol 2008N-3-FA in TPN in patients with severe acute pancreatitisN=40Wang et al,JPEN 2008Wang et al,JPEN 2008N-3-FA in

19、TPN in patients with severe acute pancreatitisN=60Xiong et al,JPEN 2008*P 0.05Recommendation VIl Elemental and semielemental formulas can be used safely in acute pancreatitis(A)l Standard polymeric formulas can be tried if they are tolerated(C)l There is no evidence for using immunomodulating formul

20、as or probioticsl If TPN has to be used,glutaminecould have a beneficial effect(B),for n-3 FA we need further trialsConclusion l Nutritional support is essential in severe acute pancreatitisl Starting with early enteral nutrition is recommendedl The combination of EN and PE make sense if enteral nut

21、rition is inadaequatel Probiotics can not be recommended yetl More studies in this field are necessaryl In PE glutamine ca be helpful后面内容直接删除就行资料可以编辑修改使用资料可以编辑修改使用主要经营：网络软件设计、图文设计制作、发布广告等公司秉着以优质的服务对待每一位客户，做到让客户满意！致力于数据挖掘，合同简历、论文写作、PPT设计、计划书、策划案、学习课件、各类模板等方方面面，打造全网一站式需求The user can demonstrate on a projector or computer,or print the presentation and make it into a film to be used in a wider field