重症病患的營養支持

Nutrition Support in Critical Care

王義明(Yi-Ming Wang) ； 黃煜爲(Yu-Wei Huang) ； 林姿伶(Tz-Ling Lin) ； 陳思穎(Szu-Ying Chen)

《重症醫學雜誌》 10卷3期 (2009/09) Pp. 229-241

摘要

營養不良(malnutrition)的定義爲：病人因爲沒有攝取足夠的營養而導致身體組成，尤其是如胞質量的減少，以及身體功能上的降低，而重症或住院病人營養不良的盛行率可高達30-55%。重症病人會因爲急慢性疾病，造成發炎反應，而進一步造成壓力相關的異化代謝反應，因爲這些代謝反應，腸道功能會受到影響病人時常會有感染、傷口癒合不良及肌肉功能受損的臨床現象，而這些現象會進一步使得病人營養不良，營養不良又使得病人的臨床狀況惡化，因此因疾病引起的營養不良會造成惡性循環。
既然營養不良的現象在加護病房如此常見，又會造成病人臨床上的不良影響，適當的營養支持是很重要的，我們如果視疼痛爲重症病人的第五個生命微象，營養應可以現爲第六個生命徵象，但是這一塊常被重症專科醫師(intensivist)所忽略。而營養在加護病房的角色已經逐漸地由單純的營養支持轉變爲營養治療。
但是要如何適當地執行營養治療？除了要瞭解基本的重症營養學知識也要瞭解目前實證建議的凖則。凖則雖然無法保證對個別病人的預後或存活有絕對的益處。不過，它們是依據實證文獻、國際性共識和專家意見所訂定的明確指引，瞭解準則，可以方便重症照顧團隊討論出最佳的營養治療處方並且避免醫療錯誤。雖然目前以實證率則爲基礎的營養臨床操作，其前瞻性大規模的隨機研究，無法證實可以改善病人的預後，但是仍有若干的益處，且執行的過程可以當作是品質改善的過程。因此，重症病患的營養支持，我們不能等到最佳的實證指引才執行，改變目前的觀念與非以實證凖則爲基礎的營養臨床操作，才能參與未來。

關鍵字

營養不良 ； 加護病房 ； 營養支持 ； 營養治療 ； 實證凖則

並列摘要

Malnutrition is a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue/ body form (body shape, size and composition) and function, and clinical outcome. The prevalence of malnutrition is high, about 30-55%, in hospital and ICU. Besides, disease related malnutrition can cause vicious cycle which influence not only infection, wound healing, impairment of muscle function but alter metabolic response and bowel function.
Since malnutrition impact critical patient so much, appropriate nutrition support is important. If pain is viewed as fifth vital sign, nutrition could be viewed as sixth vital sign. The role of nutrition in intensive care has transitioned from supporting patients recovery from underlying disease to modulating the disease response and improving the chance of survival. Thus, nutrition therapy instead of nutrition support could be used.
But, how to perform nutrition therapy appropriately for ICU patients? Except elemental knowledge of nutrition, we should understand current evidence-based guidelines and design best nutritional regimen individually. Evidence-practice gaps are common and evidence-based guidelines help reduced these gaps by promoting awareness of interventions and proven benefit and discouraging ineffective care. Although if nutritional evidence-practice in critical care improve survival remained controversial, it should be viewed as a process of quality improvement. All ICU team members should make there effort to achieve this worthwhile goal.

並列關鍵字

Malnutrition ； Critical care ； Nutrition support ； Nutrition therapy ； Evidence-based guideline