【指南解读】2022ESPEN家庭肠内营养实践指南解读

发布时间：2024-11-06 01:31

文章来源：复旦大学附属中山医院临床营养

作者：王俊杰谈善军

编辑：谈善军张知格审核：吴国豪

已授权《中国临床营养网》转载

导读：2022年2月1日，欧洲临床营养与代谢协会（European Society for Clinical Nutrition and Metabolism, ESPEN）在其官方杂志Clinical Nutrition上正式发表了ESPEN家庭肠内营养实践指南（ESPEN practical guideline: Home enteral nutrition）。该指南从临床实用性出发，对2020年发表的ESPEN家庭肠内营养指南进行缩减，从家庭肠内营养适应证、禁忌证到如何实施和监测以及防治并发症，总计给出61条推荐，并添加了流程图，更加便于临床医师、营养师及护士等在临床实践中使用。

复旦大学附属中山医院临床营养团队第一时间对此指南进行仔细研读，并整理翻译成文，供国内同行学习、交流，为我国的家庭肠内营养管理提供参考。

一、家庭肠内营养适应证和禁忌证

Fig.1. 家庭肠内营养适应证和禁忌证

1. 家庭肠内营养适应证和禁忌证 (Fig.1)

1.1. 家庭肠内营养适应证

推荐1 HEN should be offered to patients at nutritional risk or malnourished who cannot meet their nutrient requirements by normal dietary intake, who have a functioning gastrointestinal tract, who are able to receive therapy outside of an acute care setting, and who agree and are able to comply with HEN therapy with the goal of improving body weight, functional status or QoL. (Grade GPP, strong consensus 97%)

应向有营养风险或营养不良的患者提供HEN，这些患者无法通过正常饮食满足营养摄入需求，但胃肠道功能正常，能够在急症情形以外接受治疗，同意并能够遵守HEN治疗，以达到改善体重，功能状态或生活质量的目标。 （推荐等级GPP - 强烈同意97％）

推荐2 Prior to discharge from hospital of patients at risk of malnutrition (e.g. patients with neurological disease, head injury, head and neck cancer, gastrointestinal and other malignancies, non-neoplastic gastrointestinal disease including malabsorptive syndromes), either oral nutritional supplements or HEN should be considered. (Grade B, strong consensus 96%)

有营养不良风险的患者（例如神经系统疾病，头部损伤，头颈肿瘤，胃肠道和其他恶性肿瘤，非肿瘤性胃肠道疾病包括吸收不良综合征）出院前，应考虑口服营养补充剂或HEN。 （推荐等级B - 强烈同意96％）

1.2. 家庭肠内营养禁忌证

推荐3 If life expectancy is estimated to be less than one month, HEN usually shall not be initiated.(Grade GPP, consensus 78%)

如果预期寿命不到一个月，通常不应实施HEN。（推荐等级GPP – 同意78％）

推荐4 HEN shall not be performed in patients with contraindications such as severe functional disturbances of the bowel, gastrointestinal obstruction, gastrointestinal tract bleeding, severe malabsorption or severe metabolic imbalances. (Grade GPP, consensus 84%)

对存在严重肠功能障碍，胃肠道梗阻，胃肠道出血，严重吸收不良或严重代谢失衡等禁忌证患者，不应实施HEN。（推荐等级GPP – 同意84％）

推荐5 If patient and/or their legal carers do not to agree to a HEN program or are unlikely to comply with and/or if there are organizational/logistic problems which cannot be overcome, HEN should not be offered. (Grade GPP, strong consensus 97%)

如果患者和/或其法定照护人员不同意HEN计划，或不太可能遵守HEN计划，和/或存在无法克服的组织/后勤问题，则不应实施HEN。（推荐等级GPP - 强烈同意97％）

二、家庭肠内营养的喂养通路

Fig.2. 家庭肠内营养的喂养通路

2.1. 喂养管设备 (Fig.2)

2.1.1. 短期家庭肠内营养 (<6周)

推荐6 HEN can be delivered through a nasal feeding tube in patients who need HEN only for a short period of time (up to 4 - 6 weeks). (Grade 0, consensus 90%)

仅需短期HEN的患者（最多4-6周）可以使用鼻饲管实施HEN。（推荐等级0 - 同意90％）

2.1.2. 长期家庭肠内营养 (>6周)

推荐7 A PEG or, if indicated, a percutaneous endoscopic jejunostomy (PEJ) is the preferred access device and should be placed when long-term HEN is required.(Grade B, strong consensus 93%)

如果存在相关指证，首选经皮内镜胃造口术（PEG）或经皮内镜空肠造口术（PEJ），并且应当在需要长期进行HEN的患者中实施PEG或PEJ。（推荐等级B – 强烈同意93％）

推荐8 If a PEG if not suitable for long-term HEN a percutaneous laparoscopic assisted gastrostomy (PLAG) may be a safe alternative. (Grade 0, strong consensus 93%)

如果PEG不适合长期使用，经皮腹腔镜辅助胃造口术（PLAG）可作为一种安全的替代方式。（推荐等级0 – 强烈同意93％）

推荐9 Radiologically inserted gastrostomy (RIG) or percutaneous radiological gastrostomy (PRG) can be used as alternative techniques for the placement of a feeding tube into the stomach, if an endoscopically guided tube placement cannot be performed. (Grade 0, strong consensus 97%)

如果不能在内镜引导下放置肠内营养管，则可在影像学引导下插入胃造口管（RIG）或实施经皮影像学引导下胃造口术（PRG）将肠内营养喂养管放入胃内。（推荐等级0 – 强烈同意97％）

推荐10 In case of inadvertent displacement or removal of the PEG more than four weeks after initial placement, direct replacement can be safely attempted before the track closes completely. (Grade GPP, strong consensus 93%)

如果PEG不慎在初次放置四周后移位或移除，在窦道完全闭合之前尝试直接更换PEG管是安全的。（推荐等级GPP - 强烈同意93％）

推荐11 A PEG should be preferred over a surgical gastrostomy for long-term HEN, mainly due a lower complication rate, cost-effectiveness and operating time. (Grade B, strong consensus 100%)

对需要长期HEN的患者，PEG优于手术胃造口，主要是由于PEG较低的并发症发生率，成本效益和手术时间。（推荐等级B - 强烈同意100％）

2.2. 管路、通道口以及耗材

2.2.1. 护理 (Fig.3)

推荐12 Until the stoma tract is formed and the incision is healed, the PEG exit site should be daily monitored and kept clean and dry by using aseptic wound care (usually up to 5 to 7 days post procedure). (Grade B, strong consensus 100%)

在窦道形成和切口愈合前，应每日监测PEG出口部位，并通过无菌伤口护理保持其清洁和干燥（一般术后需要5-7天）。（推荐等级B - 强烈同意100％）

Fig.3. 管路、通道口以及耗材-护理

推荐13 Once the gastrostomy tract has been healed (after about one week), the tube should be rotated daily and should be moved inwards at least once a week (at least 2 cm, up to 10 cm). (Grade GPP, consensus 87%)

一旦胃造口窦道形成（约一周后），应每天转动PEG管，并应至少每周向内移动一次（至少2厘米，最多10厘米）。（推荐等级GPP - 同意87％）

推荐14 After mobilization, the tube may be returned to its initial position with some free distance (0.5 - 1 cm) between the skin and the external bolster. (Grade 0, strong consensus 93%)

移动后，可以将PEG管移回初始位置，可以在皮肤和外支架之间保留一定空隙（0.5 -1cm）。（推荐等级0 - 强烈同意93％）

推荐15 If the device is a gastrojejunostomy or gastrostomy with jejunal extension it should not be rotated (only weekly pushed in and out). ( Grade GPP, strong consensus 92%)

如果喂养管用于胃空肠吻合术或是具有空肠延长管的胃造口管，则不应转动（仅每周推入和推出）。（推荐等级GPP - 强烈同意92％）

推荐16 A glycerin hydrogel or glycogel dressing should be used as an alternative to classical aseptic wound care during the first week(s). (Grade B, strong consensus 97%)

第一周应使用甘油水凝胶或糖原质凝胶敷料作为传统无菌伤口护理的替代品。（推荐等级B - 强烈同意97％）

推荐17 After stoma healing, dressings can be reduced to one or two times a week, and the entry site can be cleansed using soap and water of drinking quality.(Grade 0, strong consensus 90%)

造口愈合后，敷料更换可以减少到每周一到两次，并且可以使用肥皂和饮用水来清洁喂养管入口处。（推荐等级0 - 强烈同意90％）

推荐18 Alternatively to recommendation 14, dressings can be omitted and the site can be left open. (Grade GPP, strong consensus 92%)

推荐17的替代方案是：可以省略敷料，无需覆盖造口。（推荐等级GPP - 强烈同意92％）

推荐19 Immediately after placement of the PEG, the external fixation plate should be subjected to very low traction, without tension. (Grade GPP, strong consensus 93%)

PEG放置后的早期，外固定板应立即承受非常低的牵引力，且无张力。（推荐等级GPP - 强烈同意93％）

2.2.2. 并发症 (Fig.4)

2.2.2.1. 渗漏

推荐20 In case of peristomal leakage of gastric contents at the stoma site, the surrounding skin can be properly protected using zinc oxide-based skin protectants. (Grade 0, strong consensus 93%)

如果造口部位有胃内容物渗漏，可以使用氧化锌皮肤保护剂保护周围皮肤。（推荐建议等级0 - 强烈同意93％）

Fig.4. 管路、通道口以及耗材-并发症

推荐21 Proton pomp inhibitors can be used for decreasing leakage by minimizing gastric acid secretion and - if used - needs to be reviewed regularly. (Grade 0, strong consensus 96%)

质子泵抑制剂可以通过降低胃酸分泌以减少渗漏，使用后需要定期评估。（推荐等级0 - 强烈同意96％）

2.2.2.2. 肉芽组织

推荐22 Excessive granulation tissue is a common problem of PEG and should be avoided or treated using appropriate methods. (Grade GPP, strong consensus 93%)

肉芽组织过度增生是PEG的常见问题，应通过适当方法进行预防和治疗。（推荐等级GPP - 强烈同意93％）

2.2.2.3. 喂养管故障

推荐23 Tube replacement should be accomplished in case of tube breakage, occlusion, dislodgement or degradation. (Grade GPP, strong consensus 93%)

若喂养管破裂，堵塞，移位或降解，应更换喂养管。（推荐等级GPP - 强烈同意93％）

2.2.2.4. 感染

推荐24 When a site infection is suspected or diagnosed, an antimicrobial agent can be topically applied to the entry site of the tube and the surrounding tissue, and - if the site infection cannot be resolved by this treatment - combined with systemic broad-spectrum antibiotics. (Grade 0, strong consensus 93%)

当怀疑或诊断喂养通路局部感染时，可以在喂养管的入口和周围组织使用抗生素，如果通过该治疗不能解决局部感染，应联用系统性广谱抗生素。 （推荐等级0 - 强烈同意93％）

推荐25 If the infection cannot be resolved by the procedure described in Recommendation 24, the tube should be removed. (Grade GPP, consensus 86%)

如果感染不能通过推荐24中的方法治愈，则应移除喂养管。 （推荐等级GPP- 同意86％）

2.3.家庭肠内营养的启动(Fig.5)

推荐26 HEN may be started when patient is medically stable and (i) correct placement of the tube position is verified; (ii) tolerance to enteral prescription (volume and formula) is demonstrated; and (iii) the patient and/or provider have appropriate knowledge and skills to manage HEN.(Grade GPP, strong consensus 100%)

当患者病情稳定并且满足以下条件后可开始HEN：（i）确认喂养管位置正确；（ii）可耐受肠内营养处方（剂量和配方）；（iii）患者和/或医护人员具有适当的管理HEN的知识和技能。 （推荐等级GPP - 强烈同意100％）

Fig.5. 家庭肠内营养的启动

推荐27 The patient with a nasogastric tube can start HEN immediately according to the previously established nutritional care plan once appropriate tube placement has been confirmed. (Grade GPP, strong consensus 96%)

有鼻胃管的患者在确认喂养管位置合适后，可以根据先前确定的营养支持计划立即开始HEN。(推荐等级GPP - 强烈同意96％）

推荐28 Adults with uncomplicated gastrostomy tube placement can commence EN within 2-4 h after the procedure.(Grade A, strong consensus 100%)

成人患者若无胃造口并发症，可在胃造口术后2至4小时内启动肠内营养（EN）。 （推荐等级A - 强烈同意100％）

推荐29 A graduated program of commencement of jejunal HEN feeds should be followed. (Grade B, strong consensus 93%)

空肠HEN喂养应遵循渐进式原则。 （推荐等级B- 强烈同意93％）

2.4. 施行 (Fig.6)

2.4.1. 营养支持团队（Nutrition support team, NST）

推荐30 T he method of HEN administration should be a decision of the multidisciplinary NST involved with the patient care, considering patient's disease, type of feeding tube in position, feed tolerance and patient preference. (Grade GPP, strong consensus 100% )

HEN的输注方法应该由参与护理患者的多学科NST决定，应考虑患者的疾病，喂养管类型，耐受性和患者偏好。 （推荐等级GPP - 强烈同意100％）

Fig.6. 家庭肠内营养的施行

2.4.2.输注泵的应用

推荐31 Bolus or intermittent continuous or continuous infusion through a pump may be used depending on clinical need, safety and level of precision required. (Grade GPP, strong consensus 92%)

家庭肠内营养的输注方式包括一次性推注、间歇性输注以及连续性经泵输注，具体根据临床需要，安全性和所需的精确度来选择。 （推荐等级GPP - 强烈同意92％）

2.4.3. 水冲洗

推荐32 Routine water flushing before and after feeding can prevent tube obstruction and should be part of patient/carer education.(Grade GPP, strong consensus 100%)

喂食前后常规进行水冲洗可以防止喂养管阻塞，此项内容是患者/护理人员宣教的一部分。 （推荐等级GPP - 强烈同意100％）

2.5.药物施用 (Fig.7)

推荐33 An enteral tube being used for EN can also be used for drug administration if the efficacy of drug administration can be confirmed. (Grade GPP, strong consensus 92%)

如果能确定给药的有效性，则用于EN的喂养管也可用于给药。（推荐等级GPP - 强烈同意92％）

Fig.7. 通过喂养管给药

推荐34 If an enteral tube is used for drug administration, adequate information should be offered to patients and carers with the involvement of a pharmacist. (Grade GPP, strong consensus 100%)

如果将喂养管用于给药，则应在药剂师的参与下向患者和护理人员提供足够的信息。（推荐等级GPP - 强烈同意100％）

推荐35 Appropriate ancillaries including syringes shall be used for drug administration through enteral tubes using connectors of a recognized standard in order to avoid misconnection errors. (Grade A, strong consensus 100%)

通过喂养管给药时，所使用的包括注射器在内的合适的辅助设备应使用符合公认标准的连接件，以避免误接。 （推荐等级A- 强烈同意100％）

推荐36 Measures shall be taken to ensure correct drug dosing when drugs are administered through enteral tubes, for example when using low-dose tip ENFit syringes. Shaking of a low-dose ENFit tip syringe to remove a drug moat shall not be done. (Grade GPP, strong consensus 100% )

当药物通过喂养管给药时，应采取措施确保药物剂量正确，例如使用低剂量ENFit注射器时。不得通过摇动低剂量ENFit注射器以去除药物结团。 （推荐等级GPP - 强烈同意100％）

推荐37 The necessity and appropriateness for a drug to be administered through an enteral tube should be confirmed, taking into account factors including any effect of the site of drug delivery and potential drug interactions with enteral formula and enteral feeding tubes. (Grade GPP, strong consensus 100% )

应确认药物通过喂养管给药的必要性和适当性，需要考虑的因素包括给药部位以及药物与肠内营养配方和喂养管之间潜在的药物相互作用。 （推荐等级GPP - 强烈同意100％）

推荐38 Drugs may be administered individually through an enteral feeding tube, and the tube flushed before, between and after each drug, using 30 mL of water. (Grade 0, strong consensus 100%)

可以通过营养管单独给药。在每种药物之前、之间和之后使用30mL水冲洗营养管。（推荐等级0 - 强烈同意100％）

三、家庭肠内营养产品（Fig.8）

Fig.8. 家庭肠内营养产品

3.1. 一般情况

推荐39 Standard commercial formula enteral tube feeds can be used, unless there is specific justification for a blended tube feed. (Grade 0, strong consensus 92%)

可以使用标准的商业配方肠内营养制剂，除非有特定的理由进行混合管饲。 （推荐等级0 - 强烈同意92％）

推荐40 For patients without diarrhea, constipation or diabetes, standard commercial tube feeds should be used according to the direction of a specialist. (Grade GPP, strong consensus 96% )

对没有腹泻，便秘或糖尿病的患者，应在专科医生的指导下使用标准的商业配方肠内营养制剂。 （推荐等级GPP - 强烈同意96％）

推荐41 Fiber-containing feeds shall normally be used for patients with diarrhea. (Grade A, strong consensus 92%)

腹泻患者一般应使用含纤维制剂。（推荐等级A - 强烈同意92％）

推荐42 Fiber-containing feeds should be used for patients with constipation. (Grade B, strong consensus 96%)

便秘患者应使用含纤维制剂的肠内营养制剂。（推荐等级B - 强烈同意92％）

3.2.2.糖尿病

推荐43 A modified enteral formula with lower sugar content, containing slowly digestible carbohydrates and a fat content enriched in unsaturated fatty acids, especially monounsaturated fatty acids may be used for patients with diabetes.(Grade 0, majority agreement 60%)

对糖尿病患者，可使用具有较低含糖量的改良肠内营养配方，其含有可缓慢消化的碳水化合物，其脂肪成分应富含不饱和脂肪酸，尤其是单不饱和脂肪酸。（推荐等级0 - 多数同意60％）

四、监测及结束家庭肠内营养

4.1. 应如何及何时监测使用家庭肠内营养的患者 (Fig.9)

推荐44 HEN patients should be monitored for the efficacy and complications of HEN, which requires a good forward planning and communication between acting persons (physicians, nurses, caregivers etc.). (Grade GPP, strong consensus 96% agreement)

应监测HEN的疗效和并发症，这需要良好的前瞻性规划和参与人员（医生，护士，照护人员等）之间的沟通。（推荐等级GPP - 强烈同意96％）

Fig.9. 家庭肠内营养的监测管理

推荐45 Monitoring of efficacy should be based primarily on body weight, body composition and hydration status, but may also include laboratory measurements, such as serum albumin or transthyretin (=prealbumin). Monitoring of complications should include tube- and EN-associated complications.(Grade GPP, consensus 83% agreement )

疗效监测主要基于体重，身体成分和液体平衡状态，但也可包括实验室指标，如血清白蛋白或转甲状腺素蛋白（前白蛋白）。并发症监测应包括管路和EN相关的并发症。 （推荐等级GPP – 同意83％）

4.2. 终止

推荐46 HEN should be terminated when the desired weight has been reached and the patient's oral intake matches his/her maintenance needs.(Grade GPP, strong consensus 92% )

当达到目标体重并且患者的口服摄入量满足维持量时，应终止HEN。 （推荐等级GPP- 强烈同意92％）

4.3. 并发症管理 (Fig.10)

推荐47 To reduce mechanical complications of HEN (blocking, dislodgement) percutaneous tubes should be used instead of nasal tubes for long-term needs (at least 4-6 weeks). (Grade B, strong consensus 98%)

为了减少HEN的机械并发症（阻塞，移位），在需要长期（至少4-6周）进行HEN时应使用经皮管代替鼻饲管。 （推荐等级B - 强烈同意98％）

Fig.10. 家庭肠内营养并发症管理

推荐48 As home-made blenderized admixtures are less effective than EN formula or commercially produced ‘whole food’ solutions, they should not be utilized in patients on HEN. (Grade GPP, majority agreement 63% )

家庭自制的混合营养剂不如EN配方或商业生产的“全食”方案有效，不应用于HEN。 （推荐等级GPP - 多数同意63％）

推荐49 As home-made blenderized admixtures are less safe than EN formula or commerc ially produced ‘whole food’ solutions, they should not be utilized in patients on HEN.(Grade GPP, consensus 76%)

家庭自制的混合营养剂不如EN配方或商业生产的“全食”方案安全，不应用于HEN。 （推荐等级GPP - 同意76％）

推荐50 A HEN team should adequately care of nasogastric and enteral tubes, as well as follow up the patients to decrease complications and rehospitalizations. (Grade B, strong consensus 100% )

HEN小组应该充分护理鼻胃管和肠营养管，并随访患者以减少并发症和再入院。 （建议等级B - 强烈同意100％）

4.4. 生活质量（QoL）评估

推荐51 During HEN treatment QoL should be measured periodically. ( Grade GPP, strong consensus 92% )

HEN期间应定期评估QoL。 （建议等级GPP - 强烈同意92％）

推荐52 F or evaluating QoL in HEN patients, validated specific questionnaires should be used. (Grade GPP, consensus 88%)

评估HEN患者的QoL时应使用经过验证的专用问卷。 （建议等级GPP - 同意88％）

五、家庭肠内营养的组织管理

5.1. 宣教和营养支持团队 (Fig.11)

推荐5 All hea lthcare professionals who are directly involved in patient care should receive education and training, relevant to their duties, on the different aspects related to the safe provision of HEN and the impo rtance of providing adequate nutrition. (Grade B, strong consensus 100%)

所有直接参与患者护理的医护人员都应接受与其职责相关的教育和培训，使其了解与安全实施HEN相关的各种考量以及提供充足营养的重要性。 （推荐等级B - 强烈同意100％）

Fig.11. 宣教和营养支持小组

推荐54 All informatio n related to HEN should be provided not only verbally but also in writing or pictures. (Grade B, strong consensus 100%)

所有与HEN相关的信息不仅应该口头告知，还应该以书面或图片形式告知。 （推荐等级B - 强烈同意100％）

推荐55 All hospitals who discharge patients with HEN should employ at least one specialized nutrition support nurse or dietician. Ideally, these hospitals should have a NST working within the clinical governance framework. (Grade B, strong consensus 96%)

开展出院后HEN的所有医院应至少雇用一名专业营养支持护士或营养师。理想情况下，这些医院应该在临床管理框架内开展NST工作。 （推荐等级B - 强烈同意96％）

推荐56 Healthcare professionals should ensure that all people who need nutrition support receive coordinated care from a multidisciplinary NST. (Grade B, strong consensus 100%)

医护人员应确保所有需要营养支持的患者都能够从多学科NST处获得协调的照护。 （推荐等级B - 强烈同意100％）

推荐57 For optimal management of HEN, a NST approach may comprise - in addition to a physician, a dietician/nutritionist and a nurse - other allied healthcare professionals (for example, speech and language therapists, physiotherapists and occupational therapists, and pharmacists as necessary). (Grade GPP, strong consensus 97%)

为了最佳地管理HEN，NST除了医生，营养师/营养师和护士外，可以包括其他专职医护人员（例如必要时可包括言语和语言治疗师，物理治疗师和职业治疗师，以及药剂师）。 （推荐 等级GPP - 强烈同意97％）

推荐58 HEN should be standardized and coordinated by a multidisciplinary NST (physician, nurse, dietician, pharmacist) as this increases the quality of the measures, reduces the complication rates and thus makes a significant contribution to improve patients QoL and to the cost-effectiveness of the measures. (Grade B, strong consensus 96%)

HEN应由多学科NST（医生，护士，营养师，药剂师）进行标准化和协调，因为这样可以提高方案的质量，降低并发症发生率，从而改善患者的生活质量和成本效益。 （推荐等级B - 强烈同意96％）

5.2. 基础设施 (Fig.12)

推荐59 The environment for patients receiving HEN should be safe in order to administer the EN without the risk of complications. (Grade B, strong consensus 100%)

接受HEN的患者所处的环境应该是安全的，以使其在进行EN时没有发生并发症的风险。 （推荐等级B - 强烈同意100％）

Fig.12. 家庭肠内营养的基础设施

推荐60 Hygiene standards should be established to prevent contamination of the home enteral product and to prevent HEN-related infections. (Grade GPP, strong consensus 10 0%)

应建立卫生标准以防止污染家庭肠内营养产品和预防HEN相关感染。（推 荐等级GPP - 强烈同意100％）

推荐61 All patients receiving HEN should have access to a professional for evaluation of the procedure and, especially in case of complications or emergencies, for adequate intervention.(Grade GPP, strong consensus 100%)

所有接受HEN的患者都应该有专业人员对其执行过程进行评估和充分的干预，尤其是在出现并发症或紧急情况时。 （推荐等级GPP - 强烈同意100％）

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