免疫營養支持在危重病中的應用_《中國呼吸與危重監護雜志》

作者：

王存真 , 康焰

四川大學華西醫院ICU（四川成都 610041）;

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重癥患者處于高分解代謝狀態。由于能量不足、蛋白質分解、機體瘦組織細胞群大量減少, 免疫系統、腸黏膜結構和功能嚴重受損。加上禁食和使用抗生素等而導致腸道微生態的破壞, 均可促進腸道細菌移位, 引發腸源性感染, 造成感染難以控制, 營養不良與感染形成惡性循環。上世紀70 年代以來, 營養支持已成為臨床治療中, 尤其是重癥患者不可缺少的治療措施。由于其代謝改變與普通饑餓病人有著顯著的差別, 因此重癥患者的營養支持有其特殊性。重癥患者往往伴有免疫功能低下或障礙, 感染性并發癥是影響重癥病人治療效果的主要原因, 臨床給予積極的營養支持并不能使重癥病人免疫功能恢復, 疾病的預后仍然較差[ 1] 。近年來, 由于藥理劑量的營養配方的發展, 使營養干預進入了疾病預防和治療的領域, 營養素增加了免疫調節成分, 以刺激機體免疫應答, 降低危重癥的發病率和病死率。其中, 備受關注的營養素主要有谷氨酰胺、精氨酸、ω-3 脂肪酸和核苷酸, 學者們將這種新的營養方式稱為免疫營養, 現綜述如下。

引用本文： 王存真,康焰. 免疫營養支持在危重病中的應用. 中國呼吸與危重監護雜志, 2009, 09(5): 514-516. doi: 復制

1.	李寧. 外科危重病人營養支持應注意的若干問題. 外科理論與實踐, 2002, 7: 11-12.
2.	Curi R, Newsholme P, Procopio J, et al. Glutamine, gene expression, and cell function. Front Biosci, 2007 , 12: 344 -357.
3.	Ziegler TR, Ogden LG, Singleton KD, et al. Parenteral glutamine increases serum heat shock protein 70 in critically ill patients. Intensive Care Med, 2005, 31: 1079-1086.
4.	張錚, 秦海東, 倪海濱, 等. 早期谷氨酰胺強化腸外營養對危重病患者體內熱休克蛋白70 的影響. 中國危重病急救醫學, 2007, 19: 481-484.
5.	Novak F, Heyland DK, Avenell A, et al. Glutamine supplementation in serious illness: a systematic review of the evidence. Crit Care Med, 2002, 30: 2022-2029.
6.	Déchelotte P, Hasselmann M, Cynober L, et al. L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: the French controlled, randomized, double-blind, multicenter study. Crit Care Med, 2006, 34: 598-604.
7.	強新華, 康焰, 易群. 谷氨酰胺雙肽對慢性阻塞性肺病合并呼吸衰竭重癥患者胰島素抵抗及臨床結局的影響. 中國循證醫學雜志, 2007, 7: 645-649.
8.	Duska F, Fric M, Waldauf P, et al. Frequent intravenous pulses of growth hormone together with glutamine supplementation in prolonged critical illness after multiple trauma: effects on nitrogen balance, insulin resistance, and substrate oxidation. Crit Care Med, 2008, 36: 1707-1713.
9.	Yang DL, Xu JF. Effect of dipeptide of glutamine and alanine on severe traumatic brain injury. Chin J Traumatol, 2007, 10: 145-149.
10.	Efron D, Barbul A. Role of arginine in immunonutrition. J Gastroenterol, 2000, 12: 20-23.
11.	Waitzberg DL, Saito H, Plank LD, et al. Postsurgical infections are reduced with specialized nutrition support. World J Surg, 2006, 30 : 1592-1604.
12.	Kalil AC, Sevransky JE, Myers DE, et al. Preclinical trial of Larginine monotherapy alone or with N-acetylcysteine in septic shock. Crit Care Med, 2006, 34: 2719-2728.
13.	Dent D, Heyland D, Levy H, et al. Immunonutrition may increase mortality in critically ill patients with pneumonia: results of a randomized trial . Crit Care Med, 2003, 30: A17.
14.	Bertolini G, Iapichino G, Radrizzani D, et al. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med, 2003, 29: 834-840.
15.	Heller AR, R　ssler S, Litz RJ, et al. Omega-3 fatty acids improve the diagnosis-related clinical outcome. Crit Care Med, 2006 , 34: 972 - 979.
16.	Wichmann MW, Thul P, Czarnetzki HD, et al. Evaluation of clinical safety and beneficial effects of a fish oil containing lipid emulsion ( Lipoplus, MLF541 ) : data from a prospective, randomized, multicenter trial. Crit Care Med, 2007, 35: 700-706.
17.	Singer P, Theilla M, Fisher H, et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med, 2006, 34 : 1033-1038.
18.	Pontes-Arruda A, Arag　o AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med, 2006, 34: 2325-2333.
19.	Mayer K, Seeger W. Fish oil in critical illness. Curr Opin Clin Nutr Metab Care, 2008, 11: 121-127.
20.	Salvatore S, Hauser B, Vandenplas Y. Chronic enterpathy and feeding. Nestle Nutr Workshop Ser Pediatr Program, 2007,59: 115-126.
21.	Yamauchi K, Komatsu T, Kulkarni AD, et al. Glutamine and arginine affect Caco-2 cell proliferation by promotion of nucleotide synthesis. Nutrition, 2002, 18: 329-333.
22.	Chuntrasakul C, Siltham S, Sarasombath S, et al. Comparison of a immunonutrition formula enriched arginine, glutamine and omega-3 fatty acid, with a currently high enriched enteral nutrition for trauma patients. JMed Assoc Thai, 2003, 86: 552-561.
23.	Montejo JC, Zarazaga A, LopezMartinez J, et al. Immunonutrition in the intensive care unit: A systematic review and consensus statement. Clin Nutr, 2003, 22: 221-233.
24.	何長生, 李為勤, 黎介壽. 重癥急性胰腺炎早期腸內免疫營養支持. 腸內與腸外營養, 2004, 11: 219-222.
25.	Pearce CB, Sadek SA, Walters AM. A double blind trial of immunonutrition verus isocaloric feeds on severe acute pancreatitis. Gastroenter, 2005, 5: 302-332.
26.	Petrov MS, Atduev VA, Zagainov VE. Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A metaanalysis. Int J Surg, 2008 , 6: 119-124 .
27.	Farreras N, Artigas V, Cardona D, et al. Effect of early postoperative enteral immunonutrition on wound healing in patients undergoing surgery for gastric cancer. Clin Nutr, 2005, 24: 55-65.
28.	王志度, 彭俊生, 陳盛, 等. 圍手術期腸內免疫營養對老年患者免疫和炎癥反應的影響. 中華醫學雜志, 2006, 86: 1410-1413.
29.	Zheng Y, Li F, Qi B, et al. Application of perioperative immunonutrition for gastrointestinal surgery: a meta-analysis of randomized controlled trials. Asia Pac J Clin Nutr, 2007 , 16( Suppl 1) : 253-257.
30.	趙德芳, 陳大志, 張珂, 等. 肝移植圍手術期腸內免疫營養治療的觀察. 腸內與腸外營養, 2008, 15: 88-91.

1. 李寧. 外科危重病人營養支持應注意的若干問題. 外科理論與實踐, 2002, 7: 11-12.
2. Curi R, Newsholme P, Procopio J, et al. Glutamine, gene expression, and cell function. Front Biosci, 2007 , 12: 344 -357.
3. Ziegler TR, Ogden LG, Singleton KD, et al. Parenteral glutamine increases serum heat shock protein 70 in critically ill patients. Intensive Care Med, 2005, 31: 1079-1086.
4. 張錚, 秦海東, 倪海濱, 等. 早期谷氨酰胺強化腸外營養對危重病患者體內熱休克蛋白70 的影響. 中國危重病急救醫學, 2007, 19: 481-484.
5. Novak F, Heyland DK, Avenell A, et al. Glutamine supplementation in serious illness: a systematic review of the evidence. Crit Care Med, 2002, 30: 2022-2029.
6. Déchelotte P, Hasselmann M, Cynober L, et al. L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in critically ill patients: the French controlled, randomized, double-blind, multicenter study. Crit Care Med, 2006, 34: 598-604.
7. 強新華, 康焰, 易群. 谷氨酰胺雙肽對慢性阻塞性肺病合并呼吸衰竭重癥患者胰島素抵抗及臨床結局的影響. 中國循證醫學雜志, 2007, 7: 645-649.
8. Duska F, Fric M, Waldauf P, et al. Frequent intravenous pulses of growth hormone together with glutamine supplementation in prolonged critical illness after multiple trauma: effects on nitrogen balance, insulin resistance, and substrate oxidation. Crit Care Med, 2008, 36: 1707-1713.
9. Yang DL, Xu JF. Effect of dipeptide of glutamine and alanine on severe traumatic brain injury. Chin J Traumatol, 2007, 10: 145-149.
10. Efron D, Barbul A. Role of arginine in immunonutrition. J Gastroenterol, 2000, 12: 20-23.
11. Waitzberg DL, Saito H, Plank LD, et al. Postsurgical infections are reduced with specialized nutrition support. World J Surg, 2006, 30 : 1592-1604.
12. Kalil AC, Sevransky JE, Myers DE, et al. Preclinical trial of Larginine monotherapy alone or with N-acetylcysteine in septic shock. Crit Care Med, 2006, 34: 2719-2728.
13. Dent D, Heyland D, Levy H, et al. Immunonutrition may increase mortality in critically ill patients with pneumonia: results of a randomized trial . Crit Care Med, 2003, 30: A17.
14. Bertolini G, Iapichino G, Radrizzani D, et al. Early enteral immunonutrition in patients with severe sepsis: results of an interim analysis of a randomized multicentre clinical trial. Intensive Care Med, 2003, 29: 834-840.
15. Heller AR, R　ssler S, Litz RJ, et al. Omega-3 fatty acids improve the diagnosis-related clinical outcome. Crit Care Med, 2006 , 34: 972 - 979.
16. Wichmann MW, Thul P, Czarnetzki HD, et al. Evaluation of clinical safety and beneficial effects of a fish oil containing lipid emulsion ( Lipoplus, MLF541 ) : data from a prospective, randomized, multicenter trial. Crit Care Med, 2007, 35: 700-706.
17. Singer P, Theilla M, Fisher H, et al. Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury. Crit Care Med, 2006, 34 : 1033-1038.
18. Pontes-Arruda A, Arag　o AM, Albuquerque JD. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock. Crit Care Med, 2006, 34: 2325-2333.
19. Mayer K, Seeger W. Fish oil in critical illness. Curr Opin Clin Nutr Metab Care, 2008, 11: 121-127.
20. Salvatore S, Hauser B, Vandenplas Y. Chronic enterpathy and feeding. Nestle Nutr Workshop Ser Pediatr Program, 2007,59: 115-126.
21. Yamauchi K, Komatsu T, Kulkarni AD, et al. Glutamine and arginine affect Caco-2 cell proliferation by promotion of nucleotide synthesis. Nutrition, 2002, 18: 329-333.
22. Chuntrasakul C, Siltham S, Sarasombath S, et al. Comparison of a immunonutrition formula enriched arginine, glutamine and omega-3 fatty acid, with a currently high enriched enteral nutrition for trauma patients. JMed Assoc Thai, 2003, 86: 552-561.
23. Montejo JC, Zarazaga A, LopezMartinez J, et al. Immunonutrition in the intensive care unit: A systematic review and consensus statement. Clin Nutr, 2003, 22: 221-233.
24. 何長生, 李為勤, 黎介壽. 重癥急性胰腺炎早期腸內免疫營養支持. 腸內與腸外營養, 2004, 11: 219-222.
25. Pearce CB, Sadek SA, Walters AM. A double blind trial of immunonutrition verus isocaloric feeds on severe acute pancreatitis. Gastroenter, 2005, 5: 302-332.
26. Petrov MS, Atduev VA, Zagainov VE. Advanced enteral therapy in acute pancreatitis: is there a room for immunonutrition? A metaanalysis. Int J Surg, 2008 , 6: 119-124 .
27. Farreras N, Artigas V, Cardona D, et al. Effect of early postoperative enteral immunonutrition on wound healing in patients undergoing surgery for gastric cancer. Clin Nutr, 2005, 24: 55-65.
28. 王志度, 彭俊生, 陳盛, 等. 圍手術期腸內免疫營養對老年患者免疫和炎癥反應的影響. 中華醫學雜志, 2006, 86: 1410-1413.
29. Zheng Y, Li F, Qi B, et al. Application of perioperative immunonutrition for gastrointestinal surgery: a meta-analysis of randomized controlled trials. Asia Pac J Clin Nutr, 2007 , 16( Suppl 1) : 253-257.
30. 趙德芳, 陳大志, 張珂, 等. 肝移植圍手術期腸內免疫營養治療的觀察. 腸內與腸外營養, 2008, 15: 88-91.

《中國呼吸與危重監護雜志》

免疫營養支持在危重病中的應用

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《中國呼吸與危重監護雜志》

免疫營養支持在危重病中的應用

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