国际多学科专家组心脏外科营养共识声明：营养支持对成人心脏手术的作用

　　2017年6月5日，英国生物医学中心旗下《重症医疗》在线发表德国亚琛科技大学医院、法兰克福大学医院、基尔大学医学中心、科隆大学心脏中心、美国约翰霍普金斯医院、西奈山伊坎医学院、麻省总医院、犹他大学医学院、俄亥俄州立大学医学院、维克弗斯特医学院、加拿大麦吉尔大学医学中心、皇家维多利亚医院、渥太华大学心脏研究所、西安大略大学、维多利亚女王大学、金斯顿总医院、希腊亚里士多德大学、俄罗斯循环病理研究所、莫斯科国立皮罗戈夫外科医学中心的国际多学科专家组心脏外科营养共识声明：营养支持对成人心脏手术的作用。全文共12页，主要内容概述如下：

　　营养支持是重症心脏外科患者的必要疗法。然而，对于该人群，缺乏包括高质量临床研究在内的确凿证据。为了明确可以改善结局的最佳策略，来自德国、加拿大、希腊、美国、俄罗斯不同临床专科的25位专家组成国际多学科专家组，讨论了确定潜在方法以确定哪些患者可从营养支持获益、什么时候发起营养支持最好、药理营养调控体外循环所致炎性反应的潜在用途。虽然知识与证据之间存在显而易见的差距，但是合理的营养支持疗法可使心脏外科患者获益。

　　有关心脏外科患者营养支持的随机研究极少，并且仅限于小样本患者，结果也表现出异质性，因此专家们无法为临床实践提出强有力的推荐意见。不过，专家确定了六条关键信息，这些信息对于治疗此类患者被认为有临床意义：

  1. 如有可能，应该针对营养不良的心脏外科患者优化术前营养状态。越来越多晚期心脏衰竭并计划植入心室辅助装置的患者，代表了可能获益于优化营养状态的亚组人群。因此，确定营养风险、优选使用结构化评分工具，应该成为患者术前评定的一部分。

  2. 为了获得最大收益，营养不良的心脏外科患者应该至少在术前2～7天接受营养疗法（例如，作为术前评价和优化疗法的一部分）。

  3. 心脏术后患者在ICU停留期间，应该对营养摄入量监测结果进行每天常规评定。尤其在第3天，应该仔细评价所有患者的营养风险，并尽快通过肠内或肠外喂养，努力达到其规定蛋白质和能量需求量的至少80%。

  4. 对于营养风险高并且预计ICU停留时间延长的患者，应该早期（术后0～24小时）开始术后营养支持。

  5. 对于长期饥饿或原有营养不良后开始营养支持的患者，注意再喂养综合征可能至关重要。对于这些患者，喂养增速应该减慢，需要3～4天的时间才能达到目标量，并满足宏量营养素和微量营养素的特殊需求。

  6. 如果ICU入住后＜24小时内开始早期术后营养，可以考虑对复杂和长时间外科手术的患者添加免疫调节成分（例如硒、鱼油）以减轻过度炎性反应。

　　为了扩展对可靠数据的需求，国际标准化方案也有助于优化心脏外科患者的营养支持，例如欧洲肠外肠内营养学会（欧洲临床营养与代谢学会，ESPEN）和国际外科代谢与营养协会（IASMEN）认可的术后加速康复（加速康复外科，ERAS）策略。由于这些患者围手术期医疗标准的异质性，并且缺乏大样本随机对照研究（RCT）提供的证据，优化围手术期医疗的多种模式ERAS方案，通过提供最佳可用证据，可能有助于减少手术应激、维持生理功能、促进术后康复。

　　此外，多学科专家组为将来的研究，确定了的六个重要课题：

  1. 针对术前营养状态进行优化可能改善术后结局。结构化评分工具应被作为术前评定的一部分进行验证和实施，以监测营养疗法的有效性。

  2. 在特定患者中，需要评价早期开始术后营养支持的可行性和临床意义。

  3. 有必要对宏量营养素和微量营养素进行剂量探索研究，以回答“心脏术后患者如何补充”和“如何组合营养素”的问题。

  4. 为了减轻经常发生的炎性反应，对于外科复杂并延长的患者，应该评价免疫调节成分（例如硒、鱼油）的临床意义。

  5. 有必要对心脏术后患者的能量需求进行验证和可靠评定。

  6. 有必要进一步评价滋养性肠内营养对患者血液动力学初步稳定后可能发挥的作用。

　　迫切需要有效和可靠的数据，以改善心脏术后患者营养筛查、评定和支持的现有非标准化临床实践。虽然炎性反应和术后并发症均可预测，但是临床实践对于最佳营养疗法存在若干限制。如何精准确定对营养疗法获益最多的患者，需要通过有充分说服力的临床研究进行验证，对于临床势在必行。

Crit Care. 2017 Jun 5;21(1):131.

Role of nutrition support in adult cardiac surgery: a consensus statement from an International Multidisciplinary Expert Group on Nutrition in Cardiac Surgery.

Stoppe C, Goetzenich A, Whitman G, Ohkuma R, Brown T, Hatzakorzian R, Kristof A, Meybohm P, Mechanick J, Evans A, Yeh D, McDonald B, Chourdakis M, Jones P, Barton R, Tripathi R, Elke G, Liakopoulos O, Agarwala R, Lomivorotov V, Nesterova E, Marx G, Benstoem C, Lemieux M, Heyland DK.

University Hospital, RWTH Aachen, Aachen, Germany; Johns Hopkins Hospital Baltimore, Baltimore, MD, USA; Royal Victoria Hospital, McGill University Health Centre, Montreal, Canada; McGill University Health Centre, Montreal, Canada; University Hospital Frankfurt, Frankfurt am Main, Germany; Icahn School of Medicine at Mount Sinai, New York, NY, USA; Massachusetts General Hospital, Boston, MA, USA; University of Ottawa Heart Institute, Ottawa, ON, Canada; Aristotle University of Thessaloniki, Thessaloniki, Greece; University of Western Ontario, London, Canada; University of Utah School of Medicine, Salt Lake City, UT, USA; The Ohio State University College of Medicine, Columbus, OH, USA; University Medical Center Schleswig-Holstein, Kiel, Germany; University of Cologne, Cologne, Germany; Wake Forest School of Medicine, Medical Center Boulevard, Winston-Salem, NC, USA; Research Institute of Circulation Pathology, Novosibirsk, Russia; National Pirogov Surgical Medical Center, Moscow, Russia; Queen's University, Kingston General Hospital, Kingston, ON, Canada.

Nutrition support is a necessary therapy for critically ill cardiac surgery patients. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking. To clarify optimal strategies to improve outcomes, an international multidisciplinary group of 25 experts from different clinical specialties from Germany, Canada, Greece, USA and Russia discussed potential approaches to identify patients who may benefit from nutrition support, when best to initiate nutrition support, and the potential use of pharmaco-nutrition to modulate the inflammatory response to cardiopulmonary bypass. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy is presented to benefit patients undergoing cardiac surgery.

Main open research topics concerning nutrition in patients after cardiac surgery

The few randomized trials of nutrition support in patients undergoing cardiac surgery are limited to small numbers of patients and demonstrate heterogeneous results, so the experts felt unable to give strong recommendations for clinical practice. Nevertheless, six key messages have been identified by the experts, which are thought to be of clinical relevance in the treatment of these patients:

  1. Whenever possible, preoperative optimization of the nutritional state should be targeted in the malnourished patient undergoing cardiac surgery. The increasing number of patients with advanced heart failure and planned VAD implant represent a subpopulation that may as well benefit from optimization of the nutritional state. Thus, determination of nutritional risk, preferably using a structured scoring tool, should be part of the patient's preoperative assessment.

  2. To reach maximum benefit, preoperative nutritional therapy should be initiated in malnourished patients after cardiac surgery at least 2-7 days before surgery (e.g., as part of a preoperative evaluation and optimization therapy).

  3. Monitoring of nutrition intake should be routinely assessed daily in patients after cardiac surgery during the ICU stay. In particular, on day 3 all patients should be carefully evaluated as to their nutrition risk and effort should be made to achieve at least 80% of their prescribed protein/energy requirements, either by enteral or parental feeding, as soon as possible.

  4. Postoperative nutrition support should be initiated early (0-24 hours after surgery) in patients at high nutritional risk with an expected prolonged ICU stay.

  5. Attention to refeeding syndrome may be of importance for patients in whom nutrition support is started after a prolonged period of starvation or in patients with preexisting malnutrition, respectively. In those patients, advancement of feeding should be slower, taking 3-4 days to reach goal, and targeting to adapt to both macronutient and micronutrient special needs.

  6. If initiated early postoperatively within <24 hours after ICU admission, an additional immune-modulating component (e.g., selenium, fish oil) to nutrition may be considered for patients with complex and prolonged surgical procedures, to counteract the overwhelming inflammatory response.

In extension to the need of reliable data, international standardized procedures such as the ESPEN and IASMEN endorsed strategy for Enhanced Recovery After Surgery (ERAS) are warranted to optimize nutrition support in cardiac surgery patients. In view of the heterogeneous standards of perioperative care in these patients and lack of evidence provided by large-scale RCTs, the multi-modal ERAS program for optimal perioperative care may help to reduce surgical stress, maintain physiological functional capacity, and facilitate postoperative recovery by providing the best available evidence.

Furthermore the multidisciplinary group identified six important topics for future research:

  1. Targeting preoperative optimization of the nutritional state may result in improved postoperative outcome. Structured scoring tools should be validated and implemented as part of preoperative assessment and to monitor the efficacy of nutrition therapy.

  2. In identified patients, the feasibility and clinical significance of early-initiated postoperative nutrition support needs to be evaluated.

  3. Dose-finding studies for both macronutrients and micronutrients are needed to answer the questions of "how to supplement patients after cardiac surgery" and "with which combination of nutrients".

  4. To counteract the frequently occurring inflammatory response, the clinical significance of an immune-modulating component (e.g., selenium, fish oil) should be evaluated in patients with complex and prolonged surgical procedures.

  5. Validated and reliable assessment of energy requirement in patients after cardiac surgery need to be developed.

  6. The role trophic EN might play in the hemodynamically stable patient after initial stabilization needs further evaluation.

Valid and reliable data are urgently needed to improve the so far non-standardized clinical practice of nutrition screening, assessment, and support in patients after cardiac surgery. Although both inflammatory response and postoperative complications are predictable, clinical practice has several restrictions, limiting optimal nutrition therapy. The accurate identification of patients who benefit most from nutritional therapy presents a clinical imperative requiring validation by adequately powered clinical studies.

KEYWORDS: Cardiopulmonary bypass; Enteral nutrition; High-risk cardiac surgery; Nutrition risk stratification; Organ dysfunctions; Pharmaco-nutrition; Postoperative nutritional management; Supplemental parenteral nutrition; Systemic inflammatory response; Underfeeding

PMID: 28583157

PMCID: PMC5460477

DOI: 10.1186/s13054-017-1690-5

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