免疫营养支持在危重病中的应用_Chinese Journal of Respiratory and Critical Care Medicine

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王存真 , 康焰

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重症患者处于高分解代谢状态。由于能量不足、蛋白质分解、机体瘦组织细胞群大量减少, 免疫系统、肠黏膜结构和功能严重受损。加上禁食和使用抗生素等而导致肠道微生态的破坏, 均可促进肠道细菌移位, 引发肠源性感染, 造成感染难以控制, 营养不良与感染形成恶性循环。上世纪70 年代以来, 营养支持已成为临床治疗中, 尤其是重症患者不可缺少的治疗措施。由于其代谢改变与普通饥饿病人有着显著的差别, 因此重症患者的营养支持有其特殊性。重症患者往往伴有免疫功能低下或障碍, 感染性并发症是影响重症病人治疗效果的主要原因, 临床给予积极的营养支持并不能使重症病人免疫功能恢复, 疾病的预后仍然较差[ 1] 。近年来, 由于药理剂量的营养配方的发展, 使营养干预进入了疾病预防和治疗的领域, 营养素增加了免疫调节成分, 以刺激机体免疫应答, 降低危重症的发病率和病死率。其中, 备受关注的营养素主要有谷氨酰胺、精氨酸、ω-3 脂肪酸和核苷酸, 学者们将这种新的营养方式称为免疫营养, 现综述如下。

Citation： 王存真,康焰. 免疫营养支持在危重病中的应用. Chinese Journal of Respiratory and Critical Care Medicine, 2009, 09(5): 514-516. doi: Copy

1.	李宁. 外科危重病人营养支持应注意的若干问题. 外科理论与实践, 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.	张铮, 秦海东, 倪海滨, 等. 早期谷氨酰胺强化肠外营养对危重病患者体内热休克蛋白70 的影响. 中国危重病急救医学, 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.	强新华, 康焰, 易群. 谷氨酰胺双肽对慢性阻塞性肺病合并呼吸衰竭重症患者胰岛素抵抗及临床结局的影响. 中国循证医学杂志, 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.	何长生, 李为勤, 黎介寿. 重症急性胰腺炎早期肠内免疫营养支持. 肠内与肠外营养, 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, 陈盛, 等. 围手术期肠内免疫营养对老年患者免疫和炎症反应的影响. 中华医学杂志, 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.	赵德芳, 陈大志, 张珂, 等. 肝移植围手术期肠内免疫营养治疗的观察. 肠内与肠外营养, 2008, 15: 88-91.

1. 李宁. 外科危重病人营养支持应注意的若干问题. 外科理论与实践, 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. 张铮, 秦海东, 倪海滨, 等. 早期谷氨酰胺强化肠外营养对危重病患者体内热休克蛋白70 的影响. 中国危重病急救医学, 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. 强新华, 康焰, 易群. 谷氨酰胺双肽对慢性阻塞性肺病合并呼吸衰竭重症患者胰岛素抵抗及临床结局的影响. 中国循证医学杂志, 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. 何长生, 李为勤, 黎介寿. 重症急性胰腺炎早期肠内免疫营养支持. 肠内与肠外营养, 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, 陈盛, 等. 围手术期肠内免疫营养对老年患者免疫和炎症反应的影响. 中华医学杂志, 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. 赵德芳, 陈大志, 张珂, 等. 肝移植围手术期肠内免疫营养治疗的观察. 肠内与肠外营养, 2008, 15: 88-91.

Chinese Journal of Respiratory and Critical Care Medicine

免疫营养支持在危重病中的应用

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