Sánchez-Izquierdo Riera J A, Montejo González J C
Departamento de Cuidados Intensivos, Hospital 12 de Octubre, Madrid.
Nutr Hosp. 1992 Mar-Apr;7(2):81-92.
The hypermetabolism that develops in patients with severe polytraumatism has led to the need for an aggressive metabolic-nutritional support from the start. Parenteral Nutrition is the preferred technique in many instances, due to the doubts on the effectiveness of enteral nutrition in the control of the metabolic response and to problems of gastrointestinal tolerance derived from its administration. However, the role of enteral nutrition as an important factor which limits the development of bacterial translocation and the chain of events leading to multiorganic failure appears to be more and more well-established and is an important argument for justifying the early administration of enteral nutrition in these patients. In accordance with the accumulated experience of several authors over the past few years, enteral nutrition may be administered early in polytraumatized patients. This is not only accompanied by the evidence of acceptable gastrointestinal tolerance to the diet, but also by additional advantages compared to parenteral nutrition, such as the maintenance of trophism and immunocompetence of the digestive mucosa, the reduction of septic complications and also greater nutritional effectiveness which can be evaluated by the behaviour of the seric proteins used as nutritional evolution markers. The interest of the different diet formulae which exist at present, for example diets enriched with branched-chain amino acids, diets with added fibre, peptidic diets, specific pulmonary diets or "euglycaemic diets" is evaluated in this review. All these diets may mean an increase in the effectiveness and/or tolerance of enteral nutrition in polytraumatized patients, and also contribute to the handling of specific problems such as "stress" hyperglycaemia or the withdrawal of mechanical ventilation support. The use of specific nutrients for the digestive mucosa, such as glutamine or short chain fatty acids seems to be an important factor in the reduction of bacterial translocation. The new concept of immunonutrition is opening up new expectations with regard to the possibility of reducing septic complications, which often lead to problems in the evolution of patients, by means of nutritional manipulation. Current knowledge has permitted the early administration of enteral nutrition in polytraumatized patients, although on occasions the nutritional requirements will have to be administered by the complementary use of enteral and parenteral nutrition.
严重多发伤患者出现的高代谢状态使得从一开始就需要积极的代谢 - 营养支持。在许多情况下，肠外营养是首选技术，这是因为对肠内营养在控制代谢反应方面的有效性存在疑问，以及其给药引发的胃肠道耐受性问题。然而，肠内营养作为限制细菌移位发展以及导致多器官功能衰竭的一系列事件的重要因素，其作用似乎越来越得到充分证实，这是在这些患者中早期给予肠内营养的重要依据。根据过去几年几位作者积累的经验，肠内营养可在多发伤患者早期给予。这不仅伴随着对饮食具有可接受的胃肠道耐受性的证据，而且与肠外营养相比还有其他优势，例如维持消化黏膜的营养状态和免疫能力、减少感染并发症，以及通过用作营养进展标志物的血清蛋白的表现来评估的更高的营养效果。本综述评估了目前存在的不同饮食配方的益处，例如富含支链氨基酸的饮食、添加纤维的饮食、肽类饮食、特定的肺部饮食或“正常血糖饮食”。所有这些饮食可能意味着多发伤患者肠内营养的有效性和/或耐受性增加，并且有助于处理特定问题，如“应激性”高血糖或机械通气支持的撤离。使用针对消化黏膜的特定营养素，如谷氨酰胺或短链脂肪酸，似乎是减少细菌移位的重要因素。免疫营养的新概念为通过营养干预减少经常导致患者病情发展问题的感染并发症的可能性带来了新的期望。目前的知识允许在多发伤患者中早期给予肠内营养，尽管有时营养需求必须通过肠内和肠外营养的互补使用来满足。
