• 四川大學(xué)華西醫(yī)院ICU（四川成都 610041）;

重癥患者處于高分解代謝狀態(tài)。由于能量不足、蛋白質(zhì)分解、機(jī)體瘦組織細(xì)胞群大量減少, 免疫系統(tǒng)、腸黏膜結(jié)構(gòu)和功能?chē)?yán)重受損。加上禁食和使用抗生素等而導(dǎo)致腸道微生態(tài)的破壞, 均可促進(jìn)腸道細(xì)菌移位, 引發(fā)腸源性感染, 造成感染難以控制, 營(yíng)養(yǎng)不良與感染形成惡性循環(huán)。上世紀(jì)70 年代以來(lái), 營(yíng)養(yǎng)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(yíng)養(yǎng)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(fā)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(yíng)養(yǎng)支持并不能使重癥病人免疫功能恢復(fù), 疾病的預(yù)后仍然較差[ 1] 。近年來(lái), 由于藥理劑量的營(yíng)養(yǎng)配方的發(fā)展, 使?fàn)I養(yǎng)干預(yù)進(jìn)入了疾病預(yù)防和治療的領(lǐng)域, 營(yíng)養(yǎng)素增加了免疫調(diào)節(jié)成分, 以刺激機(jī)體免疫應(yīng)答, 降低危重癥的發(fā)病率和病死率。其中, 備受關(guān)注的營(yíng)養(yǎng)素主要有谷氨酰胺、精氨酸、ω-3 脂肪酸和核苷酸, 學(xué)者們將這種新的營(yíng)養(yǎng)方式稱(chēng)為免疫營(yíng)養(yǎng), 現(xiàn)綜述如下。

引用本文： 王存真,康焰. 免疫營(yíng)養(yǎng)支持在危重病中的應(yīng)用. 中國(guó)呼吸與危重監(jiān)護(hù)雜志, 2009, 09(5): 514-516. doi: 復(fù)制

1. 李寧. 外科危重病人營(yíng)養(yǎng)支持應(yīng)注意的若干問(wèn)題. 外科理論與實(shí)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(qiáng)化腸外營(yíng)養(yǎng)對(duì)危重病患者體內(nèi)熱休克蛋白70 的影響. 中國(guó)危重病急救醫(yī)學(xué), 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(qiáng)新華, 康焰, 易群. 谷氨酰胺雙肽對(duì)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(jié)局的影響. 中國(guó)循證醫(yī)學(xué)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(zhǎng)生, 李為勤, 黎介壽. 重癥急性胰腺炎早期腸內(nèi)免疫營(yíng)養(yǎng)支持. 腸內(nèi)與腸外營(yíng)養(yǎng), 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(shù)期腸內(nèi)免疫營(yíng)養(yǎng)對(duì)老年患者免疫和炎癥反應(yīng)的影響. 中華醫(yī)學(xué)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(shù)期腸內(nèi)免疫營(yíng)養(yǎng)治療的觀察. 腸內(nèi)與腸外營(yíng)養(yǎng), 2008, 15: 88-91.
  1. 1. 李寧. 外科危重病人營(yíng)養(yǎng)支持應(yīng)注意的若干問(wèn)題. 外科理論與實(shí)踐, 2002, 7: 11-12.
  2. 2. Curi R, Newsholme P, Procopio J, et al. Glutamine, gene expression, and cell function. Front Biosci, 2007 , 12: 344 -357.
  3. 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. 4. 張錚, 秦海東, 倪海濱, 等. 早期谷氨酰胺強(qiáng)化腸外營(yíng)養(yǎng)對(duì)危重病患者體內(nèi)熱休克蛋白70 的影響. 中國(guó)危重病急救醫(yī)學(xué), 2007, 19: 481-484.
  5. 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. 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. 7. 強(qiáng)新華, 康焰, 易群. 谷氨酰胺雙肽對(duì)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(jié)局的影響. 中國(guó)循證醫(yī)學(xué)雜志, 2007, 7: 645-649.
  8. 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. 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. 10. Efron D, Barbul A. Role of arginine in immunonutrition. J Gastroenterol, 2000, 12: 20-23.
  11. 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. 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. 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. 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. 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. 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. 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. 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. 19. Mayer K, Seeger W. Fish oil in critical illness. Curr Opin Clin Nutr Metab Care, 2008, 11: 121-127.
  20. 20. Salvatore S, Hauser B, Vandenplas Y. Chronic enterpathy and feeding. Nestle Nutr Workshop Ser Pediatr Program, 2007,59: 115-126.
  21. 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. 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. 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. 24. 何長(zhǎng)生, 李為勤, 黎介壽. 重癥急性胰腺炎早期腸內(nèi)免疫營(yíng)養(yǎng)支持. 腸內(nèi)與腸外營(yíng)養(yǎng), 2004, 11: 219-222.
  25. 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. 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. 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. 28. 王志度, 彭俊生, 陳盛, 等. 圍手術(shù)期腸內(nèi)免疫營(yíng)養(yǎng)對(duì)老年患者免疫和炎癥反應(yīng)的影響. 中華醫(yī)學(xué)雜志, 2006, 86: 1410-1413.
  29. 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. 30. 趙德芳, 陳大志, 張珂, 等. 肝移植圍手術(shù)期腸內(nèi)免疫營(yíng)養(yǎng)治療的觀察. 腸內(nèi)與腸外營(yíng)養(yǎng), 2008, 15: 88-91.

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