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数据结构及样例
{
"url": "https://www.nejm.org/doi/full/10.1056/NEJMra2406954",
"卷": "392",
"号": "15",
"期刊发表时间": "April 16, 2025",
"栏目名称": "Review Article",
"标题": "Enteral Nutrition in Hospitalized Adults",
"作者": [
{
"index": [
"1"
],
"name": "Leah Gramlich, M.D."
},
{
"index": [
"2"
],
"name": "Peggi Guenter, Ph.D., R.N"
}
],
"研究机构": [
{
"index": "1",
"name": "University of Alberta, Edmonton, Canada"
},
{
"index": "2",
"name": "American Society for Parenteral and Enteral Nutrition, Silver Spring, MD"
}
],
"发表时间": "April 16, 2025",
"doi": "10.1056/NEJMra2406954",
"页码": {
"起始页码": "1518",
"终止页码": "1530"
},
"正文": [
{
"父级标题": "",
"父级序号": "1",
"父级内容": [
"Enteral nutrition is defined as the provision of essential nutrients through an enteral tube to prevent or treat disease-related malnutrition in patients who are unable to consume adequate nutrients by mouth.<sup>1</sup> The interplay of inadequate dietary intake and inflammation that characterizes disease-related malnutrition affects a patient’s response to medical nutrition therapy, including enteral nutrition. Randomized, controlled trials performed over the past 15 years, involving mainly critically ill patients, as well as recent studies involving medical and surgical patients who were not critically ill, have informed our current understanding of enteral nutrition. This review considers enteral nutrition in the context of disease-related malnutrition, provides evidence for the use of enteral nutrition in hospitalized patients, and discusses practice considerations."
],
"子级": []
},
{
"父级标题": "Nutrition Care for Hospitalized Patients",
"父级序号": "2",
"父级内容": [
"Disease-related malnutrition is a complex syndrome involving inadequate nutrient intake, insufficient nutrient utilization, and disease-related systemic inflammation, factors that result in altered body composition and diminished bodily function.<sup>2</sup> This disorder is associated with a high risk of adverse health and economic outcomes, including death, prolonged hospitalization, hospital readmission, and high health care costs.<sup>3,4</sup> Globally, 30 to 45% of hospitalized adults are malnourished on admission.<sup>2,3,5,6</sup> Data published in the past 5 years indicate that enteral nutrition was used in 5.2% and 4.9% of malnourished hospitalized patients in the United States and Europe, respectively.<sup>7,8</sup> These findings highlight the need to identify patients with disease-related malnutrition in order to prevent continued nutritional decline, with the use of enteral nutrition when appropriate.<sup>9</sup> During hospitalization, most patients in the intensive care unit (ICU) and up to 1 in 20 non–critically ill medical or surgical patients receive enteral nutrition.<sup>7,8</sup>",
"Key PointsEnteral Nutrition in Hospitalized Adults•Malnutrition is prevalent among hospitalized patients, many of whom may be able to meet nutritional needs through oral intake.•Standardized nutrition care pathways aid in the detection of malnutrition and the identification of patients who may benefit from enteral nutrition.•Patients with inadequate caloric intake may need enteral nutrition.•Recent evidence suggests that underfeeding (providing 70% of energy and protein requirements) is not harmful during the acute phase of critical illness in patients in the intensive care unit.•An area requiring further investigation in enteral nutrition is the dosing of nutrition during recovery and rehabilitation."
],
"子级": [
{
"子级标题": "Enteral Nutrition in Hospitalized Adults",
"子级序号": "1",
"子级内容": [
"The terms medical nutrition therapy and nutrition support are often used interchangeably. Whereas medical nutrition therapy includes patient counseling and the use of oral nutritional supplements in addition to enteral and parenteral nutrition, nutrition support refers only to enteral and parenteral nutrition.<sup>10,11</sup> The benefits of medical nutrition therapy in malnourished patients were shown in the landmark EFFORT (Effect of Early Nutritional Support on Frailty, Functional Outcomes, and Recovery of Malnourished Medical Inpatients Trial) investigation.<sup>4</sup> The EFFORT researchers randomly assigned more than 2000 patients at nutritional risk who were not receiving enteral nutrition to receive individualized medical nutrition therapy or standard care. Medical nutrition therapy led to higher mean daily caloric and protein intake than standard care (approximately 22 vs. 18 kcal per kilogram of body weight and 0.8 vs. 0.7 g of protein per kilogram per day, respectively); medical nutrition therapy also led to lower odds of an adverse outcome (adjusted odds ratio, 0.79; 95% confidence interval [CI], 0.64 to 0.97; P=0.02) and lower mortality (adjusted odds ratio, 0.65; 95% CI, 0.47 to 0.91; P=0.01).<sup>4</sup> According to the trial protocol, enteral or parenteral nutrition was used if at least 75% of the daily energy and protein requirements could not be met through oral feeding within 5 days; the need for such support was infrequent.<sup>4</sup>",
"Additional studies inform our understanding of the benefits of medical nutrition therapy. A 2019 meta-analysis of data from 6803 patients showed that medical nutrition therapy, as compared with usual care, significantly reduced the risk of death (by 27%) up to 6 months after hospital discharge, decreased nonelective hospital readmissions, improved protein and energy intake, and increased body weight.<sup>12</sup> However, no significant differences were noted in functional outcomes or hospital length of stay. A meta-analysis by Kaegi-Braun et al., who assessed in-hospital mortality among malnourished medical patients on the basis of claims data, showed a 21% lower risk of in-hospital death among 69,000 patients who received medical nutrition therapy than among matched patients who did not receive such therapy (incidence rate ratio, 0.79; 95% CI, 0.75 to 0.84; P<0.001).<sup>8</sup> This meta-analysis was later updated to include 16 randomized, controlled trials involving medical patients with two or more conditions and showed that medical nutrition therapy (mostly oral nutrition and enteral nutrition) was associated with significantly lower odds of death than no medical nutrition therapy (odds ratio, 0.68; 95% CI, 0.51 to 0.91; P=0.009), as well as with significantly lower odds of unplanned hospital readmission (odds ratio, 0.64; 95% CI, 0.45 to 0.90; P=0.01).<sup>13</sup>",
"Nutrition in hospitalized patients can be addressed through evidence-based pathways; an example is shown in Figure 1.<sup>2,14</sup> On admission, patients can be screened for malnutrition with validated tools such as the Malnutrition Screening Tool, the Malnutrition Universal Screening Tool, or Nutrition Risk Screening 2002.<sup>15,16</sup> Patients found to be at risk for malnutrition should then undergo a nutrition assessment by a skilled professional. Diagnostic criteria for disease-related malnutrition include the Global Leadership in Malnutrition (GLIM) criteria and the Academy of Nutrition and Dietetics–American Society for Parenteral and Enteral Nutrition Indicators of Malnutrition (AAIM) criteria.<sup>17,18</sup> The GLIM criteria, when applied in a secondary analysis of data from EFFORT, predicted adverse clinical outcomes and the response to nutrition treatment.<sup>19</sup> When medical nutrition therapy is needed, all available strategies to improve oral intake, including dietary modification and oral nutrition supplements, are recommended. If oral intake remains insufficient, with less than 75% of daily caloric and protein requirements met, enteral nutrition is indicated, in the absence of obvious contraindications.<sup>1</sup> The timing for initiation of enteral nutrition depends on the extent to which a patient is able to meet their needs through oral intake, the patient’s clinical condition, and the degree of malnutrition. If enteral nutrition is associated with negative effects not acceptable to the patient or with other concerns, parenteral nutrition may be used (Figure 1)."
],
"son_level": []
}
]
},
{
"父级标题": "The Role of Enteral Nutrition",
"父级序号": "3",
"父级内容": [
"Enteral nutrition should be considered in patients with conditions such as critical illness, dysphagia, neurologic disease, gastrointestinal or liver disease, cancer (particularly head and neck or esophageal cancer), cystic fibrosis, chronic obstructive pulmonary disease, and kidney disease.<sup>1,20</sup> Such patients may be unable to eat by mouth or may have chronic disease–related anorexia. Contraindications to enteral nutrition include intestinal obstruction or ileus, severe shock, intestinal ischemia, high-output fistulae, and severe intestinal hemorrhage.<sup>1</sup> Patients requiring enteral nutrition generally have polymorbidity, which itself is associated with poor outcomes.<sup>21</sup> Coordinated interdisciplinary care and patient-centered decision making are required for effective enteral nutrition.<sup>2</sup>",
"Enteral nutrition is used frequently in the ICU, which accounts for approximately 14% of beds in U.S. hospitals.<sup>22</sup> Enteral nutrition may be more effective in the ICU, with the high staff-to-patient ratios, multidisciplinary approaches to care, and focus on nutritional care, than in other hospital units.<sup>23</sup> Multiple high-quality trials have provided nuanced insights into the dose, route, timing, and composition of nutrition support in critically ill patients. Enteral nutrition is used less frequently in the treatment of general medical and surgical patients, and fewer high-quality studies have been undertaken to assess the role and effects of enteral nutrition in non–critical care settings."
],
"子级": []
},
{
"父级标题": "Pathophysiology of Malnutrition and the Acute Inflammatory Response",
"父级序号": "4",
"父级内容": [
"The development of disease-related malnutrition in hospitalized patients is multifactorial, involving reduced appetite and intake, endocrinopathies, muscle wasting associated with immobility, older age, adverse effects of disease treatments, polypharmacy, and disease-related inflammation.<sup>2,24,25</sup> Acute illness overrides the adaptive responses to starvation that normally help preserve muscle mass and reduce energy expenditure.<sup>26-28</sup> Inflammation affects metabolism through several mechanisms, including increased release of proinflammatory cytokines (e.g., tumor necrosis factor α, interleukin-6, and interleukin-1β) and C-reactive protein (CRP).<sup>2</sup> Driven by activation of the hypothalamic–pituitary–adrenal axis, altered metabolism is associated with the release of cortisol and catecholamines, increased glycogenolysis and hepatic gluconeogenesis, and peripheral insulin resistance.<sup>2</sup> In EFFORT, a subgroup analysis showed no beneficial effect of medical nutrition therapy in patients with CRP levels higher than 100 mg per liter (adjusted odds ratio for death within 30 days, 1.32; 95% CI, 0.70 to 2.50; P=0.39), a finding that suggests that the presence of inflammation affected the efficacy of medical nutrition therapy.<sup>2,25</sup> In addition, a recent GLIM consensus statement notes that inflammation is a driver of malnutrition and is one of the criteria used for diagnosis; both acute and chronic inflammation may be implicated, as indicated by clinical signs and markers such as elevated CRP levels.<sup>29</sup>",
"In ICU patients, metabolic responses are proportional to the severity of the injury or illness.<sup>2,30</sup> During the acute phase of critical illness, energy expenditure is reduced, and macronutrient metabolism is altered to provide glucose to vital organs such as the heart, brain, and red cells.<sup>31</sup> In addition, endogenous glucose production is elevated, with increases in glucose turnover in the liver, intestine, and kidneys.<sup>27,32–34</sup> Excessive protein breakdown occurs during the acute phase of critical illness as a result of overactivation of the ubiquitin–proteasome pathway. Muscle wasting occurs early and rapidly during the first week of critical illness and is more severe in people with multiorgan failure than in those with single-organ failure.<sup>27,35,36</sup> Amino acids derived from protein catabolism are the main substrates of hepatic gluconeogenesis but are diverted during critical illness to produce acute-phase proteins. In the late acute phase of critical illness, there is an increase in oxygen consumption and energy expenditure, with ongoing tissue breakdown providing substrates to preserve critical organ function. During the recovery phase, metabolic responses normalize, and protein and fat stores are gradually replenished.<sup>27,37</sup>",
"The duration of the acute phase of critical illness is a subject of debate but is generally thought to be on the order of days.<sup>38</sup> The acute phase results in anabolic resistance, suppression of cellular repair processes, and insulin resistance.<sup>38</sup> The lack of benefit of early full feeding (provision of 70 to 100% of estimated caloric requirements) may be explained by the inability of the body to counteract catabolism and the added metabolic burden of feeding, as indicated by increased ureagenesis, hyperglycemia, and hypertriglyceridemia.<sup>39-41</sup> Underfeeding (nutritional delivery of <70% of the calculated or measured energy requirements) is hypothesized to support an adaptive metabolic response by allowing for ketogenesis, avoiding hyperglycemia, and promoting autophagic clearance of cellular damage. By contrast, overfeeding in the acute phase can occur when energy and protein goals are fully met.<sup>42</sup> The concept of improving recovery in critical illness through early energy and protein restriction is further supported by additional clinical and translational evidence.<sup>42</sup> However, biomarkers and bedside monitors that can identify the resolution of the acute phase of critical illness and anabolic resistance, which would herald potential responsiveness to feeding, are currently lacking.<sup>"
],
"子级": []
}
],
"图片": [
{
"图片标题": "Nutrition Care Pathway for Hospitalized Adults from Admission to Discharge.",
"图片序号": "1",
"图片注释": "AAIM denotes Academy of Nutrition and Dietetics–American Society for Parenteral and Enteral Nutrition Indicators of Malnutrition, BMI body-mass index, GLIM Global Leadership Initiative on Malnutrition, and ICD-10 International Classification of Diseases, 10th Revision.",
"图片地址": "https://www.nejm.org/cms/10.1056/NEJMra2406954/asset/b639b8f7-c535-4af9-b96f-b639c29d2f2c/assets/images/large/nejmra2406954_f1.jpg",
"图片下载路径": "nejm/10.1056%2Fnejmra2406954/res/127df9ed079bd38f2039ef36edcac6d7.jpg"
}
],
"表格": [],
"补充材料": [],
"参考资料": []
}
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