• 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)和功能嚴(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, 營養(yǎng)不良與感染形成惡性循環(huán)。上世紀(jì)70 年代以來, 營養(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, 由于藥理劑量的營養(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)者們將這種新的營養(yǎng)方式稱為免疫營養(yǎng), 現(xiàn)綜述如下。

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

版權(quán)信息： ?四川大學(xué)華西醫(yī)院華西期刊社《中國呼吸與危重監(jiān)護(hù)雜志》版權(quán)所有，未經(jīng)授權(quán)不得轉(zhuǎn)載、改編

1. 李寧. 外科危重病人營養(yǎng)支持應(yīng)注意的若干問題. 外科理論與實踐, 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)化腸外營養(yǎng)對危重病患者體內(nèi)熱休克蛋白70 的影響. 中國危重病急救醫(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. 何長生, 李為勤, 黎介壽. 重癥急性胰腺炎早期腸內(nèi)免疫營養(yǎng)支持. 腸內(nèi)與腸外營養(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)免疫營養(yǎng)對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)免疫營養(yǎng)治療的觀察. 腸內(nèi)與腸外營養(yǎng), 2008, 15: 88-91.
  1. 1. 李寧. 外科危重病人營養(yǎng)支持應(yīng)注意的若干問題. 外科理論與實踐, 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)化腸外營養(yǎng)對危重病患者體內(nèi)熱休克蛋白70 的影響. 中國危重病急救醫(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. 何長生, 李為勤, 黎介壽. 重癥急性胰腺炎早期腸內(nèi)免疫營養(yǎng)支持. 腸內(nèi)與腸外營養(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)免疫營養(yǎng)對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)免疫營養(yǎng)治療的觀察. 腸內(nèi)與腸外營養(yǎng), 2008, 15: 88-91.

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