腫瘤患者臨床營養(yǎng)問題與評(píng)估PPT演示課件

1、,腫瘤患者臨床營養(yǎng)問題與評(píng)估,張 宇,目錄, ,腫瘤患者營養(yǎng)不良現(xiàn)狀 營養(yǎng)不良對(duì)腫瘤預(yù)后的影響 營養(yǎng)不良的腫瘤患者治療現(xiàn)狀 腫瘤患者營養(yǎng)治療方法選擇,目錄, ,腫瘤患者營養(yǎng)不良現(xiàn)狀 營養(yǎng)不良對(duì)腫瘤預(yù)后的影響 營養(yǎng)不良的腫瘤患者治療現(xiàn)狀 腫瘤患者營養(yǎng)評(píng)估,腫瘤患者營養(yǎng)代謝發(fā)生改變,Marn Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007 Jun;26(3):289-301.,腫瘤患者隨分期升高，營養(yǎng)攝入量,

2、明顯下降，導(dǎo)致體重丟失,Ravasco P, Monteiro-Grillo I, Vidal PM, et al. Cancer: disease and nutrition are key determinants of patients quality of life. Support Care Cancer. 2004 Apr;12(4):246-52.,眾多內(nèi)科疾病中，腫瘤是營養(yǎng)不良,發(fā)生率最高的,Meijers JM, Schols JM, van Bokhorst-de van der Schueren MA, et al. Malnutrition prevalence in

3、The Netherlands: results of the annual dutch national prevalence measurement of care problems. Br J Nutr. 2009 Feb;101(3):417-23.,近年來多個(gè)研究中的腫瘤營養(yǎng)風(fēng)險(xiǎn),發(fā)生率,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluate clinical outcome and quality of life in patients with c

4、ancer. Eur J Clin Nutr. 2013 Jul;67(7):732-7.,不同部位腫瘤的營養(yǎng)風(fēng)險(xiǎn)發(fā)生率比較, ,Figure 1. The prevalence of nutritional risk at admission and at 2 weeks after admission or discharge according to the different sites of primary tumors. A at admission, B 2 weeks after admission or discharge. PAN pancreas, CAR cardiac

5、, STO stomach, ESO esophagus, COL colon, LIV liver, REC rectus, UN lung, BRE breast.,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013 Jul;67(7):732-7.,腫瘤患者發(fā)生營養(yǎng)不良,的危險(xiǎn)因素,Pr

6、essoir M, Desn S, Berchery D, et al. Prevalence, risk factors and clinical implications of malnutrition in French Comprehensive Cancer Centres. Br J Cancer. 2010 Mar 16;102(6):966-71.,化療本身會(huì)加重患者的營養(yǎng)不良,Malihi Z, Kandiah M, Chan YM, et al. Nutritional status and quality of life in patients with acute le

7、ukaemia prior to and after induction chemotherapy in three hospitals in Tehran, Iran: a prospective study. J Hum Nutr Diet. 2013 Jul;26 Suppl 1:123-31.,目錄, ,腫瘤患者營養(yǎng)不良現(xiàn)狀 營養(yǎng)不良對(duì)腫瘤預(yù)后的影響 營養(yǎng)不良的腫瘤患者治療現(xiàn)狀 腫瘤患者營養(yǎng)評(píng)估,腫瘤患者營養(yǎng)狀態(tài)與全身炎癥水平,密切相關(guān),Gomes de Lima KV, Maio R. Nutritional status, systemic inflammation and pro

8、gnosis of patients with gastrointestinal cancer. Nutr Hosp. 2012 May-Jun;27(3):707-14.,營養(yǎng)不良的腫瘤患者，化療相關(guān)毒,副作用發(fā)生率顯著升高,Barret M, Malka D, Aparicio T, et al. Nutritional status affects treatment tolerability and survival in metastatic colorectal cancer patients: results of an AGEO prospective multicenter

9、study. Oncology. 2011;81(5-6):395-402.,住院期間各種并發(fā)癥發(fā)生率的比較,（有營養(yǎng)風(fēng)險(xiǎn) vs 無營養(yǎng)風(fēng)險(xiǎn)）,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013 Jul;67(7):732-7.,腫瘤相關(guān)營養(yǎng)不良降低腫瘤患者生,活質(zhì)量,Marn Caro MM

10、, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007 Jun;26(3):289-301.,體重丟失10%者，生活質(zhì)量顯著下,降,Nourissat A, Vasson MP, Merrouche Y, et al. Relationship between nutritional status and quality of life in patients with cancer. Eur J Cancer. 2008 J

11、un;44(9):1238-42.,嚴(yán)重營養(yǎng)不良患者生存率顯著低于 無營養(yǎng)不良或輕度營養(yǎng)不良的患者,Barret M, Malka D, Aparicio T, et al. Nutritional status affects treatment tolerability and survival in metastatic colorectal cancer patients: results of an AGEO prospective multicenter study. Oncology. 2011;81(5-6):395-402.,營養(yǎng)支持治療對(duì)體重下降/不良反應(yīng)發(fā)生率的影響,RR

12、=相對(duì)危險(xiǎn)度；95% CI=95%可信限,a 以年齡、性別、分期、手術(shù)和放化療進(jìn)行校正 b以年齡、性別、分期和放化療進(jìn)行校正,Pan H, Cai S, Ji J, et al. The impact of nutritional status, nutritional risk, and nutritional treatment on clinical outcome of 2248 hospitalized cancer patients: a multi-center, prospective cohort study in Chinese teaching hospitals. Nu

13、tr Cancer. 2013;65(1):62-70.,營養(yǎng)支持顯著減少化療相關(guān)毒副反,應(yīng)的發(fā)生,Hasenberg T, Essenbreis M, Herold A, et al. Early supplementation of parenteral nutrition is capable of improving quality of life, chemotherapy-related toxicity and body composition in patients with advanced colorectal carcinoma undergoing palliative

14、 treatment: results from a prospective, randomized clinical trial. Colorectal Dis. 2010 Oct;12(10 Online):e190-9.,腫瘤患者營養(yǎng)治療能改善生活質(zhì)量,Marn Caro MM, Laviano A, Pichard C. Nutritional intervention and quality of life in adult oncology patients. Clin Nutr. 2007 Jun;26(3):289-301.,接受積極營養(yǎng)治療的腫瘤患者，生,存率得到改善, Th

15、e KaplanMeier survival plot of,patients who did (n= 23) and did not(n= 30) receive invasive,nutritional support before self- expanding metal stent insertion (83.9 vs. 151.3 days,P= 0.053),Gray RT, Odonnell ME, Scott RD, et al. Impact of nutritional factors on survival in patients with inoperable oes

16、ophageal cancer undergoing self-expanding metal stent insertion. Eur J Gastroenterol Hepatol. 2011 Jun;23(6):455-60.,目錄, ,腫瘤患者營養(yǎng)不良現(xiàn)狀 營養(yǎng)不良對(duì)腫瘤預(yù)后的影響 營養(yǎng)不良的腫瘤患者治療現(xiàn)狀 腫瘤患者營養(yǎng)評(píng)估,我國腫瘤患者營養(yǎng)治療現(xiàn)狀, 營養(yǎng)治療的患者比例, 所有住院腫瘤患者中，有34.9%接受營養(yǎng)治療 有營養(yǎng)風(fēng)險(xiǎn)的患者，僅46.7%得到營養(yǎng)治療 無營養(yǎng)風(fēng)險(xiǎn)的患者，17.1%實(shí)施了營養(yǎng)治療, 腸外營養(yǎng)（PN） vs 腸內(nèi)營養(yǎng)（EN）, 30.6%的住院腫瘤患者接受PN

17、 4.4%的住院腫瘤患者接受EN PN：EN = 7：1,Yu K, Zhou XR, He SL. A multicentre study to implement nutritional risk screening and evaluate clinical outcome and quality of life in patients with cancer. Eur J Clin Nutr. 2013 Jul;67(7):732-7.,臨床營養(yǎng)的現(xiàn)狀,腸內(nèi)營養(yǎng) 腸外營養(yǎng) 歐洲 8 ： 1 美國 10 ： 1 中國 1 : 6,我國腫瘤患者營養(yǎng)治療現(xiàn)狀,惡性腫瘤營養(yǎng)不良的患病率高達(dá) 4

18、0%一 80% 住院的惡性腫瘤患者中營養(yǎng)不良的發(fā)生率就高達(dá)到63% 存在營養(yǎng)風(fēng)險(xiǎn)的患者中僅有46%得到了營養(yǎng)治療 20%的惡性腫瘤患者死于營養(yǎng)不良,目錄, ,腫瘤患者營養(yǎng)不良現(xiàn)狀 營養(yǎng)不良對(duì)腫瘤預(yù)后的影響 營養(yǎng)不良的腫瘤患者治療現(xiàn)狀 腫瘤患者營養(yǎng)評(píng)估,營養(yǎng)風(fēng)險(xiǎn)篩查,2,1,早期發(fā)現(xiàn)患者是否已發(fā)生營養(yǎng)不良或是否存在發(fā)生營養(yǎng)不良的危險(xiǎn),判定營養(yǎng)不良的嚴(yán)重度及原因，指導(dǎo)制定合理的營養(yǎng)支持的方案,用以評(píng)估營養(yǎng)支持的效果,在腫瘤患者營養(yǎng)支持的實(shí)施中，關(guān)鍵的第一步就是早期及動(dòng)態(tài)地進(jìn)行營養(yǎng)狀態(tài)的評(píng)定。,2,3,營養(yǎng)篩選,營養(yǎng)的綜合評(píng)定,營養(yǎng)評(píng)定兩步走,營養(yǎng)風(fēng)險(xiǎn)篩查工具,NRS-2002 PG-SGA,200

19、2 年6 月歐洲腸外腸內(nèi)營養(yǎng)學(xué)會(huì)(ESPEN) 在RCT 證據(jù)的基礎(chǔ)上制訂了適用于住院患者的營養(yǎng)風(fēng)險(xiǎn)篩查方法NRS-2002 (nutritionalrisk screening 2002) 目前唯一基于循證醫(yī)學(xué)證據(jù)（128個(gè)RCT的循證醫(yī)學(xué)基礎(chǔ)的）營養(yǎng)風(fēng)險(xiǎn)篩查工具 2006年中華醫(yī)學(xué)會(huì)腸外腸內(nèi)營養(yǎng)學(xué)分會(huì)推薦為住院患者營養(yǎng)風(fēng)險(xiǎn)篩查工具 簡便易行 (3個(gè)項(xiàng)目)、快速(5分鐘),NRS-2002,營養(yǎng)風(fēng)險(xiǎn)篩查初選表,如果任一問題回答是, 則進(jìn)入第二步 如果所有問題回答否, 每周復(fù)查一次,B.營養(yǎng)篩查復(fù)篩表,NRS2002內(nèi)容,疾病嚴(yán)重程度評(píng)分,營養(yǎng)狀態(tài)低減評(píng)分,年齡評(píng)分,內(nèi)容,NRS-2002營養(yǎng)

20、風(fēng)險(xiǎn)篩查結(jié)論,總分值3：患者處于營養(yǎng)風(fēng)險(xiǎn), 開始制訂營養(yǎng)計(jì)劃 總分值 3：每周進(jìn)行營養(yǎng)風(fēng)險(xiǎn)篩查,主觀整體營養(yǎng)評(píng)量表（PG-SGA）,PG-SGA（Patient-Generated Subjective Global Assessment，患者主觀整體評(píng)估）是在主觀整體評(píng)估（Subjective Global Assessment， SGA）的基礎(chǔ)上發(fā)展起來的。 美國Ottery FD于1994年提出，是專門為腫瘤患者設(shè)計(jì)的營養(yǎng)狀況評(píng)估方法。 臨床研究提示，PG-SGA是一種有效的腫瘤患者特異性營養(yǎng)狀況評(píng)估工具，因而得到美國營養(yǎng)師協(xié)會(huì)（American Dietetic Association，ADA）等單位的大力推薦與廣泛應(yīng)用。 中國抗癌協(xié)會(huì)腫瘤營養(yǎng)與支持治療專業(yè)委員會(huì)建議采用PG-SGA進(jìn)行腫瘤患者營養(yǎng)狀況調(diào)查。,評(píng)分法PG-SGA包括7項(xiàng)：體重變化，不適癥狀，食欲，體力狀況及與營養(yǎng)相關(guān)的疾病狀態(tài)，代謝狀態(tài)，體格檢查。前4項(xiàng)主要由患者完成，后3項(xiàng)主要由醫(yī)護(hù)人員完成 根據(jù)評(píng)分將患者進(jìn)行營養(yǎng)分