最新ESPEN家庭肠内营养实践指南解读2022（全文）本期导读2022年2月1日，欧洲临床营养与代谢协会（European Society for Clinical Nutrition and Metabolism, ESPEN）在其官方杂志Clinical Nutrition上正式发表了ESPEN家庭肠内营养实践指南（ESPEN practical guideline: Home enteral nutrition）。
该指南从临床实用性出发，对2020年发表的ESPEN家庭肠内营养指南进行缩减，从家庭肠内营养适应证、禁忌证到如何实施和监测以及防治并发症，总计给出61条推荐，并添加了流程图，更加便于临床医师、营养师及护士等在临床实践中使用。
一、家庭肠内营养适应证和禁忌证Fig.1. 家庭肠内营养适应证和禁忌证1. 家庭肠内营养适应证和禁忌证(Fig.1)1.1. 家庭肠内营养适应证推荐1HEN should be offered to patients at nutritional risk or malnourished who cannot meet their nutrient requirements by normal dietary intake, who have a functioning gastrointestinal tract, who are able to receive therapy outside of an acute care setting, and who agree and are able to comply with HEN therapy with the goal of improving body weight, functional status or QoL. (Grade GPP, strong consensus 97%)应向有营养风险或营养不良的患者提供HEN，这些患者无法通过正常饮食满足营养摄入需求，但胃肠道功能正常，能够在急症情形以外接受治疗，同意并能够遵守HEN治疗，以达到改善体重，功能状态或生活质量的目标。
（推荐等级GPP - 强烈同意97％）推荐2Prior to discharge from hospital of patients at risk of malnutrition (e.g. patients with neurological disease, headinjury, head and neck cancer, gastrointestinal and other malignancies, non-neoplastic gastrointestinal disease including malabsorptive syndromes), either oral nutritional supplements or HEN should be considered. (Grade B, strong consensus 96%)有营养不良风险的患者（例如神经系统疾病，头部损伤，头颈肿瘤，胃肠道和其他恶性肿瘤，非肿瘤性胃肠道疾病包括吸收不良综合征）出院前，应考虑口服营养补充剂或HEN。
（推荐等级B - 强烈同意96％）1.2. 家庭肠内营养禁忌证推荐3If life expectancy is estimated to be less than one month, HEN usually shall not be initiated.(Grade GPP, consensus 78%)如果预期寿命不到一个月，通常不应实施HEN。
（推荐等级GPP –同意78％）推荐4HEN shall not be performed in patients with contraindications such as severe functional disturbances of the bowel, gastrointestinal obstruction, gastrointestinal tract bleeding, severe malabsorption or severe metabolic imbalances. (Grade GPP, consensus 84%)对存在严重肠功能障碍，胃肠道梗阻，胃肠道出血，严重吸收不良或严重代谢失衡等禁忌证患者，不应实施HEN。
（推荐等级GPP –同意84％）推荐5If patient and/or their legal carers do not to agree to a HEN program or are unlikely to comply with and/or if there are organizational/logistic problems which cannot be overcome, HEN should not be offered. (Grade GPP, strong consensus 97%)如果患者和/或其法定照护人员不同意HEN计划，或不太可能遵守HEN计划，和/或存在无法克服的组织/后勤问题，则不应实施HEN。
（推荐等级GPP - 强烈同意97％）二、家庭肠内营养的喂养通路Fig.2. 家庭肠内营养的喂养通路2.1. 喂养管设备 (Fig.2)2.1.1. 短期家庭肠内营养(<6周)推荐6HEN can be delivered through a nasal feeding tube in patients who need HEN only for a short period of time (up to 4 - 6 weeks). (Grade 0, consensus 90%)仅需短期HEN的患者（最多4-6周）可以使用鼻饲管实施HEN。
（推荐等级0 - 同意90％）2.1.2. 长期家庭肠内营养(>6周)推荐7A PEG or, if indicated, a percutaneous endoscopic jejunostomy (PEJ) is the preferred access device and should be placed when long-term HEN is required.(Grade B, strong consensus 93%)如果存在相关指证，首选经皮内镜胃造口术（PEG）或经皮内镜空肠造口术（PEJ），并且应当在需要长期进行HEN的患者中实施PEG或PEJ。
（推荐等级B –强烈同意93％）推荐8If a PEG if not suitable for long-term HEN a percutaneous laparoscopic assisted gastrostomy (PLAG) may be a safe alternative. (Grade 0, strong consensus 93%)如果PEG不适合长期使用，经皮腹腔镜辅助胃造口术（PLAG）可作为一种安全的替代方式。
（推荐等级0 –强烈同意93％）推荐9Radiologically inserted gastrostomy (RIG) or percutaneous radiological gastrostomy (PRG) can be used as alternative techniques for the placement of a feeding tube into the stomach, if an endoscopically guided tube placement cannot be performed. (Grade 0, strong consensus 97%)如果不能在内镜引导下放置肠内营养管，则可在影像学引导下插入胃造口管（RIG）或实施经皮影像学引导下胃造口术（PRG）将肠内营养喂养管放入胃内。
（推荐等级0 –强烈同意97％）推荐10In case of inadvertent displacement or removal of the PEG more than four weeks after initial placement, direct replacement can be safely attempted before the track closes completely. (Grade GPP, strong consensus 93%)如果PEG不慎在初次放置四周后移位或移除，在窦道完全闭合之前尝试直接更换PEG管是安全的。
（推荐等级GPP - 强烈同意93％）推荐11A PEG should be preferred over a surgical gastrostomy for long-term HEN, mainly due a lower complication rate,cost-effectiveness and operating time. (Grade B, strong consensus 100%)对需要长期HEN的患者，PEG优于手术胃造口，主要是由于PEG较低的并发症发生率，成本效益和手术时间。
（推荐等级B - 强烈同意100％）2.2. 管路、通道口以及耗材2.2.1. 护理(Fig.3)推荐12Until the stoma tract is formed and the incision is healed, the PEG exit site should be daily monitored and kept clean and dry by using aseptic wound care (usually up to 5 to 7 days post procedure). (Grade B, strong consensus 100%)在窦道形成和切口愈合前，应每日监测PEG出口部位，并通过无菌伤口护理保持其清洁和干燥（一般术后需要5-7天）。
（推荐等级B - 强烈同意100％）Fig.3. 管路、通道口以及耗材-护理推荐13Once the gastrostomy tract has been healed (after about one week), the tube should be rotated daily and should be moved inwards at least once a week (at least 2 cm, up to 10 cm). (Grade GPP, consensus 87%)一旦胃造口窦道形成（约一周后），应每天转动PEG管，并应至少每周向内移动一次（至少2厘米，最多10厘米）。