Article(id=1208862460854006514, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208862455166538583, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.2021.08.17, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1605715200000, receivedDateStr=2020-11-19, revisedDate=1621267200000, revisedDateStr=2021-05-18, acceptedDate=null, acceptedDateStr=null, onlineDate=1766144870246, onlineDateStr=2025-12-19, pubDate=1630080000000, pubDateStr=2021-08-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1766144870246, onlineIssueDateStr=2025-12-19, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1766144870246, creator=13701087609, updateTime=1766144870246, updator=13701087609, issue=Issue{id=1208862455166538583, tenantId=1146029695717560320, journalId=1189873630562394117, year='2021', volume='46', issue='8', pageStart='743', pageEnd='848', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1766144868890, creator=13701087609, updateTime=1766144939527, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1208862751481524455, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208862455166538583, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1208862751481524456, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1208862455166538583, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=843, endPage=848, ext={EN=ArticleExt(id=1208862461147607797, articleId=1208862460854006514, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Nutritional support for patients after cardiac surgery: Research progress, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

The patients after cardiac surgery often suffer from malnutrition due to insufficient energy intake, which increases the incidence of complications and mortality. Thus, energy and protein intake can accelerate patients' recovery. Previously, enteral nutrition has been widely considered to be the major nutritional way, however, an increasing studies suggest a combination of enteral and parenteral way can provide nutrition to patients maximally. Albeit the timing of the inception of parenteral way of nutrition remains controversial, it is confirmed that early start of the enteral way is salubrious to patients, and the duration of nutritional support should be determined according to the specific situation of patients. Additionally, nutritional scoring system plays a crucial role. Various nutritional risk scores can predict the clinical outcome of patients, thus, the most adaptable nutritional score for patients after receiving cardiac surgery needs further study. This article reviews the importance of nutritional support for the patients after cardiac surgery, selection, timing, and duration of post-operative nutritional support, and the advances in nutritional risk assessment etc.

, correspAuthors=Hai-Tao Zhang, authorNote=null, correspAuthorsNote=
*E-mail:
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心脏外科术后患者常因能量摄入不足而出现营养障碍,从而导致并发症发生率及病死率增高。注重热量及蛋白质的补充有利于患者病情恢复,而肠内营养被认为是心脏外科术后的主要营养支持方式。越来越多的研究表明,采用肠内营养合并肠外营养的方式可为患者提供更好的营养支持,虽然肠外营养的使用时机仍有争议,但目前普遍认为术后早期使用肠内营养对患者有益。该文就营养支持对心脏外科术后患者的重要性,心脏外科术后营养支持方式的选择、时机、使用时程,以及营养风险评估等方面的进展进行综述。

, correspAuthors=张海涛, authorNote=null, correspAuthorsNote=
张海涛,E-mail:
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秦竹韵,硕士研究生,主要从事心脏外科围术期及心脏重症方面的研究

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秦竹韵,硕士研究生,主要从事心脏外科围术期及心脏重症方面的研究

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秦竹韵,硕士研究生,主要从事心脏外科围术期及心脏重症方面的研究

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心脏外科术后患者营养支持治疗研究进展
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秦竹韵 , 张海涛 *
解放军医学杂志 | 综述 2021,46(8): 843-848
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解放军医学杂志 | 综述 2021, 46(8): 843-848
心脏外科术后患者营养支持治疗研究进展
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秦竹韵, 张海涛*
作者信息
  • 北京协和医学院/中国医学科学院阜外医院成人外科术后恢复室,北京 100037
  • 秦竹韵,硕士研究生,主要从事心脏外科围术期及心脏重症方面的研究

通讯作者:

张海涛,E-mail:
Nutritional support for patients after cardiac surgery: Research progress
Zhu-Yun Qin, Hai-Tao Zhang*
Affiliations
  • Department of Surgical Intensive Care Unit, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
出版时间: 2021-08-28 doi: 10.11855/j.issn.0577-7402.2021.08.17
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心脏外科术后患者常因能量摄入不足而出现营养障碍,从而导致并发症发生率及病死率增高。注重热量及蛋白质的补充有利于患者病情恢复,而肠内营养被认为是心脏外科术后的主要营养支持方式。越来越多的研究表明,采用肠内营养合并肠外营养的方式可为患者提供更好的营养支持,虽然肠外营养的使用时机仍有争议,但目前普遍认为术后早期使用肠内营养对患者有益。该文就营养支持对心脏外科术后患者的重要性,心脏外科术后营养支持方式的选择、时机、使用时程,以及营养风险评估等方面的进展进行综述。

心脏外科手术  /  营养支持  /  肠内营养  /  肠外营养  /  围术期营养

The patients after cardiac surgery often suffer from malnutrition due to insufficient energy intake, which increases the incidence of complications and mortality. Thus, energy and protein intake can accelerate patients' recovery. Previously, enteral nutrition has been widely considered to be the major nutritional way, however, an increasing studies suggest a combination of enteral and parenteral way can provide nutrition to patients maximally. Albeit the timing of the inception of parenteral way of nutrition remains controversial, it is confirmed that early start of the enteral way is salubrious to patients, and the duration of nutritional support should be determined according to the specific situation of patients. Additionally, nutritional scoring system plays a crucial role. Various nutritional risk scores can predict the clinical outcome of patients, thus, the most adaptable nutritional score for patients after receiving cardiac surgery needs further study. This article reviews the importance of nutritional support for the patients after cardiac surgery, selection, timing, and duration of post-operative nutritional support, and the advances in nutritional risk assessment etc.

cardiac surgery  /  nutritional support  /  enteral nutrition  /  parenteral nutrition  /  perioperative nutrition
秦竹韵, 张海涛. 心脏外科术后患者营养支持治疗研究进展. 解放军医学杂志, 2021 , 46 (8) : 843 -848 . DOI: 10.11855/j.issn.0577-7402.2021.08.17
Zhu-Yun Qin, Hai-Tao Zhang. Nutritional support for patients after cardiac surgery: Research progress[J]. Medical Journal of Chinese People’s Liberation Army, 2021 , 46 (8) : 843 -848 . DOI: 10.11855/j.issn.0577-7402.2021.08.17
相比一般手术,心脏外科手术给患者造成的创伤更大。心脏外科术后可能存在血流动力学改变,导致患者并发症较多、恢复期较长,术后病死率也较高。合理的术后营养支持方式不仅能够提高心脏外科患者的营养状态,增强免疫力,还能促进患者机体的恢复及创伤的愈合,降低患者的再住院率、并发症发生率及病死率[1]。据估计,60%以上的心脏外科术后患者需要接受营养支持[2]。因此,在心脏外科术后行营养支持必不可少。近年来,国内外对心脏外科术后营养支持方面的研究越来越重视。能量与蛋白质的摄入对患者疾病及功能恢复非常重要。目前,心脏外科手术后患者的营养支持方式、营养评分选择仍然存在争议,尽管已有相关专家共识[3],但对于心脏外科术后患者的营养方式、使用时机及评分等选择尚无确切指南。因此,本文从营养支持对心脏外科手术患者的重要性、心脏外科术后营养支持方式的选择、心脏外科术后患者的能量及蛋白质摄入现状、心脏外科术后营养风险评分等方面的研究现状进行综述,旨在为心脏外科术后患者营养支持的选择提供方向。
首先,由于手术创伤、体液丢失及体外循环中异物的接触,心脏外科手术患者体内中性粒细胞、内皮细胞及血小板被激活,导致炎症介质释放,产生全身炎性反应,不利于患者心功能的恢复[4]。其次,由于心功能不全及大量血管活性药物的使用,使肠道处于低灌注状态,肠道黏膜通透性增加,菌群移位,细菌内毒素进一步诱导炎性介质及氧化产物的产生、激活及释放,加重了心功能不全[5]。手术的打击及心功能不全使患者机体营养成分发生改变,导致分解代谢增加、肌肉消耗,进而发生心源性恶液质,导致营养不良[6-7]。营养不良的患者更容易产生炎症反应、手术创伤、心肌缺血、麻醉并发症、容量丢失及血液稀释等风险,导致患者免疫功能低下,增加患者术后并发症的发生及死亡。疾病及营养不良产生恶性循环,导致患者预后不佳[4]。营养支持能增加患者蛋白质的合成,控制心脏外科术后患者的炎症反应,提高患者的免疫状态,保持正氮平衡,避免或减缓肌肉消耗,从而有利于伤口及疾病的恢复,降低并发症发生率及病死率,改善患者预后。所以,心脏外科手术后患者的营养摄入十分重要。
心脏外科术后患者能量及蛋白质需求发生变化,因此能量及蛋白质的摄入对营养状态及预后具有重要影响。然而,多项研究提示,心脏外科术后患者的能量及蛋白质摄入不足,可导致营养不良。Vilhjálmsdottir等[8]评估了61例心脏外科术后患者的能量及蛋白质摄入情况,发现其能量摄入为(19.0±5.8) kcal/(kg.d),低于最低推荐量25~30 kcal/(kg.d);蛋白质摄入为(0.9±0.3) g/(kg.d),低于最低推荐量1.2~1.5 g/(kg.d),其中14例(23%)存在营养不良或营养不良风险。Goldfarb等[9]通过观察22例心脏外科术后老年患者的营养摄入,发现其术后早期蛋白质摄入量为(0.7±0.3) g/(kg.d),低于推荐量1.5 g/(kg.d),差异有统计学意义;术后早期能量摄入为(1 211±447) kcal/d,明显低于术前的(2553±851) kcal/d及出院后的(2395±645) kcal/d,差异有统计学意义(P<0.001),提示心脏外科术后老年患者早期需注重能量及蛋白质的补充。Ogawa等[10]对250例行心脏外科手术的老年患者进行研究发现,其术后能量摄入为(22.4±3.0) kcal/(kg.d),能量摄入不足者的6分钟步行距离更短,提示老年患者的能量摄入与心功能恢复呈正相关。Sallé等[11]研究发现,心脏外科术后患者能量及蛋白质缺乏的原因是食欲减退、代谢增加。其研究了15例行主动脉瓣置换术的患者,发现术后普遍食欲减退,卡路里摄入量从1451(1272~1640) kcal减少至372(22~528) kcal,而能量消耗从1358(1180~1559) kcal增加至1613(1472~1670) kcal,差异均有统计学意义,提示心脏外科术后患者易出现能量不足。Efremov等[12]对40例心脏外科术后血流动力学紊乱的患者使用早期肠内营养(enteral nutrition,EN),发现高热量及蛋白质充足的营养(1300 kcal/L热量及66.7 g/L蛋白质)能比标准等热量的营养(1000 kcal/L热量及38 g/L蛋白质)提供更多的能量及蛋白质,前白蛋白及转铁蛋白水平更高(P<0.05),提示营养制剂的选择对能量及蛋白质的补充具有重要影响。综上,心脏外科术后患者尤其是老年患者易出现营养补充不足的情况,选择高热量及富含蛋白的营养制剂能改善患者的营养水平。
术后重症患者的营养支持,常选择EN途径,因其更符合人体营养吸收的生理特点。但由于心脏外科术后患者常常合并心功能不全,再加上大量血管活性药物的使用,目前普遍认为EN对于血流动力学不稳定的心脏外科术后患者有害,因其会影响心输出量,加重肠道缺血。与这种观念相反,大量证据表明,心脏外科术后使用EN对患者有利。Ravelly等[13]对9例需要使用血管活性药物支持的心脏术后患者使用EN,结果均未发现肠道扩张及EN相关不良反应。此研究还发现,EN能改善患者的代谢反应,升高胰岛素水平(升高500%),从而增加血糖水平(增加37%)、降低血脂水平(降低51%),此外,还能增加乳酸水平(升高34%)。使用EN 180 min后,患者平均动脉压及全身血管阻力指数降低(分别降低11%、16%),使用EN 240 min后,患者心脏指数升高(升高10%),表明使用EN能改善心脏外科术后患者的血流动力学水平。Flordelís Lasierra等[14]为了研究EN用于心脏外科术后血流动力学不稳定患者的可行性及有效性,对642例使用血管活性药物、体外膜肺氧合(extracorporeal membrane oxygenation,ECMO)、主动脉内球囊反搏以及机械辅助装置的患者使用EN,并未发现严重的胃肠道并发症或肠系膜缺血,虽然便秘是最常见的不良反应(占46%),但程度较轻。其中,使用机械辅助装置的患者EN相关并发症发生率更高(约82%)。此外,相比短时间住院患者,尽管长时间使用EN的患者并发症发生率较高,但这些并发症并不严重,也无需停用EN。总体说来,使用EN的患者疾病严重程度评分、死亡率及血流动力学改变与未使用EN的患者相比无明显差异。危宇等[15]对12例心脏外科术后使用ECMO的患者给予EN支持治疗,结果在使用ECMO期间,患者1周内EN耐受率达70%,无患者出现胃内容物误吸、腹胀、呕吐、胃肠道出血、功能性肠梗阻等严重并发症,也无患者出现感染相关并发症及血流动力学异常,表明患者对EN的耐受性高。Umezawa等[16]报道了553例需要营养支持的心脏外科术后使用ECMO的患者,EN是唯一的营养支持方式。在EN使用过程中,患者耐受性好,无相关严重不良反应,证实了在严重血流动力学不稳定的心脏外科术后患者中使用EN的安全性。由此可见,EN安全有效,可改善心脏外科术后患者的血流动力学状态,降低并发症发生率及病死率。此外,EN不仅能够增加碳水耐受、维持肠道黏膜屏障功能,还能改善心功能,提高机体免疫状态,从而降低感染发生率及炎性因子水平[13,17]。因此,对于EN耐受的患者,临床上普遍倾向于首先使用EN。值得注意的是,EN支持前需关注患者胃残余量(gastric residual volume,GRV),保证在胃肠道相对排空的情况下使用EN。
过多或过少的EN都可能产生营养风险,手术及血管活性药物的使用使胃肠道处于缺血状态,患者肠道功能恢复较慢,使得EN不利于营养的吸收,而通过PN补充营养可以弥补这一缺点。尽管单独使用PN的研究较少,但对于心脏外科术后患者,PN能改善营养状态,降低死亡风险。Christofe等[18]发现,儿童行先天性心脏病矫治术后,使用空腹加PN治疗能纠正约86.5%乳糜胸的发生。Hong等[19]对16例行冠状动脉搭桥手术的患者使用PN摄入高剂量胰岛素及氨基酸,证实了在使用高剂量胰岛素的心脏外科手术患者中,达到20%静息能量消耗量(resting energy expenditure,REE)的患者的必需氨基酸含量(包括支链氨基酸)低于达到35% REE的患者;达到35% REE的患者补充氨基酸能显著提高23%的必需氨基酸含量和12%的非必需氨基酸含量。这提示在PN治疗中,只要使用恰当的营养制剂,也可以改善高胰岛素所致的低氨基酸血症相关疾病。上述研究表明,PN对心脏外科术后患者有益,不过目前尚缺乏与其他营养方式的对照研究。但也有研究发现PN对心脏有害。Santarpia等[20]的研究表明,长期使用PN会增加患者血流动力学改变及右心房压升高的风险,从而导致心功能损害。一项动物实验表明,空腹使用PN会升高血糖,产生氧化应激反应,从而导致心肌细胞受损,而EN能缓解心肌损害[21]。Restrepo等[22]报道了1例使用PN导致心脏压塞的病例。此外,PN也可增加感染的发生[23]。综上研究,单用PN可能对心脏的恢复弊大于利。因此,除有特殊需求、无法进食或胃肠道功能受损等情况以致无法使用EN的心脏外科术后患者外,更多关于PN的研究提示其仅可作为EN的补充使用。
近年来,多项研究显示心脏外科术后患者使用EN+PN的方式进行营养支持治疗可改善患者的营养状态,对预后的改善作用甚至优于单用EN,因其能保证能量摄入的充足性,而充足的能量摄入可减少死亡及并发症,使患者获益[1]。覃少洲[24]对24例心脏瓣膜置换术后患者应用EN+PN治疗后1周,患者血液中各种蛋白水平明显增高。尽管该研究缺乏其他营养支持方式的对照,但可以肯定的是,采用EN+PN的方式使患者营养状态得到了改善。Ong等[23]对232例心脏外科术后患者使用营养支持,发现EN+PN能明显增加卡路里的摄入。EN仅可使每日摄入卡路里达到所需剂量的36%,而EN+PN可使每日摄入卡路里增加到所需剂量的77%。尽管腹泻为最常见的并发症,但与仅使用EN的患者相比,使用EN+PN患者的腹泻发生率明显降低(6% vs. 28%)。Rahman等[2]对473例心脏外科术后患者分别使用不同方式的营养支持,其中,使用EN+PN患者的卡路里摄取率为32.4%,高于仅使用EN的患者(25.5%),且EN+PN患者的蛋白质摄取率也优于EN患者(28.8% vs. 24.9%),与上述研究一致,提示EN+PN能增加能量摄入。此外,研究表明,EN+PN尤其适用于外科手术后患者的营养补充。Wischmeyer等[25]研究125例体重不足及超重的非手术及手术后重症患者,采用EN与EN+PN的方式治疗7 d后,发现EN+PN组的热量及蛋白质摄取率高于EN组(26% vs. 22%,P<0.001);相比普通监护室,术后恢复室患者的热量及蛋白质摄入更多,且EN+PN组患者预后更好,病死率更低,生活质量明显提高,而感染风险并未增加。综上所述,对于心脏外科术后患者,单用EN常常无法满足患者所需要的能量及蛋白质,加用PN能明显增加营养的摄入。因此,若无禁忌证,在单用EN不能满足患者机体营养需求时,可考虑使用EN+PN的方式进行营养支持治疗。
在关于心脏外科术后患者营养支持时机的研究中,主要是关于EN使用时机的研究,关于PN使用时机的研究较少。以往相关综述认为,心脏外科术后应早期使用EN,但关于PN的使用时机仍有争议,考虑到能量摄入不足的不良影响,建议早期使用PN[26]。术后48 h内实施的EN为早期EN,术后48 h以后实施的EN为延迟EN。关于EN的使用时机,欧洲指南及美国指南均推荐早期使用。欧洲指南建议术后血流动力学稳定的患者应尽早使用EN(24 h内),因为EN可促进肠黏膜增生,维持肠道完整性,同时改善免疫功能[27]。而美国指南推荐EN的使用时机为术后24~48 h[28]。诸多研究证实早期使用EN对血流动力学不稳定的心脏外科患者安全有效,可改善血流动力学状态,且并未增加并发症发生及死亡风险[13-16]。延迟EN可能导致患者营养状态改变不达标,如前述研究中,于术后2.3 d给予EN+PN,患者能量摄入虽然比单用EN有所增加,但仍不充足[2]。关于PN的使用时机也存在争议,欧洲指南推荐早期(术后48 h内)使用PN[29],而美国指南推荐在早期使用EN的同时,应于术后1周后开始使用PN[28]。Casaer等[30]研究发现,与早期使用PN相比,晚期使用PN可使患者疾病恢复更快,且更少发生并发症,与欧洲指南推荐相反。所以,尽管普遍认为早期EN优于延迟EN,但心脏外科术后PN的使用时机仍需进一步研究。
使用营养支持的最终目的是使患者能够通过自主进食来摄入营养,从而恢复机体健康,以往研究对营养支持的使用时程各不同。Rahman等[2]对患者使用3~12 d的营养支持。Flordelis Lasierra等[14]对使用EN的患者进行28 d的随访。Umezawa Makikado等[16]对患者使用2周营养支持后减少使用量。目前对于营养支持的具体时程尚无定论,但停止使用营养支持普遍取决于患者的机体状态及并发症的严重程度。美国指南建议,在使用EN的过程中,需监测患者的GRV,当GRV为200~500 ml时,说明患者对EN不耐受,需使用促胃动力药;当GRV高于500 ml时,需停用EN[27]。EN需维持到有血流动力学紊乱的患者完全复苏和(或)稳定后。值得注意的是,应当避免不合理地停用EN。使用PN时需监测血糖,当血糖达到7.8~10.0 mmol/L时,可根据情况停用PN。同时使用EN与PN时,当患者通过EN摄入超过60%的目标能量,且对EN的耐受性增加时,应逐渐减少PN的使用量,直至停用。由此可见,营养支持的使用时程需依据患者的具体情况而定。
因为需要评估患者的营养状态以选择营养摄入的方式及时机,所以确定心脏外科术后患者的营养风险评估标准很重要。Shibata等[31]研究了老年营养风险指数(geriatric nutritional risk index,GNRI)在1613例经导管主动脉瓣置换术(transcatheter aortic valve implantation,TAVI)患者中的应用情况,发现GNRI低评分(GNRI<92)是死亡的独立预测因子(P<0.001)。这一结论也在Lee等[32]的研究中得到证实,412例行TAVI后的患者使用控制营养状态评分(controlling nutritional status score,CONUT)及GNRI分别评估其营养风险,发现GNRI低及CONUT高的患者1年病死率更高(P=0.001、0.005),而在多变量Cox比例风险模型中,GNRI低(但CONUT不高)也可预测死亡的风险(P=0.004)。以上研究说明,GNRI用于TAVI术后患者的营养状态评估预测死亡的效果优于CONUT,但也有研究认为CONUT及预后性营养指数(prognostic nutritional index,PNI)评估营养风险的效果优于GNRI。Okuno等[33]对95例TAVI术后患者进行评估发现,CONUT及PNI评分与TAVI术后患者的1年临床结局特别是病死率相关(P<0.05),其效果优于GNRI。Teker等[34]用CONUT及PNI对149例冠状动脉搭桥术后患者进行营养风险评估,结果发现营养风险评分高的患者肾功能不全、出血性疾病的发生率及病死率也较高,说明营养风险与并发症发生率及病死率呈正相关(P<0.05),证实了CONUT及PNI对心脏外科术后患者营养评分的有效性。此外,约翰霍普金斯医院营养支持(Johns Hopkins Hospital nutrition support,JHHNS)评分能对患者术后营养需求风险进行分层,有助于对不同营养风险患者实施营养支持治疗。Ohkuma等[35]对1056例心脏外科术后患者进行研究发现,JHHNS评分每增加1分,患者的营养需求风险增加20%(P<0.001),该结论在同一研究针对1336例心脏外科术后患者的验证队列中得到了证实。
营养支持治疗在心脏外科术后患者的治疗中起着重要作用,可以促进患者快速恢复,降低并发症发生率及死亡率。在能量摄入种类的选择上,能量密度大的营养物质可改善摄入不足的情况,但目前对于心脏外科术后患者的营养支持方式、使用时机、营养评分等仍存在争议。关于营养支持的方式,研究显示EN更符合人体肠道营养吸收及代谢的生理,可改善心脏外科术后患者的血流动力学状态。因PN能使患者胃肠道得到休息,也可降低相关并发症的发生率,必要时可单独或联合EN用于心脏外科术后患者的营养支持。由于EN+PN的效果优于单独使用EN,因此在无禁忌证的情况下,对于需要长期营养支持的心脏外科术后患者,EN+PN支持治疗可作为首选的营养支持方式。使用营养支持的时机也至关重要,对于EN,推荐术后24~48 h开始使用,然而对于PN暂无推荐的使用时机,是否也应早期使用有待进一步研究。营养支持的使用时程需根据患者的自身情况而定。对于营养风险评分,GNRI为心脏外科术后患者病死率的独立预测因子,效果优于CONUT,但也有研究认为CONUT及PNI评分效果比GNRI更好;此外,JHHNS能对患者的营养风险进行分层。因此对于心脏外科术后患者营养风险评分的选择,还需进一步探讨。
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2021年第46卷第8期
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doi: 10.11855/j.issn.0577-7402.2021.08.17
  • 接收时间:2020-11-19
  • 首发时间:2025-12-19
  • 出版时间:2021-08-28
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  • 收稿日期:2020-11-19
  • 修回日期:2021-05-18
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    北京协和医学院/中国医学科学院阜外医院成人外科术后恢复室,北京 100037

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张海涛,E-mail:
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2种不同金属材料的力学参数

Family
属数
Number of
genus
种数
Number of
species
占总种数比例
Percentage of
total species (%)

Genus
种数
Number of
species
占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
栓菌属 Trametes 5 2.39
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