中国成人患者微营养素临床应用指南（2024版）

doi:10.3877/cma.j.issn.1674-0793.2024.03.001

微营养素包括微量元素和维生素，是人体代谢中不可或缺的营养素。临床上多数需要营养治疗的患者，因多种原因存在不同程度的微营养素缺乏，导致疾病进展并影响临床结局。为进一步规范医学营养治疗中的微营养素的应用，由中华医学会肠外肠内营养学分会组织国内近百位相关领域的专家，基于现有的循证医学证据，围绕微营养素的作用和应用剂量，针对临床常见疾病状态如重症、手术、烧伤、炎性肠病、短肠综合征、恶性肿瘤、慢性肝（肾）疾病、老年共病、减重营养管理和慢性感染等维生素和微量元素的使用情况等，最终提出13个问题、30条推荐意见，旨在为成人患者肠外肠内营养的临床规范应用提供参考。

关键词: 营养疗法, 微营养素, 维生素, 微量元素, 成人患者, 临床指南

Micronutrients, including trace elements and vitamins, are essential nutrients in human metabolism. The majority of patients who need nutritional therapy have different levels of micronutrient deficiency for various reasons, which can lead to disease progression and affect clinical outcomes. In order to further standardize the application of micronutrients in medical nutrition therapy, nearly 100 experts in related fields were organized by the Chinese Society of Parenteral and Enteral Nutrition (CSPEN) to elaborate on the role and dosage of micronutrients based on the existing evidence-based medical evidence in common clinical conditions such as severe illness, surgery, burns, inflammatory bowel disease, short bowel disease, malignant tumors, chronic liver and kidney disease, elderly comorbidity, weight loss and chronic infection. Finally, 13 questions and 30 recommendations were put forward to provide reference for clinical standard application of parenteral and enteral nutrition in adult patients.

Key words: Nutritional therapy, Micronutrients, Vitamins, Trace element, Adult patients, Clinical guideline

表1 微量元素和维生素的临床监测、推荐应用剂量及注意事项

微营养素	监测与评估	推荐剂量（/d）	注意事项
铬	重症患者存在胰岛素抵抗和高血糖时，可使用静脉注射铬尝试减少胰岛素用量	EN:≥35 μg/1 500 kcal； PN:≥10 μg	根据胰岛素抵抗水平考虑存在铬缺乏时，可予以静脉途径补充铬（200~250 μg/d，连用2周）；重症患者存在胰岛素抵抗，需要剂量为3~20 μg/h的铬，静脉注射10 h、≤4 d
钴	心肌病怀疑钴中毒时，可能需要测定钴	EN应通过补充维生素B₁₂的方式进行钴补充；只要补充了维生素B₁₂，则PN无需额外单独补充钴制剂	无
铜	减肥手术后或其他非十二指肠腹部手术后；病因不明的神经病变；严重烧伤者；连续2周以上的肾脏替代治疗；通过空肠造口管进行家庭肠内营养（HEN）的患者；长期接受PN者；以上患者应每6~12个月测定一次铜含量，同时需测定CRP以进一步明确铜水平	EN:1~3 mg/1 500 kcal； PN:0.3~0.5 mg	当血浆铜浓度<12 μmol/L且CRP>20 mg/L时，需补充铜；当血浆铜浓度<8 mmol/L伴或不伴CRP升高时，应予以补充。慢性疾病可首先考虑口服；严重铜缺乏时，应首选静脉补充，以4~8 mg/d缓慢输注
氟	怀疑氟中毒时应进行血液检测	EN:≤3 mg/1 500 kcal； PN:0~1 mg	氟化物中毒时，应采取生命功能支持和电解质监测对症治疗；除控制过量氟暴露的来源外，尚无治疗氟骨症的方法
碘	甲状腺疾病高发人群、碘缺乏症高发地区者、长期暴露于聚维酮碘（PVPeI）消毒者，应评估碘水平	EN:150~300 μg/1 500 kcal；PN:130 μg	碘缺乏时应通过口服或肠内途径补充（约300~ 600 μg/d），或通过肌肉注射；在急性严重碘缺乏症中，可以通过静脉注射碘化钠溶液补充碘
铁	贫血和持续严重疲劳者、疑似铁缺乏和过载者均应检测血浆铁、转铁蛋白、转铁蛋白饱和度、铁蛋白、CRP、铁调素以及红细胞形态等一系列指标	EN:18~30 mg/1 500 kcal的铁；PN:≥1 mg，或每隔一段时间予以单独补充等量铁	若补充量超过基础剂量方可纠正铁缺乏，应单次静脉注射；经低铁调素水平证明铁缺乏的重症患者，应以羧基麦芽糖铁形式补充1 g铁
锰	怀疑锰过量或中毒时，尤其是长期PN（>30 d；>55 μg/d）并出现肝功能受损或缺铁时，应当检测锰的含量，间隔至少40 d（生物半衰期）	EN:2~3 mg/1 500 kcal；安全范围:≤6 mg；PN: 55 μg	当全血或血清中锰含量超过实验室正常参考范围上限2倍时，应予以处理；锰中毒可以通过将锰从PN混合物中去除、螯合疗法或缺铁时补充铁来治疗
钼	怀疑钼缺乏时才应测定血中钼、尿液中亚硫酸盐、次黄嘌呤、黄嘌呤和血浆尿酸的浓度	EN:50~250 μg/1 500 kcal；PN:19~25 μg	可用四硫代钼酸盐治疗肝豆状核变性（Wilson病）中的铜超载
硒	所有可能接受PN>2周或即将开始HPN的患者应在开始时即测定血浆硒；并根据需要决定是否需要复测，并应同时测定CRP和白蛋白水平	EN:50~150 μg/1 500 kcal； PN:60~100 μg	血浆硒<0.4 μmol/L（<32 μg/L）时应立刻予以补充，初始剂量为100 μg/d（肠内或静脉注射），剂量可能高达400 μg/d，持续至少7~10 d后再复查
锌	胃肠道和（或）皮肤过多丢失锌的患者；开始启动长期PN时应测定血浆锌；长期PN的患者应每6~12个月测定血浆锌。需要同时测定CRP和白蛋白水平	EN:≥10 mg/1 500 kcal； PN:3~5 mg（无额外丢失锌时）	胃肠道丢失锌（瘘管、造口和腹泻）而接受PN的患者，每天通过静脉注射最多可补充12 mg；严重烧伤（烧伤面积>20%）的患者可通过静脉注射锌30~35 mg/d，持续2~3周；在获得性锌缺乏的情况下，可每天补充0.5~1.0 mg/kg的锌（二价锌离子），连续口服3~4个月；肠病性肢端皮炎患者可终身补充3 mg/kg的锌（二价锌离子）
维生素B₁（硫胺素）	心肌病和长期服用利尿剂者；长期营养支持和减肥手术后；再喂养综合征等，应测量红细胞或全血中二磷酸硫胺素（ThDP）的含量	EN:1.5~3.0 mg/1 500 kcal；PN:≥2.5 mg	急诊或重症患者，入院后应立即补充维生素B₁（100~300 mg/d，静脉注射），连用3~4 d；入院前进食量减少或饮酒量过多者，应通过口服或静脉注射补充维生素B₁（100~300 mg/d）
维生素B₂（核黄素）	怀疑维生素B₂缺乏时，可通过红细胞中的谷胱甘肽还原酶活性来评估	EN:≥1.2 mg/1 500 kcal； PN:3.6~5.0 mg	维生素B₂缺乏时，可口服（5~10 mg/d）或静脉注射核黄素（160 mg，连用4 d）；脱氢酶缺乏症（MADD）的患者可补充维生素B₂（50~200 mg/d）
维生素B₃（维生素PP、烟酸、烟酰胺）	腹泻、皮炎和痴呆等，可检测血液或组织中烟酰胺腺嘌呤二核苷酸（NAD）水平	EN:18~40 mg/1 500 kcal；PN:≥40 mg	当有维生素B₃缺乏的风险病史和（或）存在体征或症状进而怀疑存在维生素B₃缺乏时，可能需要补充更高剂量
维生素B₅（泛酸、D-泛醇）	结合神经症状决定是否检测血液维生素B₅水平	EN:≥5 mg/1 500 kcal； PN:≥15 mg	无典型神经系统症状时，维生素B₅可与其他B族维生素一起服用
维生素B₆（吡哆醇、吡哆醛、吡哆胺）	有维生素B₆缺乏表现时，应测量血浆或红细胞磷酸吡哆醛（PLP）水平	EN:≥1.5 mg/1 500 kcal； PN:4~6 mg	异烟肼过量或乙二醇中毒时，应予以大剂量维生素B₆治疗
维生素B₇（生物素）	直接测量血和尿中的维生素B₇，并通过测定生物素酶活性来完善	EN:≥30 μg/1 500 kcal； PN:60 μg	哺乳期母亲需口服（≥35 μg/d）；接受肾替代治疗的患者可额外补充；根据肠道功能，可通过口服、肠内或静脉给予维生素B7
维生素B₉（叶酸）	大细胞性贫血或有营养不良风险者应在首次就诊时评估维生素B₉水平；补充3个月后再次评估	EN:330~400 μg DFE/1 500 kcal； PN:400~600 μg	饮食不足或长期血液透析者，可口服叶酸（1.5 mg/d）；口服治疗无效或不耐受者，可给予叶酸（0.1 mg/d）皮下注射、静脉注射或肌肉注射
维生素B₁₂（钴胺素）	所有贫血、孤立性大细胞增多症、多发性神经病、神经退行性疾病或精神病的患者应监测维生素B₁₂；自身免疫性疾病或舌炎、贫血和神经病变者，无论维生素B₁₂水平如何，应监测抗内在因子抗体（抗IFAB）	EN:≥2.5 μg/1 500 kcal； PN:≥5 μg	哺乳期应口服（≥2.8 μg/d）；维生素B₁₂吸收受损的患者应终身服用补充剂（350 μg/d），或每1~3个月肌肉注射1 000~2 000 μg；若表现为急性缺乏临床症状、抗IFAB阳性、有全胃切除术史或持续消化道不良疾病者，应采用肌肉注射途径，初始予以高剂量维生素B₁₂（1 000 μg，1次/2 d），连用2周（或1次/d，连用5 d）
维生素A（视黄醇）	消化道吸收不良的患者应测定血清视黄醇和视黄酸酯	EN:900~1 500 μg RE/1 500 kcal； PN:800~1 100 μg RE	脂肪吸收不良时，可以口服维生素A
维生素C（抗坏血酸）	坏血病或长期摄入不足的患者，应监测血浆维生素C浓度	EN:≥100 mg/1 500 kcal； PN:100~200 mg	慢性氧化应激状态（糖尿病、心力衰竭、严重COPD和长期透析）或消化不良的患者，可口服维生素C（200~500 mg/d）；重症患者可适当增加用量
维生素D	存在维生素D消耗或缺乏风险的患者，测定血清25-(OH)D水平	EN:≥1000 U（25 μg）/1 500 kcal；PN:≥200 U（5 μg）	既往缺乏复发的患者，应服用4 000~5 000 U(100~125 μg)/d，为期2个月，目标25-(OH)D水平为40~60 μg/L
维生素E（生育酚）	囊性纤维化、a-β脂蛋白血症和TTP患者应测定维生素E	EN:≥15 mg/1 500 kcal； PN:≥9 mg	血浆a-生育酚水平<12 μmol/L时，应补充维生素E
维生素K（叶绿醌）	长期使用广谱抗生素和慢性肾病者，应通过生物标志物和饮食摄入情况来判断维生素K水平	EN:≥120 μg/1 500 kcal； PN:150 μg维生素K₁	接受抗凝治疗特别是华法林治疗者，应慎重评估补充维生素K的剂量和风险

表1 微量元素和维生素的临床监测、推荐应用剂量及注意事项

微营养素	监测与评估	推荐剂量（/d）	注意事项
铬	重症患者存在胰岛素抵抗和高血糖时，可使用静脉注射铬尝试减少胰岛素用量	EN:≥35 μg/1 500 kcal； PN:≥10 μg	根据胰岛素抵抗水平考虑存在铬缺乏时，可予以静脉途径补充铬（200~250 μg/d，连用2周）；重症患者存在胰岛素抵抗，需要剂量为3~20 μg/h的铬，静脉注射10 h、≤4 d
钴	心肌病怀疑钴中毒时，可能需要测定钴	EN应通过补充维生素B₁₂的方式进行钴补充；只要补充了维生素B₁₂，则PN无需额外单独补充钴制剂	无
铜	减肥手术后或其他非十二指肠腹部手术后；病因不明的神经病变；严重烧伤者；连续2周以上的肾脏替代治疗；通过空肠造口管进行家庭肠内营养（HEN）的患者；长期接受PN者；以上患者应每6~12个月测定一次铜含量，同时需测定CRP以进一步明确铜水平	EN:1~3 mg/1 500 kcal； PN:0.3~0.5 mg	当血浆铜浓度<12 μmol/L且CRP>20 mg/L时，需补充铜；当血浆铜浓度<8 mmol/L伴或不伴CRP升高时，应予以补充。慢性疾病可首先考虑口服；严重铜缺乏时，应首选静脉补充，以4~8 mg/d缓慢输注
氟	怀疑氟中毒时应进行血液检测	EN:≤3 mg/1 500 kcal； PN:0~1 mg	氟化物中毒时，应采取生命功能支持和电解质监测对症治疗；除控制过量氟暴露的来源外，尚无治疗氟骨症的方法
碘	甲状腺疾病高发人群、碘缺乏症高发地区者、长期暴露于聚维酮碘（PVPeI）消毒者，应评估碘水平	EN:150~300 μg/1 500 kcal；PN:130 μg	碘缺乏时应通过口服或肠内途径补充（约300~ 600 μg/d），或通过肌肉注射；在急性严重碘缺乏症中，可以通过静脉注射碘化钠溶液补充碘
铁	贫血和持续严重疲劳者、疑似铁缺乏和过载者均应检测血浆铁、转铁蛋白、转铁蛋白饱和度、铁蛋白、CRP、铁调素以及红细胞形态等一系列指标	EN:18~30 mg/1 500 kcal的铁；PN:≥1 mg，或每隔一段时间予以单独补充等量铁	若补充量超过基础剂量方可纠正铁缺乏，应单次静脉注射；经低铁调素水平证明铁缺乏的重症患者，应以羧基麦芽糖铁形式补充1 g铁
锰	怀疑锰过量或中毒时，尤其是长期PN（>30 d；>55 μg/d）并出现肝功能受损或缺铁时，应当检测锰的含量，间隔至少40 d（生物半衰期）	EN:2~3 mg/1 500 kcal；安全范围:≤6 mg；PN: 55 μg	当全血或血清中锰含量超过实验室正常参考范围上限2倍时，应予以处理；锰中毒可以通过将锰从PN混合物中去除、螯合疗法或缺铁时补充铁来治疗
钼	怀疑钼缺乏时才应测定血中钼、尿液中亚硫酸盐、次黄嘌呤、黄嘌呤和血浆尿酸的浓度	EN:50~250 μg/1 500 kcal；PN:19~25 μg	可用四硫代钼酸盐治疗肝豆状核变性（Wilson病）中的铜超载
硒	所有可能接受PN>2周或即将开始HPN的患者应在开始时即测定血浆硒；并根据需要决定是否需要复测，并应同时测定CRP和白蛋白水平	EN:50~150 μg/1 500 kcal； PN:60~100 μg	血浆硒<0.4 μmol/L（<32 μg/L）时应立刻予以补充，初始剂量为100 μg/d（肠内或静脉注射），剂量可能高达400 μg/d，持续至少7~10 d后再复查
锌	胃肠道和（或）皮肤过多丢失锌的患者；开始启动长期PN时应测定血浆锌；长期PN的患者应每6~12个月测定血浆锌。需要同时测定CRP和白蛋白水平	EN:≥10 mg/1 500 kcal； PN:3~5 mg（无额外丢失锌时）	胃肠道丢失锌（瘘管、造口和腹泻）而接受PN的患者，每天通过静脉注射最多可补充12 mg；严重烧伤（烧伤面积>20%）的患者可通过静脉注射锌30~35 mg/d，持续2~3周；在获得性锌缺乏的情况下，可每天补充0.5~1.0 mg/kg的锌（二价锌离子），连续口服3~4个月；肠病性肢端皮炎患者可终身补充3 mg/kg的锌（二价锌离子）
维生素B₁（硫胺素）	心肌病和长期服用利尿剂者；长期营养支持和减肥手术后；再喂养综合征等，应测量红细胞或全血中二磷酸硫胺素（ThDP）的含量	EN:1.5~3.0 mg/1 500 kcal；PN:≥2.5 mg	急诊或重症患者，入院后应立即补充维生素B₁（100~300 mg/d，静脉注射），连用3~4 d；入院前进食量减少或饮酒量过多者，应通过口服或静脉注射补充维生素B₁（100~300 mg/d）
维生素B₂（核黄素）	怀疑维生素B₂缺乏时，可通过红细胞中的谷胱甘肽还原酶活性来评估	EN:≥1.2 mg/1 500 kcal； PN:3.6~5.0 mg	维生素B₂缺乏时，可口服（5~10 mg/d）或静脉注射核黄素（160 mg，连用4 d）；脱氢酶缺乏症（MADD）的患者可补充维生素B₂（50~200 mg/d）
维生素B₃（维生素PP、烟酸、烟酰胺）	腹泻、皮炎和痴呆等，可检测血液或组织中烟酰胺腺嘌呤二核苷酸（NAD）水平	EN:18~40 mg/1 500 kcal；PN:≥40 mg	当有维生素B₃缺乏的风险病史和（或）存在体征或症状进而怀疑存在维生素B₃缺乏时，可能需要补充更高剂量
维生素B₅（泛酸、D-泛醇）	结合神经症状决定是否检测血液维生素B₅水平	EN:≥5 mg/1 500 kcal； PN:≥15 mg	无典型神经系统症状时，维生素B₅可与其他B族维生素一起服用
维生素B₆（吡哆醇、吡哆醛、吡哆胺）	有维生素B₆缺乏表现时，应测量血浆或红细胞磷酸吡哆醛（PLP）水平	EN:≥1.5 mg/1 500 kcal； PN:4~6 mg	异烟肼过量或乙二醇中毒时，应予以大剂量维生素B₆治疗
维生素B₇（生物素）	直接测量血和尿中的维生素B₇，并通过测定生物素酶活性来完善	EN:≥30 μg/1 500 kcal； PN:60 μg	哺乳期母亲需口服（≥35 μg/d）；接受肾替代治疗的患者可额外补充；根据肠道功能，可通过口服、肠内或静脉给予维生素B7
维生素B₉（叶酸）	大细胞性贫血或有营养不良风险者应在首次就诊时评估维生素B₉水平；补充3个月后再次评估	EN:330~400 μg DFE/1 500 kcal； PN:400~600 μg	饮食不足或长期血液透析者，可口服叶酸（1.5 mg/d）；口服治疗无效或不耐受者，可给予叶酸（0.1 mg/d）皮下注射、静脉注射或肌肉注射
维生素B₁₂（钴胺素）	所有贫血、孤立性大细胞增多症、多发性神经病、神经退行性疾病或精神病的患者应监测维生素B₁₂；自身免疫性疾病或舌炎、贫血和神经病变者，无论维生素B₁₂水平如何，应监测抗内在因子抗体（抗IFAB）	EN:≥2.5 μg/1 500 kcal； PN:≥5 μg	哺乳期应口服（≥2.8 μg/d）；维生素B₁₂吸收受损的患者应终身服用补充剂（350 μg/d），或每1~3个月肌肉注射1 000~2 000 μg；若表现为急性缺乏临床症状、抗IFAB阳性、有全胃切除术史或持续消化道不良疾病者，应采用肌肉注射途径，初始予以高剂量维生素B₁₂（1 000 μg，1次/2 d），连用2周（或1次/d，连用5 d）
维生素A（视黄醇）	消化道吸收不良的患者应测定血清视黄醇和视黄酸酯	EN:900~1 500 μg RE/1 500 kcal； PN:800~1 100 μg RE	脂肪吸收不良时，可以口服维生素A
维生素C（抗坏血酸）	坏血病或长期摄入不足的患者，应监测血浆维生素C浓度	EN:≥100 mg/1 500 kcal； PN:100~200 mg	慢性氧化应激状态（糖尿病、心力衰竭、严重COPD和长期透析）或消化不良的患者，可口服维生素C（200~500 mg/d）；重症患者可适当增加用量
维生素D	存在维生素D消耗或缺乏风险的患者，测定血清25-(OH)D水平	EN:≥1000 U（25 μg）/1 500 kcal；PN:≥200 U（5 μg）	既往缺乏复发的患者，应服用4 000~5 000 U(100~125 μg)/d，为期2个月，目标25-(OH)D水平为40~60 μg/L
维生素E（生育酚）	囊性纤维化、a-β脂蛋白血症和TTP患者应测定维生素E	EN:≥15 mg/1 500 kcal； PN:≥9 mg	血浆a-生育酚水平<12 μmol/L时，应补充维生素E
维生素K（叶绿醌）	长期使用广谱抗生素和慢性肾病者，应通过生物标志物和饮食摄入情况来判断维生素K水平	EN:≥120 μg/1 500 kcal； PN:150 μg维生素K₁	接受抗凝治疗特别是华法林治疗者，应慎重评估补充维生素K的剂量和风险

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Guidelines for clinical application of micronutrients in Chinese adult patients (2024 edition)

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Guidelines for clinical application of micronutrients in Chinese adult patients (2024 edition)