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Curr Opin Crit Care:持续或间断喂养的优缺点

2018-08-07 吴舒沁 骆建军 重症医学

综述的目的: 为重症患者提供营养支持以加强康复和提高存活率方面的关注焦点,最近发生了变化。目前关注的主要方向是评估我们目前营养支持方法,包括持续喂养是否最佳,特别是对于减少肌肉萎缩,血糖水平的管理,喂养不耐受以及器官水平方面。本综述将从重症患者管理的几个方面讨论使用间断和持续喂养的优缺点。


综述的目的:

为重症患者提供营养支持以加强康复和提高存活率方面的关注焦点,最近发生了变化。目前关注的主要方向是评估我们目前营养支持方法,包括持续喂养是否最佳,特别是对于减少肌肉萎缩,血糖水平的管理,喂养不耐受以及器官水平方面。本综述将从重症患者管理的几个方面讨论使用间断和持续喂养的优缺点。

最近的发现:

很少有研究表明间断喂养优于持续喂养。总体而言,间断喂养尚未显示出增加血糖波动或IBD%E8%AF%8A%E6%B2%BB%E8%BF%87%E7%A8%8B%E4%B8%AD%E7%9A%84%E8%AF%84%E4%BC%B0-Part%203" target="_blank">胃肠不耐受,根据这两个原因持续喂养是首选方法。目前正在进行的一项关于间断与持续喂养的效应的研究,被期待能够更加深入揭示对肌肉萎缩的影响。

总结:

尽管在重症成人患者中,对于间断喂养的安全性和有效性好于持续喂养方式的研究数量有限,但仍有一些理论上的优势。进一步的研究应该对这些进行调查,同时,应该根据患者的个体化因素来制定喂养方案。

引言

重症患者的营养支持正在经历一场革命。原因有两方面;  首先, 几项大型临床试验未显示出在营养支持的组成、剂量、时间和喂养途径的益处;   其次,我们的治疗目标发生了模式化的转变,目前的重点主要是加强康复和提高存活率。目前人们普遍认为仅仅一个营养不会影响死亡率,与此同时,我们也评估了目前对重症患者营养支持的方法。事实上,随着对早期重症疾病期间骨骼肌萎缩病理生理机制的深入了解,我们正在从目前在危重护理中提供营养的方法—基于关于提供营养支持的一般假设,转向一种基于强有力证据的方法,其基础是详细说明骨骼肌萎缩的机制,然后制定预防或减少骨骼肌消耗的干预措施。目前的假设之一是,喂饲方法应持续24小时以上,而不是间歇或弹丸式注射喂食。

20多年前,重症患者的间断喂养被证实是安全和可行的。然而,继发性感染预防临床试验未能显示出益处,导致这种做法在ICU中被放弃。此外,随着针对血糖目标控制和胰岛素的广泛应用成为重症监护管理的一部分,持续喂养已成为国际认可的喂养方法的核心组成。

尽管支持持续喂养方案临床有效性的数据有限,但维持葡萄糖控制同时限制血糖波动的理由,再加上提高肠内营养耐受性的假定好处,已经为持续喂养方案提供了支持。的确,这种喂养方法的临床支持反映在美国和加拿大的重症营养指南中,但这些建议仅以专家意见为基础。

在我们提倡以病人的护理和预后为中心的时代,临床医生和研究人员对喂养方式研究的兴趣越来越大,这种方法可以一种多层面的方式提高病人的预后。间歇喂养,或弹丸式注射喂养,是一种被认为具有潜在代谢和生理益处的方法。本综述将讨论连续喂养和间断喂养在危重成人中的利弊。

关键点

? 对于临床医生和研究人员来说,研究可能以多层面方式提高病人结局的喂养方法是一个首要任务。

? 持续肠内喂养是目前重症患者的首选喂养方法。

? 重症患者的间断/弹丸式推注肠内喂养理论上可以提供代谢和生理上的益处超过持续喂养,但研究是有限的。

喂养方式的定义

在讨论不同喂养计划的优缺点之前,理解术语和定义很重要。在饮食临床实践中,可以根据患者的临床状况和喜好选择几种肠内喂养方法。  有持续的,周期性的,间断的和推注的。 它们的定义可以在表1中看到。虽然持续和周期性的定义很简单,但间断和弹丸式推注喂养这两个术语通常可以互换使用。 间歇喂养通常提供4-6次/天,营养泵喂养20-60分钟。 然而,最常使用注射器或重力法在5-10分钟内推注喂养,通常也是4-6次/天。为了这篇综述的一致性,将使用间断喂养这一术语,但是,我们将根据指定的喂养时间,因为这两种方法可能导致不同的结果。

ICU的肠外营养通常在24小时内提供,但在长期肠外营养患者中给予12-18小时(周期性)的较短时间,以减少对肝功能的负面影响。弹丸式推注和间断肠外营养对患者来说并不安全,也不是最理想的选择,尽管重症患者(不仅仅需要肠外营养的患者)周期性静脉注射氨基酸正越来越受欢迎,以满足最近推荐的高蛋白质目标。

连续或间歇喂养:证据的现状

在考虑持续和间断喂养的优缺点时(表2),需要考虑几个因素。 我们将分别讨论这些。

血糖控制

尽管在21世界初,采用强化胰岛素治疗来严格控制血糖是首页任务,但这种做法现在已转向避免血糖波动和低血糖,因为这已被证实会导致不良预后。许多临床医生相信,持续比间断喂养有助于减少这种波动。然而,最近一项针对50例重症患者的研究表明,通过经皮内镜下IBD%E8%AF%8A%E6%B2%BB%E8%BF%87%E7%A8%8B%E4%B8%AD%E7%9A%84%E8%AF%84%E4%BC%B0-Part%203" target="_blank">胃造瘘(PEG)弹丸式推注喂养与持续喂养相比,血糖波动或胰岛使用量没有差异。值得注意的是,本研究的参与者必须适合放置PEG管,这意味着他们可能是一个更稳定的群体(本研究中病人的平均APACHE II评分为14分),在这个群体中,血糖波动要么不常见,要么不受关注。此外,没有详细的说明弹丸式推注喂养是如何提供,或者在什么时间框架提供,导致难以解释这些结果。

尽管没有比较持续和间断喂养,但持续喂养当然也有低血糖的风险。在CALORIES 和NUTRIREA-2试验中,比较了早期肠外营养和肠内营养,报告指出肠内喂养组有更多患者发生低血糖(3.7 vs. 6.2% in CALORIES and 1 vs. 2% in NUTRIREA-2)。这可能是因为床旁停止输注肠内营养或其它被视为必定带来风险的程序时,胰岛素仍在输注,虽然是推测性的。目前的血糖控制策略已经被设计、实施和审核,以确保持续喂养的安全性和依从性。需要进行进一步的工作,以确定在使用间断或弹丸式静注喂养方案的同时,在维持足够的营养供给和安全的血糖控制方面仍存在的困难。

肌肉充分效应( the ‘muscle full effect’)

在健康状态下,骨骼肌量通过平衡肌蛋白合成(MPS)和肌蛋白分解(MPB)来维持。我们已经显示重症疾病抑制肌蛋白合成和引发肌蛋白分解,并且这种效应可能部分与ICU使用喂养方式有关。虽然饥饿导致肌肉萎缩,但蛋白质摄入通常会刺激肌蛋白合成。然而,这种效应依赖于氨基酸浓度的间歇性“脉冲”升高。这一过程在健康人群中被证明是短暂的,肌蛋白合成在摄入氨基酸90分钟后恢复到基线水平。尽管血浆和肌肉中的氨基酸连续可用,但仍出现回到基线水平的现象,这表明持续的氨基酸供应不会进一步刺激MPS。这一概念被称为“肌肉充分效应”。鉴于大多数ICU患者接受持续的肠内或肠外喂养,认为这可能通过“肌肉充分效应”导致肌肉萎缩的解释并非不合理。我们的数据表明,这种情况可能确实发生了,因为肌肉体积的丧失与肠内输送蛋白质的数量直接相关。

虽然在重症患者中尚未直接测量到“肌肉充分效应”,当在3-h时间内静脉注射相当于1g/kg/d的蛋白质时,全身蛋白质平衡随着蛋白质的合成而增加。重要的是,氨基酸未被氧化,表明它们在这种摄入水平上的利用。然而,由于测量了全身蛋白质的转化率,因此无法从该研究中确定与肌蛋白质合成的直接关系。此外,从用作新生儿模型的小猪上得来的数据表明,与持续喂养相比,弹丸式推注喂养刺激肌蛋白质合成更多,并且还导致更大量的蛋白质沉积。这可以通过推注喂养时发生的循环氨基酸和胰岛素的快速且显著的增加来解释,其允许激活细胞内信号传导途径,从而实现mRNA翻译。虽然成人和新生儿对氨基酸摄入的反应不同,但这些数据很有意思,并且推导了一个假设:间断喂养实际上可以改善重症患者的肌蛋白合成。

与上述相反,在包括创伤性颅脑损伤(TBI)患者的一项小研究中,与持续或联合(肠内和肠胃外)喂养相比,间断喂养与改善的氮平衡无关。然而,两组能量和蛋白质目标均未达标,持续和间断喂养的定义不明确。

虽然在危重病成人中没有数据,但上述结果表明,连续喂养可能不允许对间歇性MPS进行生理刺激,因此间歇喂养(图1)可能恢复一种代谢功能。然而,第IIb阶段的多中心随机对照试验已经完成(NCT 0235812;www.clinicaltrials.gov),并可能提供一些见解。

尽管危重患者中没有数据,但上述表明持续喂养可能不允许间歇性肌蛋白合成的生理刺激,因此间断(推注)喂养(图1)可能恢复合成代谢功能的测量。然而,IIb期多中心随机对照试验已经完成,可能提供一些见解。

(持续和间断喂养的“肌肉充分效应”的视觉图。左图显示了肌蛋白合成在重症患者持续喂养中的理论反应。这与(右图)的肌蛋白合成进行了比较,在健康的个体中,尽管血浆和肌肉中仍存在氨基酸,但在摄入口服蛋白质45分钟后,肌蛋白合成增加了三倍,并在90分钟后恢复正常。)

胃肠不耐受

营养支持方法的最根本的是每种营养成分需要从胃肠道输送到血浆中,然后运输到细胞中以供肌肉利用 ——一种可变和复杂的过程。

胃肠不耐受常见于重症患者,特别是在胃排空延迟的病人。研究表明,即使采用幽门后喂养作为喂养方式,营养吸收的速率和程度也会受到影响。这些损伤可能会混淆任何可能导致营养对预防肌肉萎缩产生积极影响的可能性。间断喂养可通过增加缩胆囊素和肽YY浓度以及通过增加肠系膜上动脉血流量来增加肠道运动,尽管尚未在重症疾病的情况下进行测量。然而,已发表的“a three-arm trial”,比较持续肠内喂养与使用注射器静推超过15-20分钟喂养,以及通过营养泵在18小时内提供的间断喂养的效果。有36名重症脓毒症患者,并在3天内评估胃肠不耐受的症状。结果显示两组没有差异,但是本研究中的患者特征报告很少,因此不能得出确定的结论,并且需要进一步的工作来确定间断喂养能或不能改善胃动力。

长期营养学

血脂、蛋白质和能量稳态在一定程度上受昼夜节律的影响。这种中心时钟调节反过来调节负责新陈代谢和细胞过程的局部时钟,如周围组织(包括骨骼肌)的自噬。针对重症患者生理和肌肉萎缩的改变,肝脏时钟调节血糖控制和葡萄糖清除,胰腺时钟调节胰岛素分泌和敏感性,骨骼肌时钟调节葡萄糖摄取和代谢。适应新的喂养方式(例如重症患者的持续喂养)不是立竿见影的,从3天(肝)到7天(心脏),骨骼肌的适应时间未知。

昼夜失调对新陈代谢有害。持续的营养供给改变了肠道激素的昼夜节律,以及餐后胃饥饿素和胰岛素的释放对营养的反应。

骨骼肌自噬过程的中断已在重症疾病喂养人群中被注意到,并可能是进一步的肌肉萎缩的危险因素。这些生理变化的模式可以通过使用间断喂养方案来防止昼夜节律的重新编程来避免,但是需要研究来证实这一假设。

日常医疗安排因素

重症患者由于各种临床原因,如常规和紧急程序、按照时间安排进手术室手术或进行影像学检查等,经常不能达到喂养目标。在这些情况下间断喂养可能是有益的,允许工作人员弹丸式推注错过的喂养,因此增加了达到喂食目标的机会。这在前面提到的针对TBI患者的研究中没有显示,但这可能是由于作者在文章中讨论的当地日常医疗安排素造成的。

虽然没有具体的研究检测出肠内营养供给对重症监护室患者活动的影响,但间断喂养有两个潜在的益处。首先,可以在间断喂养的间歇,患者可以自由运动,确保他们更有可能达到目标。其次,在运动后给予推注喂养,患者可以利用运动后这段时间来增强肌蛋白合成。

这种增加肌肉体积的窗口在老年患者中尤其重要,尤其对喂养和运动的反应迟钝的患者。

最后,在决定间断和持续喂养方法时,应考虑患者安全因素。在许多国家,鼻胃管(NGT)位置的确认是通过pH。由于碱性肠内营养对结果的影响,这在持续喂养的设置情况下,变得不可解释。因此,许多ICU选择在20小时而不是24小时内喂养患者,以使胃的pH恢复正常,从而确认鼻导管的位置。间断喂养可能使这种做法更容易发生。但是,其他因素可能导致不良的pH值(例如质子泵抑制剂的使用和鼻胃管的位置),这一点应该得到权衡,这可能不能否定反复进行胸部X线检查的必要性以及与此相关的风险。

肠外与肠内途径

虽然所有上述优点和缺点都与营养输送途径无关(胃动力除外),但间断喂养可能不适合鼻空肠管患者。到目前为止,我们还不知道任何与安全相关的研究

总结

迄今为止,间断喂养较持续喂养具有更大的潜在益处和安全性的研究还很有限,但仍有一些理论上的优势。在期望给予成功的间歇喂养时,需要考虑病人的个体化特点和日常医疗安排因素。最合适和最有益的喂养方法可能是考虑到这些因素,并根据每个病人的入院时间节点和个体化目标加以修正。在未来的研究中应考虑这些因素。

原始出处:

Bear DE,et al.Continuous or intermittent feeding: pros and cons.Curr Opin Crit Care. 2018 Aug;24(4):256-261. doi: 10.1097/MCC.0000000000000513.

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  2. 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topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, 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    2018-10-12 TZF0811
  3. 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  4. 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  5. 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createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Oct 12 05:40:00 CST 2018, time=2018-10-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2068292, encodeId=2a9320682927a, content=<a href='/topic/show?id=baa725e8823' target=_blank style='color:#2F92EE;'>#优缺点#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=25788, encryptionId=baa725e8823, topicName=优缺点)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e03212, createdName=liao1619, createdTime=Sat Dec 22 10:40:00 CST 2018, time=2018-12-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1665060, encodeId=cd361665060af, content=<a href='/topic/show?id=c8664008e1a' target=_blank style='color:#2F92EE;'>#喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=40087, encryptionId=c8664008e1a, topicName=喂养)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ed425881542, createdName=ms1948154235210413, createdTime=Mon Sep 17 18:40:00 CST 2018, time=2018-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337326, encodeId=398233e32675, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/07/a9772c74ffd6edc03a7f9af07b4747f6.jpg, createdBy=b3722138742, createdName=sunfeifeiyang, createdTime=Wed Aug 08 15:43:46 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337322, encodeId=022333e322bc, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Wed Aug 08 15:42:02 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337319, encodeId=d71833e3193b, content=学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/08/05/2be42de705dd506439382c6df2ef7ff1.jpg, createdBy=f3e12414585, createdName=三不猴, createdTime=Wed Aug 08 15:03:40 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337253, encodeId=2ab433e253cf, content=谢谢分享,学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Aug 08 05:43:41 CST 2018, time=2018-08-08, status=1, ipAttribution=)]
    2018-08-08 sunfeifeiyang

    学习

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1969867, encodeId=bbf4196986e19, content=<a href='/topic/show?id=8e75563406f' target=_blank style='color:#2F92EE;'>#持续或间断喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56340, encryptionId=8e75563406f, topicName=持续或间断喂养)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Mon Jun 10 08:40:00 CST 2019, time=2019-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1632780, encodeId=c3331632e80f1, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, 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encryptionId=c8664008e1a, topicName=喂养)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ed425881542, createdName=ms1948154235210413, createdTime=Mon Sep 17 18:40:00 CST 2018, time=2018-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337326, encodeId=398233e32675, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/07/a9772c74ffd6edc03a7f9af07b4747f6.jpg, createdBy=b3722138742, createdName=sunfeifeiyang, createdTime=Wed Aug 08 15:43:46 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337322, encodeId=022333e322bc, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Wed Aug 08 15:42:02 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337319, encodeId=d71833e3193b, content=学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/08/05/2be42de705dd506439382c6df2ef7ff1.jpg, createdBy=f3e12414585, createdName=三不猴, createdTime=Wed Aug 08 15:03:40 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337253, encodeId=2ab433e253cf, content=谢谢分享,学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Aug 08 05:43:41 CST 2018, time=2018-08-08, status=1, ipAttribution=)]
    2018-08-08 神功盖世

    学习

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1969867, encodeId=bbf4196986e19, content=<a href='/topic/show?id=8e75563406f' target=_blank style='color:#2F92EE;'>#持续或间断喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56340, encryptionId=8e75563406f, topicName=持续或间断喂养)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Mon Jun 10 08:40:00 CST 2019, time=2019-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1632780, encodeId=c3331632e80f1, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, 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encryptionId=c8664008e1a, topicName=喂养)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ed425881542, createdName=ms1948154235210413, createdTime=Mon Sep 17 18:40:00 CST 2018, time=2018-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337326, encodeId=398233e32675, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/07/a9772c74ffd6edc03a7f9af07b4747f6.jpg, createdBy=b3722138742, createdName=sunfeifeiyang, createdTime=Wed Aug 08 15:43:46 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337322, encodeId=022333e322bc, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Wed Aug 08 15:42:02 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337319, encodeId=d71833e3193b, content=学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/08/05/2be42de705dd506439382c6df2ef7ff1.jpg, createdBy=f3e12414585, createdName=三不猴, createdTime=Wed Aug 08 15:03:40 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337253, encodeId=2ab433e253cf, content=谢谢分享,学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Aug 08 05:43:41 CST 2018, time=2018-08-08, status=1, ipAttribution=)]
    2018-08-08 三不猴

    学习啦

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1969867, encodeId=bbf4196986e19, content=<a href='/topic/show?id=8e75563406f' target=_blank style='color:#2F92EE;'>#持续或间断喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56340, encryptionId=8e75563406f, topicName=持续或间断喂养)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Mon Jun 10 08:40:00 CST 2019, time=2019-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1632780, encodeId=c3331632e80f1, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, 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encryptionId=c8664008e1a, topicName=喂养)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ed425881542, createdName=ms1948154235210413, createdTime=Mon Sep 17 18:40:00 CST 2018, time=2018-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337326, encodeId=398233e32675, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/07/a9772c74ffd6edc03a7f9af07b4747f6.jpg, createdBy=b3722138742, createdName=sunfeifeiyang, createdTime=Wed Aug 08 15:43:46 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337322, encodeId=022333e322bc, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Wed Aug 08 15:42:02 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337319, encodeId=d71833e3193b, content=学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/08/05/2be42de705dd506439382c6df2ef7ff1.jpg, createdBy=f3e12414585, createdName=三不猴, createdTime=Wed Aug 08 15:03:40 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337253, encodeId=2ab433e253cf, content=谢谢分享,学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Aug 08 05:43:41 CST 2018, time=2018-08-08, status=1, ipAttribution=)]
    2018-08-08 liumin1987

    谢谢分享,学习了。

    0

  9. [GetPortalCommentsPageByObjectIdResponse(id=1969867, encodeId=bbf4196986e19, content=<a href='/topic/show?id=8e75563406f' target=_blank style='color:#2F92EE;'>#持续或间断喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56340, encryptionId=8e75563406f, topicName=持续或间断喂养)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Mon Jun 10 08:40:00 CST 2019, time=2019-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1632780, encodeId=c3331632e80f1, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Oct 12 05:40:00 CST 2018, time=2018-10-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2068292, encodeId=2a9320682927a, content=<a href='/topic/show?id=baa725e8823' target=_blank style='color:#2F92EE;'>#优缺点#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=25788, encryptionId=baa725e8823, topicName=优缺点)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e03212, createdName=liao1619, createdTime=Sat Dec 22 10:40:00 CST 2018, time=2018-12-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1665060, encodeId=cd361665060af, content=<a href='/topic/show?id=c8664008e1a' target=_blank style='color:#2F92EE;'>#喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=40087, encryptionId=c8664008e1a, topicName=喂养)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ed425881542, createdName=ms1948154235210413, createdTime=Mon Sep 17 18:40:00 CST 2018, time=2018-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337326, encodeId=398233e32675, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/07/a9772c74ffd6edc03a7f9af07b4747f6.jpg, createdBy=b3722138742, createdName=sunfeifeiyang, createdTime=Wed Aug 08 15:43:46 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337322, encodeId=022333e322bc, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Wed Aug 08 15:42:02 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337319, encodeId=d71833e3193b, content=学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/08/05/2be42de705dd506439382c6df2ef7ff1.jpg, createdBy=f3e12414585, createdName=三不猴, createdTime=Wed Aug 08 15:03:40 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337253, encodeId=2ab433e253cf, content=谢谢分享,学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Aug 08 05:43:41 CST 2018, time=2018-08-08, status=1, ipAttribution=)]
    2018-08-08 张新亮1853311252142e2fm

    好文章学习了

    0

  10. [GetPortalCommentsPageByObjectIdResponse(id=1969867, encodeId=bbf4196986e19, content=<a href='/topic/show?id=8e75563406f' target=_blank style='color:#2F92EE;'>#持续或间断喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=64, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56340, encryptionId=8e75563406f, topicName=持续或间断喂养)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=139a316, createdName=wumeihua88, createdTime=Mon Jun 10 08:40:00 CST 2019, time=2019-06-10, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1632780, encodeId=c3331632e80f1, content=<a href='/topic/show?id=10a09e25096' target=_blank style='color:#2F92EE;'>#间断#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=78, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=97250, encryptionId=10a09e25096, topicName=间断)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=c86a21951359, createdName=TZF0811, createdTime=Fri Oct 12 05:40:00 CST 2018, time=2018-10-12, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2068292, encodeId=2a9320682927a, content=<a href='/topic/show?id=baa725e8823' target=_blank style='color:#2F92EE;'>#优缺点#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=90, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=25788, encryptionId=baa725e8823, topicName=优缺点)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=e03212, createdName=liao1619, createdTime=Sat Dec 22 10:40:00 CST 2018, time=2018-12-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1665060, encodeId=cd361665060af, content=<a href='/topic/show?id=c8664008e1a' target=_blank style='color:#2F92EE;'>#喂养#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=73, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=40087, encryptionId=c8664008e1a, topicName=喂养)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=0ed425881542, createdName=ms1948154235210413, createdTime=Mon Sep 17 18:40:00 CST 2018, time=2018-09-17, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337326, encodeId=398233e32675, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2017/09/07/a9772c74ffd6edc03a7f9af07b4747f6.jpg, createdBy=b3722138742, createdName=sunfeifeiyang, createdTime=Wed Aug 08 15:43:46 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337322, encodeId=022333e322bc, content=学习, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/vi_32/fhZdOu27e88Voqh19n8eF8cLplo8L4nicKtH0WnE3KFELXns5XDu8rsiceK2HHDZc2SEStia5VV3Pia2QLMVqlWbHw/0, createdBy=6e012139475, createdName=神功盖世, createdTime=Wed Aug 08 15:42:02 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337319, encodeId=d71833e3193b, content=学习啦, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/08/05/2be42de705dd506439382c6df2ef7ff1.jpg, createdBy=f3e12414585, createdName=三不猴, createdTime=Wed Aug 08 15:03:40 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337253, encodeId=2ab433e253cf, content=谢谢分享,学习了。, beContent=null, objectType=article, channel=null, level=null, likeNumber=109, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://cdnapi.center.medsci.cn/medsci/head/2018/07/16/3b24606172648eea459125cb74754afe.jpg, createdBy=6c022216608, createdName=liumin1987, createdTime=Wed Aug 08 08:40:14 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337228, encodeId=f31033e2280a, content=好文章学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=117, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=b5a62240667, createdName=张新亮1853311252142e2fm, createdTime=Wed Aug 08 06:50:04 CST 2018, time=2018-08-08, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=337211, encodeId=285f33e21104, content=学习了,谢谢分享, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=7c592194322, createdName=1209e435m98(暂无昵称), createdTime=Wed Aug 08 05:43:41 CST 2018, time=2018-08-08, status=1, ipAttribution=)]
    2018-08-08 1209e435m98(暂无昵称)

    学习了,谢谢分享

    0

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