腸外營養(yǎng)在ICU的應(yīng)用

1、腸外營養(yǎng)在ICU的應(yīng)用Intensive Carr Med (2011) 37:601/09DOI 10.l007/s0013401l-2146.zORIGINAL精細(xì)熱量控制研究針對危重病人營養(yǎng)支持的一項(xiàng) 前沿性，隨機(jī)性，對照試驗(yàn)研究。Pierre SingerRonii AnbarJonathan CohenHaim ShapiroMichal Shalita-CbexnerShaul LevElad (irozovskiMirvam I heilhSigal FrishmimThe tight calorie control study (TICACOS): a prospective,

2、 randomized, controlled pilot study of nutritional support in critically ill patientsESPEN要求* A * * * * ( * 4 W * *ICU內(nèi)患者饑餓或喂養(yǎng)不足，發(fā)病率和死亡率增加B級逬行腸外營養(yǎng)的ICU患者應(yīng)該接受能滿足他們需要的C級THE EUROPEANSOCIETY FORCLINICALNUTRITION ANDMETABOLISM提供盡可能接近測量能量肖耗的能量，以減少能量負(fù)平衡B 級所有經(jīng)腸內(nèi)莒養(yǎng)3天后未達(dá)標(biāo)的患者，應(yīng)接受胃腸外補(bǔ)充莒養(yǎng) C級營養(yǎng)風(fēng)險(xiǎn)評估ICU專用工具識別咼風(fēng)險(xiǎn)患者營養(yǎng)

3、量避免喂養(yǎng)不足避免過度喂養(yǎng)如果可行，使用間接測熱法營養(yǎng)踣徑盡可能進(jìn)行腸內(nèi)營養(yǎng)（優(yōu)化公差）胃勵卜補(bǔ)充營養(yǎng)，以滿足需求J時機(jī)依銅險(xiǎn)分層獲益 風(fēng)險(xiǎn)監(jiān)測藥理宮養(yǎng)營養(yǎng)成分-每日重新評估和調(diào)整谷氨酰胺能量實(shí)驗(yàn)室數(shù)據(jù)，臨床狀態(tài)，流體魚油蛋白質(zhì)L 狀態(tài)1 命牛崗1 彳散量營養(yǎng)素避免危重病人喂養(yǎng)不足Not a problem Able to3 days?NoMain ouished High riskxYesontraindicatbnto EN?NoAvoiding underfeeding in severely ill oatierrts ArvedWeimonn, Pierre Sinqerwww.th

4、 Vol 381 May 25, 2013WaitStart EN: gradually increase infusion rate (target 25 kcal/kg per day) and optimise delivery (promotility agents, postpyloric tube)Start EN in 24 hrDays 3-412345671111111) 12345671111111 1234567ICU DayEPaNIC Trial (N=4640)SPN Trial (N=305)TICACOS(N = 130)Mixed med

5、ical and surgical (unselected) With nutritional risk (NRS, &3)Mixed medical and surgical (on day 4) Eligible for EN but 60% targetMixed medical and surgicalMore with early PNBetween day 9 and day 28: less with SPNFrom randomization to day 28: unaffectedMore with REELonger with early PNUnaffectedLong

6、er with REELonger with early PNUnaffectedLonger with REEUnaffectedUnaffectedUnaffected(trend toward reduced hospital mortality)手表定律Watch LawCasaer M Pf Van den Berghe G. Nutrition in the acute phase of critical illnessJ. New England Journal of Medicine, 2014, 370(13): 1227-1236.EEN :優(yōu)點(diǎn)：傅戶粘膜屏障，舷腸道功 能

7、檢復(fù)缺點(diǎn):操作復(fù)雜、胃腸道科授、瞬不足EPN :魚點(diǎn)：侵入性、費(fèi)用增加、并發(fā)癥 咼優(yōu)點(diǎn)：保證達(dá)到目標(biāo)量早期營養(yǎng)是否_定要給EN ? CALORIES研究CALORIES硏究,2014年發(fā)表于NEJM 實(shí)用性、開放、多中心、平行、隨機(jī)、對照試驗(yàn) 共納入33個ICU , 2388名患者,其中PN1191名，EN1197名 所有患者從36小時之內(nèi)開始營養(yǎng)支持，并一曲續(xù)5天 主要結(jié)果 30天死亡率沒有顯著差異次要結(jié)果30天內(nèi)脫離特定器官支持的時間(包括對于呼吸系統(tǒng)、心血管 系統(tǒng)、腎、神經(jīng)系統(tǒng)以及胃腸道)沒有顯著差異 感染并發(fā)癥發(fā)生率沒有顯著差異 PN組低血糖(3.7% vs 6.2% , P=0.00

8、6 )和嘔吐(37.3% vs 39.1% , P 0.001 )的發(fā)生率顯著降低 其它次要臨床結(jié)局沒有顯著差異Episodes of hypoglycemiaElevated liver enzymesNausea requiring treatmentAbdominal distentionVomitingNew or substantizlly worsened44/1191 (3.7)*212/1191 (17.8)44/1191 (3.7)78/1191 (6.5)100/1191 (8.4)181/1190 (15.2)74/1197 (6.2)ft2.49 (0.75 to 4.

9、22)|0.006179/1197 (15.0)-2.85 (-5.81 to 0.12)|0.0753/1197 (4.4)0.73 (-0.85 to 2.32)f0.41$99/1197 (8.3)1.72 (-0.38to3.82)T0.12$194/1197 (16.2)7.81 (5.20 to 10.43)f 5 d邨Mechanical obstructionPeritoneal carcinosisShort bowel syndromeMesenteric infarctionExtensive small bowel resection ileal)Crohn disea

10、se, and other inflammatoiy bowel diseases Excessive time to EN or oral (7 days?)Recurrent regurgitatiofiInsuHicient energy intakesHyperemesis gravidarumCritical illnessProvision of poorly absorbed specific nutrientsBerger MM, Clin Nutr 2014The NEW ENGLAND JOURNAL of MEDICINEORIGINAL ARTICLE早期和晩期病人腸道

11、營養(yǎng) 對照組。針對危3成人組Early versus Late Parenteral Nutritionin Critically Ill AdultsEPaNIC研究研究設(shè)計(jì):前瞻性、隨機(jī)、對照、平行組、多中心目的:探索EN攝入不足的ICU成人患者中早期和晚期開始腸外營養(yǎng)的區(qū)別研究分組- 早期組：n=2312 ,入住ICU病房后48小時內(nèi)開始PN- 晚期組：n=2328 ,入住ICU病房后8天開始FN研究結(jié)果- 相對于較早期組，晚期組患者存活出1些（風(fēng)險(xiǎn)比1.06 , 95%CI1.00-1.13 , P=0.04 ）和出院（風(fēng)險(xiǎn)比1.06 , 95%GI : 1.00-1.13 , P=0

12、.04 ）時間縮短-晚期組出院時營養(yǎng)狀態(tài)和生理機(jī)并未降彳氐- 兩細(xì)CU和醫(yī)院內(nèi)死亡率以及90天生存率相似- 與早期組相比，晚期組患者感染率P軻氐（22.8% vs. 26.2% , 20.008 ）,且膽汁淤積的發(fā)生率降低（ PBhod stream142 (&.1)174 (7.5)0.05Wound64 (2 7)98 (4 2)O.OOSUrinary tract60 (2.6) p.l)0.28InflammationMedian peak Cnreactive protein level during ICU s-t3y (interquartile range) 一 mg/lite

13、r190.6(100.8-263.2)159J (84.3-2435)2 days no. (%)846 (363930 (40 2)0.006Hazard ratio (95% Cl) for time to definiwe weaning from ventilation1.06 (0.99-1J2)0.07Tracheostomy 一 no. (%)134(5.8162 (7 0)0.08Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients:

14、a ran demisedcontrolled clinicaltrial2013年發(fā)表在Lancet能源供應(yīng)與危重患者補(bǔ)充腸外營養(yǎng)的最優(yōu) 化。一項(xiàng)隨機(jī)臨床對照試驗(yàn)2中心、隨機(jī)、對照背景：ICU患者推薦的EN常常不能達(dá)到營養(yǎng)目標(biāo),如果采用SPN將入ICU后第4 8天的能量目標(biāo)100%兩足,是否對臨床結(jié)局有筮？對象：如ICU后3天內(nèi)EN達(dá)不到60%目標(biāo)能量的患者- SPN組：n=153 ,第48天平均獲取自覆28kCal/kg/day- EN組：n=152 z第48天平均獲取自覆20kCal/kg/day 主要結(jié)局：第828天的院內(nèi)感染發(fā)生率主要結(jié)局：SPN組免于感染的患者比例顯著高于EN團(tuán)0右

15、78g尹 tinas adinkskn tn ICUNumber at rtskSPN153US99EN152U771其它次要臨床結(jié)局SPN (n=153)EN (n=152)p valueCoefficient (95% G)Mean (SD) or n (%)95% ClMean (SD)orn(%)95% ClFollow-up (days 9-28)Antibiotic days for nosocomial infections*3(6)2-45(7)4-60 0337-04 (-0-8 to-00)Antibiotic days64-78(8)7-10oooiot-23 (-41

16、to-0 5)Antibiotic-free days14(8)12-1512 (8)10-13001972 1(0-3 to 39)Hours on mechanical ventilation in all patients!6o (ill)43-8166 (110)49-850 6258-01 (-0-4 to 0-3)(Hours on mechanical ventilation in patients without nosocomial infection*15 (59)1-3229 (61)14-4700028十-13(-2 Ito-0 4)Duration of study

17、(days 1-28)Antibiotic days for nosocomial infections*5(7)4-66(7)5-70 0298-03 (-0-6 to-0-0)Antibiotic days11(8)9-121311-1400257-2-2 (-4-2 to-03)An tibiotic-frec days15(9)14-1713(10)11-14001262 7 (0-6 to4 8)Hours on mechanical ventilation in all patients!153 (163)126-178166 (160)138-18902912-01 (-03 t

18、o 04)Hours on mechanical ventilation in patients without nosocomial infection*83 (101)58-105108 (115)77-13500747-03(-06 to 00)Days in ICU13 (10)11-1413 (11)12-1402592-13 (-3 5 to 10)Days in hospital31 (23)役3832 (23)29-3908/81-0 4(-59 to 50)ICU mortalityS8(5%)3-1012(7%)5-130-21180 6 (0 2 to 1-6)Gener

19、al mortalityS20 (13%)41928 (18%)13-250119306 (03 to 1-2)Linear regression analyses were done for all secondary outcomes (acyusted for Simplified Acute Physiology II SAPS 町 score, hospital, and admission category) except for antibiotic days for nosocomial infections, hours on mechanical ventilation,

20、and mortality. SPN=supplemental parenteral nutrition EN=enteral nutrition. ICU=intensive-care unit Negative binomial regression analysis was adjusted for SAPS II score, hospital, and admission category.十 Statistically significant with 8enjamini-H(xhberg correction. Negative binomial regression analy

21、sis was adjusted for SAPS II score, hospital and admission category, and controlled for length of ICU stay SCox proportional hazard ratios, adjusted for SAPS II score, hospital and admission category.Table 4： Seco ndary outcomes during follow-up and throughout duration of study CARING FOR 11 IECRITI

22、CALLY ILL PATIEXIONLINE FIRSTly Parenteral Nutrition in Critically III Patients th Short-term Relative Contraindicationsto Early Enteral NutritionA Randomized Controlled Trial重癥患者的早期的腸外營養(yǎng)伴隨 著短期的相對禁忌癥早期腸內(nèi)營Pa?iorrt3 necefirg enteralEnergy recwed per patfar by study day12345DayshlOJ67&1B7B611 SIS 43E37

23、63136KKB 49C 410S3.331692 詼 6QQ 頃 410 3a 301Figure 2. Enteral and Parenteral Nutrition Delivety Prcxess Pleasures for Patients Remaining in the Study ICUMa. ci parentsEarVwrecraj E31CTO611S1943378313nutritionStanaardcmt E32EftMO4334103i3301Day 1 K the day of study enroilm&nt Energy received was calc

24、ulated tram enteral nutnon, parenteral nutnuon, and mraveroiK infus&ns with 10% glucose, erct bars indicate standard error; ICUr Intensive care unitTable 4. New Infections During StudyPatients With NewInfections*No. (%)Risk Difference (Exact 95% Cl)ExactP Value bIStandard Care(n = 682)Early PN(n = 6

25、81)Catheterc32 (4.69)31 (4.55)0.14 (5.45 to 5.12).99Catheter tipc28(4.11)26 (3.82)-0.29 (-5.60 to 5.01).89Surgical v/ound27 (3.96)22 (3.23)一 0.73( - 6Q4 to 457).56Bloodstream33 (4.84)39 (5.73)0.89 (-4.43 to 6.18).47Abdominal3 (0.44)6 (0.88)0.44 (-4.89 to 574).34Clinically significant UTI1 (0.15)2 (0

26、.29)0.15 (-5.16 to 5.45).62Airway or lungd123 (18.04)101 (14.83)-3.20 (-8.52 to 2.08).12CPIS-probable pn eumoniae96(14.08)81 (11.89)2.18 (7.50 to 3.11).26CPIS-confirmed pneumoniaf45 (6.60)43 (6.31)-0.28 (-50to 5.01).91Any major infections78 (11.4)74 (10.9)-0.57 (-5.89 to 472)30Table 2. Mortality, Qu

27、ality of Lifer and Length of StayStandard Care(n = 680)aEarly PN(n = 678)aRisk Difference, %Odds Ratio(95% Cl)(95% Cl)P ValueDeaths before study day 60, No. (%)155 (22.8)146(21.5)-1.26 (-6.6 to 4.1)0.93 (0.71 to 1.21).60Covariate-adjusted deaths before study day 60b0.04 (-4.2 to 4.3)1.03 (0.76 to 1.

28、31).99Quality of life and physical function, mean (SD)C(n = 525)(n = 532)Difference (95% Cl)RAND-36 general heatth statusd45.5 (26.8) (n = 516)49.8 (27.6) (n = 525)4.3 (0.95 to 7.58).01ECOG performance statuse1.53 (1.1)(n = 6)1.51 (1.1) (n = 526)-0.02 (-0.16to0.11).70RAND-36 physical funotionf40.7 (

29、29.6) (n = 513)42.5 (20.8) (n = 524)1.8 (-1.85 to 5.52)妁Discharge status and length of stay(n = 682)(n = 681)DiffGrenco (95% Cl)ICU stay, mean (95% Cl), d9.3 (8.9 to 9.7)8.6 (8.2 to 9.0)-0.75 (-1.47 to 0.04).06Deaths before ICU discharge, No. (%)100(14.66)81 (11.891-2.77% (-8.08% to 2.52%).15Hospita

30、l stay, mean (95% CO. d24.7 (23.7 to 25.8)25.4 (24.4 to 26.6)0.7 (-1.4 to 3.1).50Deaths before hospital discharge, No. (%)151 (22.1)140 (20.6)-1.68% (-69 % to 3.69%).61Nutrition in the Acute Phaseof Critical Illness營養(yǎng)危重病的急性期Michael P. Casaerr M.D PKD.t and GreetVan den Berghet M.D,t Ph.D.Full (N =49

31、2) Early PN(N=686)Early PN(N=2312)Full (N=153)REE (N=65)EDEN Trial (N = 1000)Early PN Trial (N-1372)Type of PatientsMedical (acute lung injury) Eligible for ENMixed medical and surgical EN relatively contraindicated (short term)New Infections in ICUUnaffectedUnaffectedDuration of Mechanical Ventilat

32、ionUnaffectedShorter with early PNLength of Stay in ICUUnaffectedUnaffectedMortality in ICUUnaffectedUnaffected(60-day mortality: unaffected)EPaNIC Trial (N=4640)SPN Trial (N3O5)TICACOS(N-130)Mixed medical ard surgical (unselcctcd)With nutritional risk (NRS, z3)Mixed medical and surgical (on day 4)E

33、ligible for EN but 60% targetMixed medical and surgicalMore with early PN8etween day 9 and day 28: less with SPNFrom randomization to day 28: unaffectedMore with REELonger with early PNUnaffectedLonger with REELonger with early PNUnaffectedLonger with REEUnaffectedUnaffectedUnaffected (trend toward

34、reduced hospital mortality)ICU DayCasaer M Pf Van den Berghe G. Nutrition in the acute phase of critical illnessJ. New England Journal of Medicine, 2014, 370(13): 1227-1236.目前共識：提供足夠的能量和蛋白質(zhì)THE EUROPEANSOCIETY FORCLINICALNUTRITION ANDMETABOLISM熱卡和蛋白質(zhì)攝入不足是重癥 病人醫(yī)源性營養(yǎng)不良的主要原 因熱卡及蛋白質(zhì)缺乏影響危重病 人預(yù)后充足的熱卡及蛋白質(zhì)供給

35、應(yīng)該 是危重病人治療中一個重要目 標(biāo)熱量二實(shí)測的能量消耗值或-25Kcal/kg/day蛋白質(zhì)=1.3 2.0g/kg能量&蛋白質(zhì)攝左UJomyg NUJCDoxlzENERGY INTAKERG 2. Relationship ol K Marat und energy:rubb with diets ol differ ng protrn 膩8, Betrwn energy hte A (E) and 9 (higher) two finco ere paraiW (From Munro, rtf.pcrmgbn )Adolph M, et al: ESPEN Guideline-Upda

36、te 2014 (in press)危重病人的能量需求Pragmatic approach to nutrition in the ICU: Expert opinion regarding which calorie protein target1：rPierre SingerMichael Hiesmayr Gianni Bioloc, Thomas W. Felbingerc,Mette Berger Christiane Goeters Jens Kondrup Christian Wunder h,Claude Pichard2IC u第一周能量欠缺快速累積且不能完全避免特定亞組病人（如老年,肥胖,營養(yǎng)不良,癱瘓）能量消耗不易確定, 增加了營養(yǎng)處方的難度必須識別最彳時口最高的能量安全劑量最佳方法是使用間接能量測定儀在沒有間接能量測定儀時,給予20 - 25kcal/kg （急性期）,給予動力學(xué) 穩(wěn)定病人25 30kcal/kg能量危重病人的蛋白質(zhì)需求Pragmatic approach to nutrition in the ICU: Expert opinion regarding which calorie protei