Department of Intensive Care Medicine, University Hospitals of the Catholic University of Leuven, Leuven, Belgium.
N Engl J Med. 2011 Aug 11;365(6):506-17. doi: 10.1056/NEJMoa1102662. Epub 2011 Jun 29.
Controversy exists about the timing of the initiation of parenteral nutrition in critically ill adults in whom caloric targets cannot be met by enteral nutrition alone.
In this randomized, multicenter trial, we compared early initiation of parenteral nutrition (European guidelines) with late initiation (American and Canadian guidelines) in adults in the intensive care unit (ICU) to supplement insufficient enteral nutrition. In 2312 patients, parenteral nutrition was initiated within 48 hours after ICU admission (early-initiation group), whereas in 2328 patients, parenteral nutrition was not initiated before day 8 (late-initiation group). A protocol for the early initiation of enteral nutrition was applied to both groups, and insulin was infused to achieve normoglycemia.
Patients in the late-initiation group had a relative increase of 6.3% in the likelihood of being discharged alive earlier from the ICU (hazard ratio, 1.06; 95% confidence interval [CI], 1.00 to 1.13; P=0.04) and from the hospital (hazard ratio, 1.06; 95% CI, 1.00 to 1.13; P=0.04), without evidence of decreased functional status at hospital discharge. Rates of death in the ICU and in the hospital and rates of survival at 90 days were similar in the two groups. Patients in the late-initiation group, as compared with the early-initiation group, had fewer ICU infections (22.8% vs. 26.2%, P=0.008) and a lower incidence of cholestasis (P<0.001). The late-initiation group had a relative reduction of 9.7% in the proportion of patients requiring more than 2 days of mechanical ventilation (P=0.006), a median reduction of 3 days in the duration of renal-replacement therapy (P=0.008), and a mean reduction in health care costs of €1,110 (about $1,600) (P=0.04).
Late initiation of parenteral nutrition was associated with faster recovery and fewer complications, as compared with early initiation. (Funded by the Methusalem program of the Flemish government and others; EPaNIC ClinicalTrials.gov number, NCT00512122.).
对于那些仅通过肠内营养无法达到热量目标的危重症成人患者，何时开始给予肠外营养存在争议。
在这项随机、多中心试验中，我们比较了在重症监护病房（ICU）中，早期（欧洲指南）与晚期（美国和加拿大指南）开始给予肠外营养来补充不足的肠内营养的效果。在 2312 例患者中，肠外营养在 ICU 入院后 48 小时内开始（早期起始组），而在 2328 例患者中，肠外营养在第 8 天之前未开始（晚期起始组）。两组均采用肠内营养早期起始方案，并输注胰岛素以实现血糖正常。
与晚期起始组相比，早期起始组 ICU 更早出院（风险比，1.06；95%置信区间[CI]，1.00 至 1.13；P=0.04）和更早出院到医院（风险比，1.06；95%CI，1.00 至 1.13；P=0.04）的可能性相对增加了 6.3%，且出院时的功能状态没有下降的证据。两组 ICU 死亡率、医院死亡率和 90 天生存率相似。与早期起始组相比，晚期起始组 ICU 感染发生率较低（22.8%比 26.2%，P=0.008），且胆汁淤积发生率较低（P<0.001）。与早期起始组相比，晚期起始组需要机械通气超过 2 天的患者比例相对减少了 9.7%（P=0.006），肾脏替代治疗持续时间中位数减少了 3 天（P=0.008），医疗保健费用平均减少了 1110 欧元（约合 1600 美元）（P=0.04）。
与早期起始相比，晚期开始给予肠外营养与更快的康复和更少的并发症相关。（由佛兰德政府的 Methusalem 计划和其他机构资助；EPaNICClinicalTrials.gov 编号，NCT00512122。）
