危重症患者补充性肠外营养的能量供给优化：一项随机对照临床试验。

Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial.

机构信息

Service of Intensive Care, Geneva University Hospital, Geneva, Switzerland.

出版信息

Lancet. 2013 Feb 2;381(9864):385-93. doi: 10.1016/S0140-6736(12)61351-8. Epub 2012 Dec 3.

DOI:10.1016/S0140-6736(12)61351-8

PMID:23218813

Abstract

BACKGROUND

Enteral nutrition (EN) is recommended for patients in the intensive-care unit (ICU), but it does not consistently achieve nutritional goals. We assessed whether delivery of 100% of the energy target from days 4 to 8 in the ICU with EN plus supplemental parenteral nutrition (SPN) could optimise clinical outcome.

METHODS

This randomised controlled trial was undertaken in two centres in Switzerland. We enrolled patients on day 3 of admission to the ICU who had received less than 60% of their energy target from EN, were expected to stay for longer than 5 days, and to survive for longer than 7 days. We calculated energy targets with indirect calorimetry on day 3, or if not possible, set targets as 25 and 30 kcal per kg of ideal bodyweight a day for women and men, respectively. Patients were randomly assigned (1:1) by a computer-generated randomisation sequence to receive EN or SPN. The primary outcome was occurrence of nosocomial infection after cessation of intervention (day 8), measured until end of follow-up (day 28), analysed by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00802503.

FINDINGS

We randomly assigned 153 patients to SPN and 152 to EN. 30 patients discontinued before the study end. Mean energy delivery between day 4 and 8 was 28 kcal/kg per day (SD 5) for the SPN group (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the EN group (77% [27%]). Between days 9 and 28, 41 (27%) of 153 patients in the SPN group had a nosocomial infection compared with 58 (38%) of 152 patients in the EN group (hazard ratio 0·65, 95% CI 0·43-0·97; p=0·0338), and the SPN group had a lower mean number of nosocomial infections per patient (-0·42 [-0·79 to -0·05]; p=0·0248).

INTERPRETATION

Individually optimised energy supplementation with SPN starting 4 days after ICU admission could reduce nosocomial infections and should be considered as a strategy to improve clinical outcome in patients in the ICU for whom EN is insufficient.

FUNDING

Foundation Nutrition 2000Plus, ICU Quality Funds, Baxter, and Fresenius Kabi.

摘要

背景

肠内营养（EN）被推荐用于重症监护病房（ICU）的患者，但它并不能始终达到营养目标。我们评估了在 ICU 期间从第 4 天到第 8 天通过 EN 提供 100%能量目标，并辅以补充性肠外营养（SPN）是否可以优化临床结局。

方法

这项随机对照试验在瑞士的两个中心进行。我们招募了在 ICU 入院第 3 天接受的 EN 少于其能量目标 60%、预计住院时间超过 5 天且存活时间超过 7 天的患者。我们在第 3 天通过间接热量测定法计算能量目标，如果无法进行，则分别为女性和男性设定 25 和 30 kcal/kg 理想体重/天的目标。患者通过计算机生成的随机序列以 1:1 的比例随机分配接受 EN 或 SPN。主要结局是干预停止后（第 8 天）发生医院获得性感染，直到随访结束（第 28 天）进行测量，采用意向治疗进行分析。该试验在 ClinicalTrials.gov 注册，编号为 NCT00802503。

结果

我们将 153 名患者随机分配至 SPN 组，152 名患者分配至 EN 组。30 名患者在研究结束前退出。SPN 组在第 4 天至第 8 天期间的平均能量输送量为 28 kcal/kg/天（SD 5），占能量目标的 103%（SD 18%），而 EN 组为 20 kcal/kg/天（SD 7）（占 77%（27%））。在第 9 天至第 28 天期间，SPN 组 153 名患者中有 41 名（27%）发生医院获得性感染，而 EN 组 152 名患者中有 58 名（38%）（风险比 0.65，95%CI 0.43-0.97；p=0.0338），SPN 组每位患者的医院获得性感染平均数量较少（-0.42[-0.79 至-0.05]；p=0.0248）。