Medical-Surgical Intensive Care Unit, CHD de la Vendée, La Roche-sur-Yon, France,
Intensive Care Med. 2015 May;41(5):875-86. doi: 10.1007/s00134-015-3730-4. Epub 2015 Mar 20.
Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock.
In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics.
We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day.
In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.
关于机械通气合并休克患者的最佳营养方式，目前数据有限。本研究旨在评估机械通气合并休克患者（插管后 48 小时内）早期营养（<48 小时）、喂养途径和热量摄入与死亡率和呼吸机相关性肺炎（VAP）风险之间的关联。
在前瞻性 OutcomeRea 数据库中，我们确定了机械通气时间超过 72 小时和休克（动脉收缩压<90mmHg）的患者，这些患者在插管后 48 小时内发生休克。使用边缘结构 Cox 模型创建一个准人群，其中治疗不受个体特征的影响。
共纳入 3032 例患者。早期营养与 28 天死亡率降低相关[风险比（HR）0.89，95%置信区间（CI）0.81-0.98，P=0.01]和 7 天死亡率降低相关（HR 0.76，CI 0.66-0.87，P<0.001），但与 7 天至 28 天死亡率降低无关（HR 1.00，CI 0.89-1.12，P=0.98）。早期营养增加了 28 天内 VAP 风险（HR 1.08，CI 1.00-1.17，P=0.046）和直至第 7 天（HR 7.17，CI 6.27-8.19，P<0.001），但降低了第 7 天至 28 天 VAP 风险（HR 0.85，CI 0.78-0.92，P<0.001）。与肠外营养相比，肠内营养与 VAP 风险略有增加相关（HR 1.11，CI 1.00-1.22，P=0.04），但与死亡率无关。早期热量摄入≥20 和<20 kcal/kg/day 之间的死亡率和 VAP 风险均无差异。
在机械通气合并休克的患者中，早期营养与死亡率降低相关。喂养途径和早期热量摄入均与死亡率无关。早期营养和肠内喂养与 VAP 风险增加相关。
