Zusman Oren, Theilla Miriam, Cohen Jonathan, Kagan Ilya, Bendavid Itai, Singer Pierre
Department of Internal Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
Department of General Intensive Care and Institute for Nutrition Research, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel.
Crit Care. 2016 Nov 10;20(1):367. doi: 10.1186/s13054-016-1538-4.
Intense debate exists regarding the optimal energy and protein intake for intensive care unit (ICU) patients. However, most studies use predictive equations, demonstrated to be inaccurate to target energy intake. We sought to examine the outcome of a large cohort of ICU patients in relation to the percent of administered calories divided by resting energy expenditure (% AdCal/REE) obtained by indirect calorimetry (IC) and to protein intake.
Included patients were hospitalized from 2003 to 2015 at a 16-bed ICU at a university affiliated, tertiary care hospital, and had IC measurement to assess caloric targets. Data were drawn from a computerized system and included the % AdCal/REE and protein intake and other variables. A Cox proportional hazards model for 60-day mortality was used, with the % AdCal/REE modeled to accommodate non-linearity. Length of stay (LOS) and length of ventilation (LOV) were also assessed.
A total of 1171 patients were included. The % AdCal/REE had a significant non-linear (p < 0.01) association with mortality after adjusting for other variables (p < 0.01). Increasing the percentage from zero to 70 % resulted in a hazard ratio (HR) of 0.98 (CI 0.97-0.99) pointing to reduced mortality, while increases above 70 % suggested an increase in mortality with a HR of 1.01 (CI 1.01-1.02). Increasing protein intake was also associated with decreased mortality (HR 0.99, CI 0.98-0.99, p = 0.02). An AdCal/REE >70 % was associated with an increased LOS and LOV.
The findings of this study suggest that both underfeeding and overfeeding appear to be harmful to critically ill patients, such that achieving an Adcal/REE of 70 % had a survival advantage. A higher caloric intake may also be associated with harm in the form of increased LOS and LOV. The optimal way to define caloric goals therefore requires an exact estimate, which is ideally performed using indirect calorimetry. These findings may provide a basis for future randomized controlled trials comparing specific nutritional regimens based on indirect calorimetry measurements.
关于重症监护病房（ICU）患者的最佳能量和蛋白质摄入量存在激烈争论。然而，大多数研究使用预测方程，结果表明这些方程在确定能量摄入量目标方面并不准确。我们试图研究一大群ICU患者的预后情况，这些预后与通过间接测热法（IC）获得的摄入热量占静息能量消耗的百分比（%AdCal/REE）以及蛋白质摄入量有关。
纳入的患者于2003年至2015年期间在一所大学附属的三级护理医院的一间拥有16张床位的ICU住院，并进行了IC测量以评估热量目标。数据来自一个计算机系统，包括%AdCal/REE、蛋白质摄入量及其他变量。使用Cox比例风险模型评估60天死亡率，对%AdCal/REE进行建模以适应非线性关系。还评估了住院时间（LOS）和通气时间（LOV）。
共纳入1171例患者。在对其他变量进行调整后（p < 0.01），%AdCal/REE与死亡率存在显著的非线性关联（p < 0.01）。将百分比从零增加到70%会使风险比（HR）为0.98（95%置信区间[CI]为0.97 - 0.99），表明死亡率降低，而增加到70%以上则表明死亡率增加，HR为1.01（CI为1.01 - 1.02）。增加蛋白质摄入量也与死亡率降低相关（HR为0.99，CI为0.98 - 0.99，p = 0.02）。AdCal/REE > 70%与LOS和LOV增加相关。
本研究结果表明，喂养不足和喂养过度似乎对重症患者均有害，因此达到70%的Adcal/REE具有生存优势。较高的热量摄入也可能以LOS和LOV增加的形式造成伤害。因此，确定热量目标的最佳方法需要精确估计，理想情况下应使用间接测热法进行。这些发现可能为未来基于间接测热法测量结果比较特定营养方案的随机对照试验提供依据。
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