Department of Intensive Care Medicine, Gelderse Vallei Hospital, Willy Brandtlaan 10, 6716 RP, Ede, The Netherlands.
Intensive Care Unit, UZ Brussel, Vrije Universiteit Brussel, Brussels, Belgium.
Crit Care. 2019 Nov 21;23(1):368. doi: 10.1186/s13054-019-2657-5.
Although mortality due to critical illness has fallen over decades, the number of patients with long-term functional disabilities has increased, leading to impaired quality of life and significant healthcare costs. As an essential part of the multimodal interventions available to improve outcome of critical illness, optimal nutrition therapy should be provided during critical illness, after ICU discharge, and following hospital discharge.
This narrative review summarizes the latest scientific insights and guidelines on ICU nutrition delivery. Practical guidance is given to provide optimal nutrition therapy during the three phases of the patient journey.
Based on recent literature and guidelines, gradual progression to caloric and protein targets during the initial phase of ICU stay is recommended. After this phase, full caloric dose can be provided, preferably based on indirect calorimetry. Phosphate should be monitored to detect refeeding hypophosphatemia, and when occurring, caloric restriction should be instituted. For proteins, at least 1.3 g of proteins/kg/day should be targeted after the initial phase. During the chronic ICU phase, and after ICU discharge, higher protein/caloric targets should be provided preferably combined with exercise. After ICU discharge, achieving protein targets is more difficult than reaching caloric goals, in particular after removal of the feeding tube. After hospital discharge, probably very high-dose protein and calorie feeding for prolonged duration is necessary to optimize the outcome. High-protein oral nutrition supplements are likely essential in this period. Several pharmacological options are available to combine with nutrition therapy to enhance the anabolic response and stimulate muscle protein synthesis.
During and after ICU care, optimal nutrition therapy is essential to improve the long-term outcome to reduce the likelihood of the patient to becoming a "victim" of critical illness. Frequently, nutrition targets are not achieved in any phase of recovery. Personalized nutrition therapy, while respecting different targets during the phases of the patient journey after critical illness, should be prescribed and monitored.
尽管几十年来危重疾病导致的死亡率有所下降，但长期存在功能障碍的患者人数却有所增加，导致生活质量受损和医疗保健费用显著增加。作为改善危重疾病预后的多种治疗方法的重要组成部分，危重期间、重症监护病房（ICU）出院后和出院后都应提供最佳的营养治疗。
本综述性叙述总结了最新的关于 ICU 营养供给的科学见解和指南。为提供患者旅程的三个阶段的最佳营养治疗提供了实用指导。
根据最近的文献和指南，建议在 ICU 入住初期逐渐达到热量和蛋白质目标。在这个阶段之后，可以提供全热量剂量，最好基于间接测热法。应监测磷以检测再喂养性低磷血症，一旦发生，应限制热量摄入。对于蛋白质，初始阶段后至少应达到 1.3 g/kg/天的目标。在慢性 ICU 阶段和 ICU 出院后，应提供更高的蛋白质/热量目标，最好与运动相结合。在 ICU 出院后，与达到热量目标相比，达到蛋白质目标更为困难，尤其是在拔除喂养管后。在出院后，可能需要长时间高剂量的蛋白质和热量喂养以优化结果。高蛋白口服营养补充剂在这一时期可能是必不可少的。有几种药理学选择可与营养治疗结合使用，以增强合成代谢反应并刺激肌肉蛋白质合成。
在 ICU 治疗期间和之后，最佳的营养治疗对于改善长期预后以降低患者成为危重疾病“受害者”的可能性至关重要。在恢复的任何阶段，营养目标通常都无法实现。应规定和监测个性化营养治疗，同时在危重疾病后患者旅程的各个阶段尊重不同的目标。
