Department of Anesthesiology and Surgery, Duke University School of Medicine, Box 3094 Mail # 41, 2301 Erwin Road, 5692 HAFS, Durham, NC, USA.
Departments of Nutrition and Dietetics and Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK.
Crit Care. 2023 Jul 4;27(1):261. doi: 10.1186/s13054-023-04539-x.
Personalization of ICU nutrition is essential to future of critical care. Recommendations from American/European guidelines and practice suggestions incorporating recent literature are presented. Low-dose enteral nutrition (EN) or parenteral nutrition (PN) can be started within 48 h of admission. While EN is preferred route of delivery, new data highlight PN can be given safely without increased risk; thus, when early EN is not feasible, provision of isocaloric PN is effective and results in similar outcomes. Indirect calorimetry (IC) measurement of energy expenditure (EE) is recommended by both European/American guidelines after stabilization post-ICU admission. Below-measured EE (~ 70%) targets should be used during early phase and increased to match EE later in stay. Low-dose protein delivery can be used early (~ D1-2) (< 0.8 g/kg/d) and progressed to ≥ 1.2 g/kg/d as patients stabilize, with consideration of avoiding higher protein in unstable patients and in acute kidney injury not on CRRT. Intermittent-feeding schedules hold promise for further research. Clinicians must be aware of delivered energy/protein and what percentage of targets delivered nutrition represents. Computerized nutrition monitoring systems/platforms have become widely available. In patients at risk of micronutrient/vitamin losses (i.e., CRRT), evaluation of micronutrient levels should be considered post-ICU days 5-7 with repletion of deficiencies where indicated. In future, we hope use of muscle monitors such as ultrasound, CT scan, and/or BIA will be utilized to assess nutrition risk and monitor response to nutrition. Use of specialized anabolic nutrients such as HMB, creatine, and leucine to improve strength/muscle mass is promising in other populations and deserves future study. In post-ICU setting, continued use of IC measurement and other muscle measures should be considered to guide nutrition. Research on using rehabilitation interventions such as cardiopulmonary exercise testing (CPET) to guide post-ICU exercise/rehabilitation prescription and using anabolic agents such as testosterone/oxandrolone to promote post-ICU recovery is needed.
ICU 营养的个体化是重症监护未来的关键。本文呈现了来自美国/欧洲指南的推荐意见和纳入最新文献的实践建议。入院后 48 小时内可开始给予低剂量肠内营养（EN）或肠外营养（PN）。虽然 EN 是首选的给药途径，但新数据强调可以安全地给予 PN 而不会增加风险；因此，当早期 EN 不可行时，提供等热量的 PN 是有效的，并且结果相似。欧洲/美国指南均推荐在 ICU 入院后稳定后进行能量消耗（EE）的间接测热法（IC）测量。在早期阶段应使用低于测量值的 EE（70%）目标，并且在入住期间增加到与 EE 匹配。低蛋白剂量可在早期（D1-2）（<0.8g/kg/d）使用，然后在患者稳定时增加至≥1.2g/kg/d，对于不稳定患者和未进行 CRRT 的急性肾损伤患者，考虑避免更高的蛋白质。间歇性喂养方案具有进一步研究的前景。临床医生必须了解提供的能量/蛋白质以及提供的营养代表目标的百分比。计算机化营养监测系统/平台已广泛应用。对于有微量营养素/维生素丢失风险的患者（即 CRRT），应在 ICU 后第 5-7 天评估微量营养素水平，并在有指征时补充缺乏的营养。未来，我们希望使用肌肉监测仪（如超声、CT 扫描和/或 BIA）来评估营养风险并监测营养反应。在其他人群中，使用专门的合成代谢营养素（如 HMB、肌酸和亮氨酸）来改善力量/肌肉质量具有很大的前景，值得进一步研究。在 ICU 后环境中，应考虑继续使用 IC 测量和其他肌肉测量来指导营养。需要研究使用心肺运动测试（CPET）等康复干预来指导 ICU 后的运动/康复处方以及使用睾酮/氧雄龙等合成代谢药物来促进 ICU 后的恢复。
