ICU的重癥病人一直推薦使用腸內營養(yǎng)，但是這并不能達到標準營養(yǎng)目標。近日發(fā)表于《柳葉刀 感染》子刊的一項調查研究評估了在ICU住院治療4-8天的病人進行腸內營養(yǎng)和腸外營養(yǎng)能否達到100%的營養(yǎng)供給的目標。

    這項隨機控制實驗在瑞士的兩家醫(yī)療中心進行。研究者納入了住進ICU第3天的重癥病人，這些重癥病人通過腸內營養(yǎng)只能接受正常所需60%的營養(yǎng)。研究者通過間接測熱法測定重癥病人一天所需要的熱量后，按照電腦生成的隨機序列將病人分為腸內營養(yǎng)組和腸外營養(yǎng)組。進行營養(yǎng)介入8天后進行28天的隨訪，通過院內感染的發(fā)生率判定實驗結果。

    腸外營養(yǎng)組有153名重癥病人，腸內營養(yǎng)組有152名重癥病人。腸外營養(yǎng)組的平均營養(yǎng)供給為每天每公斤體重28千卡，腸內營養(yǎng)組為20千卡。在第9天至第28天的隨訪中發(fā)現(xiàn)，153名腸外營養(yǎng)組的重癥病人有41個發(fā)生院內感染，感染率為27%，而腸內營養(yǎng)組152名重癥病人中有58個發(fā)生院內感染，感染率為38%。

    ICU重癥病人在住院第4天給予腸外營養(yǎng)可降低院內感染的發(fā)生，該項研究提示當腸內營養(yǎng)無法提供充足熱量時，可以進行腸外營養(yǎng)改善臨床結果。

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

    Claudia Paula Heidegger MD a, Prof Mette M Berger MD d, Séverine Graf BSc a b, Walter Zingg MD c, Patrice Darmon MD b, Prof Michael C Costanza PhD e, Ronan Thibault MD b, Prof Claude Pichard MD b Summary

    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.