Feeding, simvastatin, and linezolid.
Feeding, simvastatin, and linezolid.
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喂养，辛伐他汀和利奈唑胺。
DOI：
10.1164/rccm.201203-0549rr
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发表时间：
2012
影响因子：
24.7
通讯作者：
Braun,AndrewT
中科院分区：
文献类型：
--
作者：
Kamdar,BirenB;Akulian,JasonA;Braun,AndrewT
营养支持很重要，但对接受机械通气的患者尤其具有挑战性。目前针对这一人群的指南建议尽早开始肠内喂养，相关数据支持肠内喂养可改善死亡率和感染结局(2)。尽管有这些建议，重症监护病房患者肠内营养的最佳剂量仍然未知。尽管一些研究表明，充分的肠道营养可以改善预后，但其他研究表明，营养（最小）喂养是足够的，并且产生的胃肠道并发症较少(2)。为了解决这些相互矛盾的数据，Rice及其同事提出了一项ARDS临床试验网络随机对照试验的结果，比较了急性肺损伤（ALI）危重患者的完全喂养和营养喂养(1)。在ALI发病48小时内和开始机械通气72小时内，44家医院的患者随机接受6天的全喂养方案，从25ml /小时开始，并随着热量目标的耐受而增加，或10ml /小时营养喂养方案。6天后，仍接受机械通气的患者给予全喂养方案。在研究期间，全喂养组的492名患者每天摄入约1300千卡（目标的80%），而营养喂养组的508名患者每天摄入约400千卡（目标的25%）。与全饲组和营养喂养组相比，无呼吸机天数（15.0 vs. 14.9； P= 0.89）、60天死亡率（22.2 vs. 23.2%； P= 0.77）、感染率、器官衰竭天数或无重症监护病房天数均无显著差异。营养喂养组的胃残量和反流、呕吐、便秘发生率显著降低，但两组的实际并发症发生率均较低。本研究的优势包括其随机、意向治疗设计、大样本和使用标准化给药方案。局限性包括其开放标签、非等效设计和排除无ALI的危重患者。总体而言，这项设计良好的随机对照试验表明，初始完全喂养与营养喂养在无呼吸机天数或死亡率方面没有差异，并支持两种策略在ALI中的相对安全性。目前尚不清楚是否存在其他与喂养时间或持续时间相关的临床重要结果，以支持一种策略优于另一种策略。
Nutritional support is important but particularly challenging for patients receiving mechanical ventilation. Current guidelines for this population recommend early initiation of enteral feeding, supported by data associating enteral feeding with improved mortality and infection outcomes (2). Despite these recommendations, the optimal dose of enteral nutrition in intensive care unit patients remains unknown. Although some studies suggest that full enteric nutrition improves outcomes, others have demonstrated that trophic (minimal) feedings are sufficient and produce fewer gastrointestinal complications (2). To resolve these conflicting data, Rice and colleagues present the results of an ARDS Clinical Trials Network randomized controlled trial comparing full versus trophic feeding in critically ill patients with acute lung injury (ALI)(1). Within 48 hours of ALI onset and 72 hours of initiation of mechanical ventilation, patients at 44 hospitals were randomized to receive 6 days of either a full-feeding protocol, starting at 25 ml/hour and up-titrated as tolerated toward a caloric goal, or a 10-ml/hour trophicfeeding protocol. After 6 days, patients still receiving mechanical ventilation were given the full-feeding protocol. During the study period, the 492 patients in the full-feeding group received approximately 1,300 kcal each day (80% of goal), whereas the 508 patients in the trophic-feeding group received approximately 400 kcal (25% of goal). Comparing the full-and trophic-feeding groups, there were no significant differences in ventilator-free days (15.0 vs. 14.9; P= 0.89), 60-day mortality (22.2 vs. 23.2%; P= 0.77), infection rates, organ failure–free days, or intensive care unit–free days. The trophic-feeding group had significantly lower gastric residual volumes and rates of regurgitation, emesis, and constipation, but actual rates of these complications were low in both groups.The strengths of this study include its randomized, intentionto-treat design, large size, and use of standardized dosing protocols. Limitations include its open-label, nonequivalence design and the exclusion of critically ill patients without ALI. Overall, this well-designed randomized controlled trial demonstrated no difference in ventilator-free days or mortality with initial full versus trophic feeding, and supports the relative safety of both strategies in ALI. It remains unknown whether other clinically important outcomes related to the timing or duration of feeding exist to favor one strategy over the other.