Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition A Randomized Controlled Trial
Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition A Randomized Controlled Trial
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DOI：
10.1001/jama.2013.5124
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发表时间：
2013-05-22
影响因子：
120.7
通讯作者：
Peake, Sandra
中科院分区：
文献类型：
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作者：
Doig, Gordon S.;Simpson, Fiona;Peake, Sandra
重要性 系统评价表明，重症监护病房 (ICU) 中具有早期肠内营养 (EN) 相对禁忌症的成年患者可能会受益于 ICU 入院 24 小时内提供的肠外营养 (PN)。 目的 确定为具有早期肠内营养 (EN) 相对禁忌症的危重成人提供早期 PN 是否会改变结局。 设计、环境和受试者 2006 年 10 月至 2011 年 6 月在 ICU 中进行的多中心、随机、单盲临床试验澳大利亚和新西兰的 31 家社区和三级医院。参与者是具有早期 EN 相对禁忌症的危重成人，预计在 ICU 停留时间超过 2 天。干预措施随机分配至实用标准护理或早期 PN。主要结果和措施第 60 天死亡率；生活质量、感染和身体成分。 结果 共有 1372 名患者被随机分配（686 名患者接受标准护理，686 名患者接受早期 PN）。在接受标准护理的 682 名患者中，199 名患者 (29.2%) 最初开始 EN，186 名患者 (27.3%) 最初开始 PN，278 名患者 (40.8%) 仍未进食。接受标准护理的患者达到 EN 或 PN 的时间为 2.8 天（95% CI，2.3 至 3.4）。接受早期 PN 的患者平均在入组后 44 分钟开始 PN（95% CI，36 至 55）。第 60 天死亡率没有显着差异（标准护理为 22.8%，早期 PN 为 21.5%；风险差异，-1.26%；95% CI，-6.6 至 4.1；P=.60）。早期 PN 患者对第 60 天的生活质量（RAND-36 总体健康状况）进行了统计学评分，但没有临床意义，较高（标准护理为 45.5，早期 PN 为 49.8；平均差，4.3；95% CI，0.95 至 7.58；P=.01）。早期 PN 患者需要有创通气的天数较少（每 10 名患者 x ICU 天 7.73 对比 7.26 天，风险差异，-0.47；95% CI，-0.82 至 -0.11；P=.01），并且基于主观整体评估，肌肉萎缩较少（每周评分增加 0.43 对比 0.27；平均差，-0.16；95% CI，-0.28 至-0.038；P=.01）和脂肪减少（每周评分增加 0.44 vs 0.31；平均差，-0.13；95% CI，-0.25 至 -0.01；P=.04）。结论和相关性 与标准护理相比，为具有早期 EN 相对禁忌症的危重成人提供早期 PN 并不会导致第 60 天死亡率的差异。早期 PN 策略显着减少了有创通气的天数，但并未显着缩短 ICU 或住院时间。
Importance Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission.Objective To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes.Design, Setting, and Participants Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days.Interventions Random allocation to pragmatic standard care or early PN.Main Outcomes and Measures Day-60 mortality; quality of life, infections, and body composition.Results A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN; risk difference, -1.26%; 95% CI, -6.6 to 4.1; P=.60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN; mean difference, 4.3; 95% CI, 0.95 to 7.58; P=.01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient x ICU days, risk difference, -0.47; 95% CI, -0.82 to -0.11; P=.01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference, -0.16; 95% CI, -0.28 to -0.038; P=.01) and fat loss (0.44 vs 0.31 score increase per week; mean difference, -0.13; 95% CI, -0.25 to -0.01; P=.04).Conclusions and Relevance The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays.