Timing der TEN/TPN

Der Patient nach Autounfall
Die Patientin mit Aspergillom
Der Patient mit Suizidversuch
Die ältere Dame mit Sepsis
Der jüngere Herr mit Pneumonie
Wie
ernähren
Sie diese
Patienten
?
!6
So many
guidelines on
nutrition in ICU
– which one
should we use
!7
Richtlinien
Kanadische Richtlinien
(www.criticalcarenutrition.com)
Australische - Neuseeländische
Richtlinien
(www.auspen.org.au)
Europäische Richtlinien
(www.espen.org)
Deutsche Gesellschaft für
Ernährung (www.dgem.de)
!8
Phasen des Postaggressionsstoffwechsels nach Cuthbertson
Ebbphase
Katabole
Flowphase
Anabole
Flowphase
Dauer: Stunden
Dauer: Tage
Dauer: Wochen
Absoluter Insulinmangel
Relativer Insulinmangel
Reparationsphase
Erhöhung antiinsulinärer
Hormone
Negative Stickstoffbilanz
Positive Stickstoffbilanz
Katabolie
Katabolie
Anabolie
!9
Cuthbertson DP, Br Med Bull 1954; 10: 33-37
Energieumsatz
Trauma
Wende
Rekonvaleszenz
parenteral
enteral
Norm
flow
Katabolie
Anabolie
ebb
24-48 h
Zeit
7-21 Tage
!10
Enterale Ernährung
!11
Enterale Ernährung
‣
Klar bevorzugte Applikationsform
‣
bewahrt die GI-Integrität
‣
reduziert die Zahl infektiöser Komplikationen
‣
Verhinderung der Dünndarmatrophie
‣
weniger bakterielle Proliferation
‣
geringere Komplikationsraten
‣
weniger Kosten, geringere Überwachung
‣
physiologischer als die TPN
‣
kann den Outcome von Traumapatienten verbessern
!12
Scott A, Postgrad Med J 1996; 72: 395-402 / Cerra FB, Chest 1997; 111: 769-778
Enterale Ernährung
‣
„...frühe enterale Ernährung über eine nasogastrale Sonde
sollte gegenüber TPN bevorzugt werden...“ (C)
‣
eine TPN ist zu vermeiden, wenn mittels TEN die errechnete
Zielzufuhr näherungsweise erreicht wird (A)
Kanadische Richtlinien (www.criticalcarenutrition.com)
Australische - Neuseeländische Richtlinien (www.auspen.org.au)
Europäische Richtlinien (www.espen.org)
Deutsche Gesellschaft für Ernährung (www.dgem.de)
!13
Wann ist eine enterale
Ernährung angezeigt?
Alle Patienten, bei welchen innert 3 Tagen kein
voller Nahrungsaufbau zu erwarten ist, sollten
enteral ernährt werden. (C)
Nahrungsmenge
Während der akuten und Frühphase der Erkrankung kann ein
Überschreiten von 20-25 kcal / kg KG / d mit einem schlechteren
Outcome assoziiert sein (C).
Während der anabolen Erholungsphase sollte das Ziel 25-30 kcal / kg
KG / d sein (C).
Schwer mangelernährte Patienten sollten eine enterale Ernährung mit
bis zu 25-30 kcal / kg KG / d erhalten. Falls dieser Zielwert nicht
erreicht wird, sollte eine supplementierende parenterale Ernährung
gegeben werden (C).
Applikationsweg
Verwenden Sie enterale Ernährung bei allen Patienten, die auf dem enteralen
Weg ernährt werden können (C).
Bei kritisch Kranken besteht kein signifikanter Unterschied in der
Wirksamkeit einer jejunalen im Vergleich zu einer gastralen Ernährung (C).
Vermeiden Sie eine zusätzliche parenterale Ernährung bei Patienten, die eine
enterale Ernährung tolerieren und die annähernd an ihren Zielwert ernährt
werden können (Ausnahme: schwer mangelernährte Patienten) (A).
Studien
Zeitpunkt einer
supplementierenden
parenteralen Ernährung
!18
„All patients who are not expected to be
on normal nutrition within 3 days should
receive PN within24-48 h if EN is
contraindicated or if they cannot tolerate
EN.“
!19
Singer P, Clin Nutr 2009, 28: 387-400
„...with no evidence of proteincalorie malnutrition, use of PN
should be reserved and initiated
only after the first 7 days of
hospitalization.“
!20
Heyland DK, JPEN 2003; 27: 355-373
Near-Target Caloric Intake in Critically Ill
Medical-Surgical Patients Is Associated
With Adverse Outcomes
Arabi YM, JPEN Journal of parenteral and enteral nutrition 2010; 34: 280-288
ARABI
Design
Kohortenstudie
Patienten
n = 523
Herkunft
interdisziplinäre ICU
Intervention
keine
Gruppe 1
Kalorienziel < 33,4%
Gruppe 2
Kalorienziel: 33,4 -64,6%
Gruppe 3
Kalorienziel: > 64,6%
Arabi YM, JPEN Journal of parenteral and enteral nutrition 2010; 34: 280-288
Outcomes
< 33.4% 33.4 - 64.6% > 64.6%
p
Spitalsterblichkeit
20.6 %
28.2 %
40.1 %
ICU-Infekte
18.2 %
42.5 %
55.2 % < 0.0001
7.7 %
21.0 %
27.9 %
<0.0001
Beatmungsdauer
4.7
9.4
12.8
<0.0001
IPS-Aufenthalt
6.1
10.5
13.9
<0.0001
Spitalaufenthalt
41.3
53.2
72.7
<0.0001
VAP
Arabi YM, JPEN Journal of parenteral and enteral nutrition 2010; 34: 280-288
0.003
igure 1. The association among intensive care unit (ICU) mortality, hospital mortality, ICU-acquired infections, and ventilator
ssociated pneumonia (VAP) rate and caloric intake/requirement.
Arabi YM, JPEN Journal of parenteral and enteral nutrition 2010; 34: 280-288
Conclusion
„The data demonstrate that near - target caloric intake is
associated with significantly increased hospital mortality, ICUacquired infections, mechanical ventilation duration, and ICU and
hospital LOS.“
Arabi YM, JPEN Journal of parenteral and enteral nutrition 2010; 34: 280-288
:
!26
Early versus Late Parenteral
Nutrition in Critically Ill Adults
Greet Van
den Berghe
(EPaNiC)
Michael P. Casaer, N Engl J Med 2011, 365: 506-517
EPaNIC
Design
prospektive, randomisierte
Multizenterstudie
Patienten
n = 4640
Herkunft
in 60% Herzchirurgie
Intervention
Enterale Ernährung und PN
Gruppe 1
PN in Form von 20% Glukose
für 48 h, gefolgt von TPN
Gruppe 2
PN als supplementierende
Ernährung ab Tag 8
Endpunkte
Mortalität, LOS,
Beatmungstage, Infekte
Michael P. Casaer, N Engl J Med 2011, 365: 506-517
B Discharge Alive from ICU
0.93
Cumulative Proportion Discharged
Alive from ICU (%)
Cumulative Proportion Discharged
from ICU (%)
A Discharge from ICU
Late initiation
0.90
Early initiation
0.80
0.70
0.50
0.20
0.00
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30
0.93
0.90
Late initiation
Early initiation
0.80
0.70
0.50
0.20
0.00
0
2
4
6
Days after Randomization
Days after Randomization
No. at Risk
No. at Risk
C Discharge from Hospital
0.70
0.60
0.50
574
646
291
342
122
147
Late initiation 2328
Early initiation 2312
623
694
376
418
236
253
D Discharge Alive from Hospital
Späte SPN führte zu:
-einer Verkürzung des IPS-Aufenthaltes
-weniger Infektionen: 22,8% vs 26,2%
0.70 (p=0.008)
Late initiation
-weniger
Beatmungstagen: 36,3% vs 40,2% (>2 Tage) Late initiation
0.60 der IPS lebend entlassen
- einer signifikant
höheren
Chance
von
Early initiation
Early initiation
zu werden (75,2% vs 71,7%)
0.50
0.40
0.20
0.05
Michael P. Casaer, N Engl J Med 2011, 365: 506-517
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30
Cumulative Proportion Discharged
Alive from Hospital (%)
Late initiation 2328
Early initiation 2312
Cumulative Proportion Discharged
from Hospital (%)
8 10 12 14 16 18 20 22 24 26 28 30
0.40
0.20
0.05
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30
Early initiation 2312
646
147
342
0.70
Late initiation
0.60
Early initiation
0.50
0.40
0.20
0.05
0
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30
0.70
253
418
Late initiation
0.60
Early initiation
0.50
0.40
0.20
0.05
0
Days after Randomization
2
4
6
8 10 12 14 16 18 20 22 24 26 28 30
Days after Randomization
No. at Risk
Late initiation 2328
Early initiation 2312
694
D Discharge Alive from Hospital
Cumulative Proportion Discharged
Alive from Hospital (%)
Cumulative Proportion Discharged
from Hospital (%)
C Discharge from Hospital
Early initiation 2312
No. at Risk
2084
2059
1061
1159
508
574
Late initiation 2328
Early initiation 2312
2136
2117
1162
1260
657
724
Figure 3. Kaplan–Meier Estimates of the Time to Discharge from the Intensive Care Unit (ICU) and from the Hospital.
Shown are the cumulative proportions of patients who were discharged from the ICU (Panel A), discharged alive from the ICU (Panel B),
discharged from the
hospitalSPN
(Panel führte
C), and discharged
alive from the hospital (Panel D). For the analysis of the time to discharge from
Späte
zu:
the ICU and the hospital, data for patients who died were censored at the time of death. For the analysis of the time to discharge alive
-
einer Verkürzung des Spitalaufenthaltes from the ICU and the hospital, data for patients who died were censored at a time point after the last surviving patient had been dis- drawn
vermehrten
schweren
Hypoglykämien:
vs effect
1,9%
for the first 30 days
after randomization,
for the sake of3,5%
clarity. The
size(p<0.001)
was calculated by Cox procharged.35 Plots were
portional-hazards analysis
for the entire
stay inEffekt
the ICU auf
and the
except for one patient who was still in the hospital 90 days af-
zeigte
keinen
diehospital,
Mortalität
ter the enrollment of the last patient, whose data were censored at 90 days.
teral nutrition was surgically contraindicated ap- of infection and delayed recovery from organ failpeared to have a greater benefit from late initia- ure that are associated with the early administration of
parenteral
nutrition
than
did365:
other
patients, tion of parenteral nutrition may be explained by a
Michael
P. Casaer,
N Engl J Med
2011,
506-517
Conclusion
„Late initiation of parenteral nutrition was associated with
faster recovery and fewer complications, as compared with
early initiation.“
Michael P. Casaer, N Engl J Med 2011, 365: 506-517
:
!32
The tight calorie control study: a
prospective, randomized, controlled pilot
study of nutritional support in critically ill
patients
P. Singer
(TICACOS)
Singer P, Intensive Care Med 2011; 37: 601-9
Ticacos
Design
prospektive, randomisierte
Singlecenterstudie
Patienten
n = 130
Herkunft
interdisziplinäre ICU
Intervention
Indirekte Kaloriemetrie und
EN und SPN
Gruppe 1
EN gemäss Kaloriemetrie
(+SPN) n=65
Gruppe 2
25 kcal/kgKG; n=65
Endpunkte
Mortalität, LOS,
Beatmungstage, Infekte
Singer P, Intensive Care Med 2011; 37: 601-9
Energieziele Studiengruppe
Singer P, Intensive Care Med 2011; 37: 601-9
Energieziele Kontrollgruppe
nother as the measured IC changed significantly (p \ 0.008) over time for the
achieved using parenteral first 10 days studied. Patients received higher energy
remaining
patients, 56 intake from both sources compared to measured daily
Singer P, Intensive Care Med 2011; 37: 601-9
of energy
ters during
eans of all
CU stay) in
oup
Energieaufnahme
605
Parameter
Study group
(n = 56)
Mean REE (kcal/day)
Mean energy delivered/day (kcal/day)
Mean enterally delivered energy/day (kcal/day)
Mean parenterally delivered energy/day (kcal/day)
Route of administration (n)
Enteral
Parenteral
Enteral and parenteral
Mean protein delivered/day (g/day)
Mean daily energy balance (kcal)
Cumulative energy balance (kcal)
Maximum negative energy balance (kcal)
Daily mean blood glucose (mg/dL)
1,976
2,086
1,515
571
±
±
±
±
34
3
19
76 ±
186 ±
2,008 ±
15.7 ±
119.6 ±
468
460
756
754
16
206
2,177
883
21.8
Control group
(n = 56)
1,838
1,480
1,316
164
±
±
±
±
48
1
7
53 ±
-312 ±
-3,550 ±
-3,895 ±
127.3 ±
p
468
356
456
294
0.6
0.01
0.09
0.001
16
481
4,591
4,144
33.7
0.001
0.001
0.01
0.01
0.82
REE resting energy expenditure, kcal kilocalories
ive energy balance in the study group,
se balances were negative in the control
1 for both balances). Mean daily protein
Singer P,higher
Intensive Care
37: 601-9
nificantly
in Med
the 2011;
study
group
measures of energy expenditure resulted in significantly
lower hospital mortality for critically ill patients. We also
observed that these patients had a longer ICU stay and
duration of mechanical ventilation.
606
Table 4 Secondary outcomes for all patients (n = 130). Infectious
complications are expressed in absolute numbers and percentage
between brackets
Variable
Intention to treat: n= 130
p = 0.058
Study
group
(n = 65)
Control
group
(n = 65)
p value
ICU mortality (%)
24.60%
26.20%
1.0
Duration ventilation
(days)
Mean
16.1 ± 14.7
10.5 ± 8.3
0.03
Median (range)
12.5 (1–82)
9 (1–33)
Duration ICU stay
(days)
Mean
17.2 ± 14.6
11.7 ± 8.4
0.04
Median (range)
14 (1–84)
10 (0.5–35)
Duration hospital
stay (days)
Mean
33.8 ± 22.9
31.8 ± 27.3
0.33
Median (range)
29 (4–101)
21 (4–142)
Infectious
37
20
0.05
Fig.
2
a
Kaplan–Meier
curves
for
hospital
discharge
mortality for
complications (n)
all
patients
(intention
to
treat)
(n
=
130).
The
study
group
showed
VAP (%)
18 (27.7%)
9 (13.8%)
0.08
an improved outcome compared to the control group (Breslow,
Bacteremia (%)
(20.0%)
8 (12.3%)
p = 0.058).13
b Kaplan–Meier
curves
for hospital0.33
discharge mortalUrinary tractity for all 0patients (per protocol)
1 (1.5%)
1.0
(n = 112). The study group
infections (%)
showed an improved outcome compared to the control group
Wound
1 (1.5%)
0.21
(Breslow, p5=(7.7%)
0.023)
infections (%)
Abdominal
1 (1.5%)
1 (1.5%)
1.0
infections (%)
New pressure
26 (40.0%)
20 (30.8%)
0.34higher intake
The study
group received
a significantly
ulcers (%) of protein, related solely to the nutrition composition
Unplanned surgery
4 (6.2%)
3 (4.6%)
based on the
calories received.
Strack van1.0
Schijndel et al.
and surgical
[22] observed that reaching an energy goal guided by IC
complications
and a protein goal of 1.2 g/kg in ICU patients reduced
(%)
ICUa and hospital
mortality.
Alberda et al.0.49
[23] observed
14 (21.6%)
10 (15.4%)
Renal impairment
& requirement
that increasing both calorie intake and protein intake were
for RRT (%)
associated
with improved 60-day survival.
b
8 (12.3%)
0.8 stressed the
Liver impairmentPrevious
studies of EN10in(15.4%)
the ICU have
(%)
Per protocol: n = 112
p = 0.023
VAP ventilato
therapy
a
Serum creati
b
Serum biliru
study, could
meta-analysi
PN [26]. Sig
received PN
control group
energy goals
required to a
clinical outc
Tight cal
represents a
hand and ov
dangers of
However, ov
difficulties associated with achieving nutritional targets patients, and
[9–11]. Combining
EN and
PNrenal
[24, 25],
as we did in our as increased
VAP ventilator-associated
pneumonia,
RRT
replacement
Krankenhaussterblichkeit
Singer P, Intensive Care Med 2011; 37: 601-9
Fig. 2 a Kaplan–Meier curves for hospital discharge mortality for
Mean
Median (rang
Duration hospi
stay (days)
Mean
Median (rang
Infectious
complication
VAP (%)
Bacteremia (%
Urinary tract
infections (%
Wound
infections (
Abdominal
infections (%
New pressure
ulcers (%)
Unplanned sur
and surgical
complication
(%)
Renal impairm
& requireme
for RRT (%
Liver impairm
(%)
therapy
Serum creatinine [1.2 mg/dL
a
Sekundäre Endpunkte
Table 4 Secondary outcomes for all patients (n = 130). Infectious
complications are expressed in absolute numbers and percentage
between brackets
Variable
Study
group
(n = 65)
Control
group
(n = 65)
p value
ICU mortality (%)
Duration ventilation
(days)
Mean
Median (range)
Duration ICU stay
(days)
Mean
Median (range)
Duration hospital
stay (days)
Mean
Median (range)
Infectious
complications (n)
Singer P, Intensive Care
Med 2011;
VAP
(%) 37: 601-9
24.60%
26.20%
1.0
16.1 ± 14.7
12.5 (1–82)
10.5 ± 8.3
9 (1–33)
0.03
17.2 ± 14.6
14 (1–84)
11.7 ± 8.4
10 (0.5–35)
0.04
33.8 ± 22.9
29 (4–101)
37
31.8 ± 27.3
21 (4–142)
20
0.33
18 (27.7%)
9 (13.8%)
0.08
0.05
Conclusion
„In conclusion, we have shown in a single-center pilot study that a bundle
comprising actively supervised nutritional intervention and providing near
target energy requirements based on repeated energy measurements using
both EN and PN was achievable in a general ICU and may be associated
with lower hospital mortality. However, this was also associated with
prolonged duration of mechanical ventilation and ICU stay.“
Singer P, Intensive Care Med 2011; 37: 601-9
:
!41
Optimisation of energy provision
with supplemental parenteral
nutrition in critically ill patients: a
randomized controlled clinical trial
C. Heidegger
(SPN)
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381: 1351-8
SPN
Design
prospektive, randomisierte
Zweicenterstudie
Patienten
n = 305
Herkunft
interdisziplinäre ICU
Intervention
Indirekte Kaloriemetrie Tag 3
mit anschliessender SPN
Gruppe 1
Indirekte Kaloriemetrie +
SPN (n=153)
Gruppe 2
Indirekte Kaloriemetrie + EN
Endpunkte
Hospitalinfektionen Tag 8 und
28
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381: 1351-8
60% of their energy target from EN at day 3 after
admission to the ICU, were expected to stay for more
than 5 days, expected to survive for more than 7 days,
and had a functional gastrointestinal tract. We excluded
those who were receiving PN, had persistent gastrointestinal dysfunction and ileus, were pregnant, refused
to consent, or had been readmitted to the ICU after
previous randomisation.
Trial design
SPN+EN
100
EN
60
40
EN
20
0
1
ICU admission
2
Inclusion and
randomisation
Energy provision (%)
80
3
Intervention period
4
Indirect calorimetry
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381: 1351-8
5
6
7
Days since ICU admission
Follow-up
8
9
28
!44
A
120
Proportion of energy
target provided (%)
100
Enteral delivery
SPN
EN
80
60
40
20
0
B
120
Parenteral delivery
Proportion of energy
target provided (%)
100
80
60
Energieversorgung: enteral
40
20
Heidegger CP,
0 Berger MM, Pichard C, Lancet 2012;381: 1351-8
B
120
Parenteral delivery
Proportion of energy
target provided (%)
100
80
60
40
20
0
C
120
Total energy delivery
Proportion of energy
target provided (%)
100
80
60
Energieversorgung: parenteral
40
20
0 Berger MM, Pichard C, Lancet 2012;381: 1351-8
Heidegger CP,
C
120
Total energy delivery
Proportion of energy
target provided (%)
100
80
60
40
20
0
1
2
3
4
5
6
7
8
Days in ICU
Figure 3: Energy delivery
Energy (nutritional products and non-nutritional fluids) expressed in percentage (%) of energy target according
to method of delivery: enteral route (A), parenteral route (B), or a combination of both routes (C) in the
intention-to-treat patients. Horizontal lines within the boxes show the median, and the boxes show IQR.
EN=enteral nutrition. ICU=intensive-care unit. SPN=supplemental parenteral nutrition.
Energieversorgung: gesamt
4
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381: 1351-8
www.thelancet.com Published onli
s
p=0·0338*
1·0
Proportion without nosocomial infection
y
t
l
U
d
n
r
,
n
e
f
n
g
s
n
d
t
e
n
e
SPN
EN
0·9
0·8
0·7
0·6
0·5
Number at risk
SPN
EN
0
9
153
152
148
147
28
Days since admission to ICU
99
71
Kaplan-Meyer-Analyse der
nosokomialen Infekte
Figure 4: Kaplan-Meier analysis of nosocomial infections
SPN=supplemental parenteral nutrition. EN=enteral nutrition. *Statistically significant with
Benjamini-Hochberg correction.
Intervention period (days 4–8)
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381:SPN
1351-8
EN
Follow-up (days 9–28)
SPN
EN
!48
Outcomes
SPN
Mean or n(%)
EN
Mean or n(%)
p
Antibiotikatage
6 (7)
8 (8)
0.001
Antibiotikafreie
Tage
14 (8)
12 (8)
0.019
Beatmungsstunden
(ohne Infekte)
15 (59)
29 (61)
0.002
Mortalität
20 (13)
28 (18)
0.119
Infektionen
41 (27)
58 (38)
0.033
+124 kcal
- 2317 kcal
<0.001
Kummulative
Energiebilanz
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381: 1351-8
Conclusion
„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.“
Heidegger CP, Berger MM, Pichard C, Lancet 2012;381: 1351-8
:
!51
Early Parenteral Nutrition in Critically Ill
Patients With Short-term Relative
Contraindications to Early Enteral
Nutrition: a randomized controlled trial
Gordon S. Doig, JAMA 2013; 309: 2130-2138
Australia
Design
prospektive, randomisierte,
single-blind Multicenterstudie
Patienten
n = 1372
Herkunft
interdisziplinäre ICU
Intervention
Frühe parenterale Ernährung
bei Patienten mit KI für EN
Gruppe 1
Standard-PN innert 44
Minuten nach Randomiserung
Gruppe 2
Standard-Ernährung (frei)
Endpunkte
Mortalität am Tage 60
Gordon S. Doig, JAMA 2013; 309: 2130-2138
ARLY
RLY
EARLY
PARENTERAL
PARENTERAL
PARENTERAL
NUTRITION
NUTRITION
NUTRITION
IN
INCRITICALLY
IN
CRITICALLY
CRITICALLY
ILL
ILLILL
PATIENTS
PATIENTS
PATIENTS
gure
ure
Figure
2.2.Enteral
Enteral
2. Enteral
and
andand
Parenteral
Parenteral
Parenteral
Nutrition
Nutrition
Nutrition
Delivery
Delivery
Delivery
Process
Process
Process
Measures
Measures
Measures
for
forPatients
for
Patients
Patients
Remaining
Remaining
Remaining
ininthe
the
in Study
the
Study
Study
ICU
ICUICU
Energy
Energy
Energy
received
received
received
per
perpatient
patient
per patient
bybystudy
study
by study
day
day day
1.0
1.0 1.0
1600
16001600
Early
Earlyparenteral
Early
parenteral
parenteral
1200
12001200
Standard
Standard
Standard
care
carecare
23 3
34 4
45 5
2020 20
400
400 400
00
12 2
3030 30
800
800 800
Standard
Standard
Standard
care
carecare
200
200 200
0
11
Mean, g
Mean, g
1000
10001000
0.4
0.4 0.4
00
4040 40
Mean kcal
0.6
0.6 0.6
0.2
0.2 0.2
6060 60
Early
Earlyparenteral
Early
parenteral
parenteral
nutrition
nutrition
nutrition
5050 50
nutrition
nutrition
nutrition
1400
14001400
Mean kcal
Mean kcal
Mean Percentage
Mean Percentage
Mean Percentage
Early
Earlyparenteral
Early
parenteral
parenteral
0.8
0.8 0.8
nutrition
nutrition
nutrition
56 6
67 7
7
Days
DaysDays
ininICU
ICU
in ICU
of
. No.
ofpatients
patients
of patients
681
681 681
676
676 676
611
611 611
518
518 518
435
435 435
376
376 376
313
313 313
arly
ly parenteral
Early
parenteral
parenteral
utrition
nutrition
nutrition
682
682 682
675
675 675
599
599 599
480
480 480
410
410 410
353
353 353
301
301 301
andard
tandard
Standard
care
carecare
00
12 2
23 3
34 4
45 5
56 6
Standard
Standard
Standard
care
carecare
1010 10
0
11
Protein
Protein
Protein
received
received
received
per
perpatient
patient
per patient
bybystudy
study
by study
day
day day
Mean, g
Patients
Patients
Patients
receiving
receiving
receiving
enteral
enteral
enteral
ororparenteral
parenteral
or parenteral
nutrition
nutrition
nutrition
each
eachday
each
day day
67 7
7
0
11
12 2
23 3
34 4
45 5
56 6
67 7
7
Days
DaysDays
ininICU
ICU
in ICU
Days
DaysDays
ininICU
ICU
in ICU
681
681 681
676
676 676
611
611 611
518
518 518
435
435 435
376
376 376
313
313 313
681
681 681
676
676 676
611
611 611
518
518 518
435
435 435
376
376 376
313
313 313
682
682 682
675
675 675
599
599 599
480
480 480
410
410 410
353
353 353
301
301 301
682
682 682
675
675 675
599
599 599
480
480 480
410
410 410
353
353 353
301
301 301
ay1Day
1isisthe
1the
isday
the
dayof
day
ofstudy
study
of study
enrollment.
enrollment.
enrollment.
Energy
Energy
Energy
received
received
received
was
wascalculated
was
calculated
calculated
from
from
from
enteral
enteral
enteral
nutrition,
nutrition,
nutrition,
parenteral
parenteral
parenteral
nutrition,
nutrition,
nutrition,
and
andintravenous
and
intravenous
intravenous
infusions
infusions
infusions
with
withwith
$10%
$10%
$10%
glucose.
glucose.
glucose.
Error
Error
Error
srsindicate
bars
indicate
indicate
standard
standard
standard
error;
error;
error;
ICU,
ICU,ICU,
intensive
intensive
intensive
care
careunit.
care
unit.unit.
Energie- und Proteinzufuhr
!0.62
!0.62
toto!0.21)
to
!0.21)
!0.21)
attributable
attributable
attributable
totoearly
to
early
early
groups
groups
(adjusted
(adjusted
(adjusted
RD,
RD,
RD,
0.0%;
0.0%;
0.0%;
95%
95%
95%
CI,
CI,CI,!0.62
egun
gun
begun
aamean
mean
a mean
ofof44
44
ofminutes
44
minutes
minutes
after
after
after
ranranran-groups
parenteral
parenteral
parenteral
nutrition
nutrition
nutrition
(eTable
(eTable
(eTable
5).
5).There
5).
There
There
!4.2%
!4.2%
toto4.3%;
to
4.3%;
4.3%;
P=.99).
P=.99).
P=.99).
omization
mization
domization
(95%
(95%
(95%
CI,
CI,CI,
36-55),
36-55),
36-55),
with
with
with
adad-ad-!4.2%
were
were
no
noother
no
other
other
significant
significant
significant
differences
differences
differences
statistically
A statistically
significant
significant
significant
improveimproveimprove-were
itional
ional
ditional
vitamin
vitamin
vitamin
supplementation
supplementation
supplementation
comcomcom- AAstatistically
(TABLE
(TABLE
ment
ment
ininquality
quality
in quality
ofoflife
life
of (RAND-36
life
(RAND-36
(RAND-36
GenGenGen-(T
ABLE
3).
3).3).
mencing
encing
mencing
2.8
2.8days
2.8
days
days
after
after
after
study
study
study
parenteral
parenteral
parenteralment
1515 15
eral
eral
Health
Health
Health
Status)
Status)
Status)
(45.5
(45.5
(45.5
for
forfor
stanstanstan- There
There
There
were
were
were
no
nosignificant
no
significant
significant
differdifferdifferutrition
trition
nutrition
initiation
initiation
initiation
(95%
(95%
(95%
CI,
CI,CI,
2.7-3.0)
2.7-3.0)
2.7-3.0)eral
dard
dard
care
care
care
vsvs49.8
vs
49.8
49.8
for
forfor
early
early
early
parenteral
parenteral
parenteralences
ences
ences
between
between
between
groups
groups
groups
ininrates
in
rates
rates
ofofnew
of
new
new
nd
dand
additional
additional
additional
mineral/trace
mineral/trace
mineral/trace
element
element
elementdard
ABLE
4).
4).4).
nutrition;
nutrition;
mean
mean
mean
difference,
difference,
difference,
4.3;
4.3;4.3;
95%
95%
95%
CI,
CI,CI,infection
infection
infection
(T
(TABLE
(TABLE
upplementation
pplementation
supplementation
starting
starting
starting
2.2
2.22.2
days
days
days
afaf-af-nutrition;
Standard
Standard
care
care
care
patients
patients
patients
experienced
experienced
experienced
0.95
0.95
toto7.58;
7.58;
to 7.58;
P=.01)
P=.01)
P=.01)
was
waswas
detected
detected
detected
ininfafain fa- Standard
rter
study
study
study
parenteral
parenteral
parenteral
nutrition
nutrition
nutrition
initiainitiainitia-0.95
significantly
significantly
greater
greater
greater
muscle
muscle
muscle
wasting
wasting
wasting
vorvor
ofofpatients
of
patients
patients
receiving
receiving
receiving
early
early
early
parenparenparen-significantly
on
ntion
(95%
(95%
(95%
CI,
CI,CI,
2.1-2.3).
2.1-2.3).
2.1-2.3).
Of
Ofall
Of
allpatients
all
patients
patientsvor
(0.43
(0.43
vsvs0.27
0.27
vs 0.27
increase
increase
increase
ininSGA
SGA
in SGA
score
score
score
per
perper
teral
teral
nutrition;
nutrition;
nutrition;
however,
however,
however,
the
thethe
magnimagnimagni-(0.43
ocated
located
allocated
totoearly
early
to early
parenteral
parenteral
parenteral
nutrition,
nutrition,
nutrition,teral
Gordon S. Doig, JAMA 2013; 309: 2130-2138
Ernährungstherapie
Kontrollgruppe
29,2%
EN ab Tag 3 + PN abTag
5 bei 24%
27,3%
PN aber Tag 3
2,8%
EN + PN ab Tag 6
40,8%
erhielten NIE EN oder PN
Interventionsgruppe
100 %
PN innert 44 Minuten
nach Randomisierung
40,2%
EN während des IPSAufenthaltes
!55
Gordon S. Doig, JAMA 2013; 309: 2130-2138
Outcomes
Standard (n=680)
Tod vor Tag 60
Frühe PN (n=678)
p
155 (22.8)
146 (21.5)
0.6
9.3
8.6
0.6
100 (14.6)
81 (11.8)
0.15
Spitalaufenthalt (d)
24.7
25.4
0.5
Lebensqualität
45.5
49.8
0.01
-1.07
0.01
351
ns
IPS-Aufenthalt (d)
Tod vor IPSVerlegung
Beatmungstage
Infektionsrate
Gordon S. Doig, JAMA 2013; 309: 2130-2138
466
Conclusion
„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.“
Gordon S. Doig, JAMA 2013; 309: 2130-2138
:
!58
Table 4. (continued)
Parameter
Hospital mortality
Tertile I
Tertile II
Tertile III
ICU-acquired infections
Tertile I
Tertile II
Tertile III
Ventilator-associated pneumoniaa
Tertile I
Tertile II
Tertile III
Adjusted OR
95% CI
P Value
1.00
0.88
1.49
Reference
0.44–1.75
0.77–2.88
Reference
.72
.23
1.00
1.84
2.07
Reference
0.96–3.51
1.08–3.98
Reference
.07
.03
1.00
1.83
1.73
Reference
0.76–4.40
0.72–4.16
Reference
.18
.22
Kritikpunkte
ICU, intensive care unit; LOS, length of stay; CI, confidence interval; OR, odds ratio; BMI, body mass index; APACHE II, Acute
Physiology and Chronic Health Evaluation II score.
a
Outcomes included ICU mortality, hospital mortality, ICU-acquired infections, and ventilator-associated pneumonia rates. Multiple
logistic regressions were used, adjusting for APACHE II score, admission category, sex, mechanical ventilation, insulin therapy allocation, BMI, and ICU LOS for all patients, and for APACHE II score, sex, mechanical ventilation, insulin therapy allocation, BMI,
and ICU LOS for nonoperative and postoperative patients.
b
Restricted for mechanically ventilated patients.
Figure 1. The association among intensive care unit (ICU) mortality, hospital mortality, ICU-acquired infections, and ventilatorassociated pneumonia (VAP) rate and caloric intake/requirement.
Gruppen waren klar unterschiedlich krank (70% vs 90% Beatmete
Daten aus BZ-Studie: These: mehr Kalorien, mehr Actrapid, mehr Hypoglykämien,
mehr Todesfälle.
!59
Kritikpunkte
Herzchirurgische Patienten sind eher nicht kritisch krank (über 90% chirurgisch,
58,5% elektiv)
Die Hälfte aller Patienten war nach 48 Stunden bereits extubiert
Die Hälfte aller Patienten wurde am Tag 3 oder 4 verlegt (und hätten peroral
ernährt werden können)
Patienten mit BMI<17 kg/m2 waren ausgeschlossen (hätten aber am meisten
profitiert)
!60
Kritikpunkte
Die Patienten erhielten gemäss Studienprotokoll zwischen 30-34 kcal/kgKG/d
(Overfeeding): was als Ursache für die höhere Infektrate angesehen wird
Alle Patienten wurden einer tight glucose control unterzogen, ein Procedere,
welches bei der early PN Gruppe häufiger angewandt wurde und aufgrund der
Hypoglykämien als gefährlich gilt
Nur gerade bei 20% wurde in der späten PN Gruppe überhaupt noch mit einer PN
begonnen.
Die Patienten auf den Intensivstationen „all over the world“ entsprechen nicht den
in dieser Studie beobachteten. (Mortalität: 6.2%)
!61
Conclusion
Eine frühe parenterale Ernährung mit 20%igen
Glukoseinfusionen für die ersten 48 Stunden postoperativ nach
herzchirurgischen Eingriffen ist nicht mit Vorteilen für die
Patienten behaftet.
Kritikpunkte
Overfeeding: nicht-ernährungsbedingte Kalorienzufuhr nicht
berücksichtigt (Glukose/Propofol) ≈ 100-400 Kcal/d
erhöhte Morbidität
vermehrte Infekte
längere ICU-und Hospitalisationszeit
In beiden Gruppen ungenügende Proteinzufuhr (0,5-0,8g)
In der „post-hoc-Analyse“ war die Proteinmenge der am stärksten mit
dem Outcome verknüpfte Parameter
!63
Kritikpunkte
Indirekte Kaloriemetrie: wie zuverlässig
Keine Angaben zur Proteinmenge
Relativ tiefe Mortalität für IPS-Patienten: wie schwer krank?
!64
Kritikpunkte
Vergleich einer supplementierenden PN mit „alltäglicher“ Kontrollgruppe
(40% ohne irgendeine Ernährung)
!65
Übersicht
EPaNiC
TICACOS SWISS
Australia
IPS-Zeit
3.5d
12 d
> 5d
9.3d
Spital-Zeit
15 d
25 d
-
24.7 d
6.2 %
25.4 %
6 %
13.2 %
10.65 %
38.3 %
15.5 %
21.8 %
nein
Mortalität
Infekte
Beatmung
IPS-Mortal.
Spital-Mortal.
Benefit
!66
!
Zusammenfassung
1. Ernähren sie primär nasogastral
2. Bei Unverträglichkeitssymptomen:
nasoduodenal
3. Allenfalls SPN (mit/nach Kaloriemetrie)