This article was published on October 22, 2018, at NEJM.org.

Transcription

1 b E 8 b E C T aa 4 JG R d

2 This article was published on October 22, 2018, at NEJM.org.

3 (ESPEN) (ASPEN/SCCM) CCPG 20-25kcal/kg/day 25-30kcal/kg/day EN PN( ) Enteral Nutrition EN 24 ICU ICU Parenteral Nutrition PN EN 2 EN 7

4 ESPEN 2018 ASPEN/SCCM 2016 CCPG kcal/day 70% % 25-30kcal/kg/day ARDS,MV 72 trophic/full 80%or 20ml/kg/day(PN) EN PN( ) Underfeeding ARDS 5 trophic EN ICU 48 ICU ICU PN EN 1 EN +EN ICU EN 7-10 EN

5 EN PN 1 (2B) EN 1/4 or500kcal/day(2d) PN: (1A) (1B) (2C) 1 EN 20ml/h PN (2B)

6 EN

7 EN 2 1 EN (48 )PN Crit Nutr 2009;28: VS. EN 7 1 Hypocarolic enteral nutrition Crit Care Med 2009;37:

8 ESPEN vs. ASPEN/SCCM EPaNIC trial Design Randomised controlled, Prospective, Multicenter Patients ICU NRS Intervention/Control ICU 48 PN (Early-initiation ) ICU 7 PN (Late-initiation ) Outcome Primary:ICU Secondary: ICU

9 ICU Late-Initiation Late-Ini,a,on

10 EPaNIC trial overfeeding PN 2018/1/23 JC

11 AmJ Clin Nutr 2011;93: Design X factorial, Randomised controlled Patients mmol/L(110mg/dl) ICU 240 Intervention/Control 60%-70%(permissive underfeeding ) % 90%-100%(target feeding ) % mmol/L IIT mmol/L(CIT ) 4 (PU+IIT,PU+CIT,TG+IIT,TG+CIT) Outcome Primary 28 Secondary:ICU 180

12 Permissive underfeeding Primary outcome

13 90-100% Underfeeding(60%-70%) 60%-70%(permissive underfeeding ) % 90%-100%(target feeding ) %

14 Design Randomised, open-lavel, Multiple-center Patients ALI Intervention/Control 400 kcal/ 25% 6 (Trophic-feeding ) 25kcal/kg/ 1300 kcal/ 80%(Full-feeding ) Outcome Primary:28 (VFDs) Secondary 60 ICU free

15 VFD 60 ICU free

16 EDEN trial Trophic feeding (400kcal/ ) Full feeding ( 80%) 80%

17 Lancet 2013;381: SPN(supplemental PN) trial Design Two-center, Randomised controlled Patients ICU 3 60% Intervention/Control 20-30ml/h EN 3 SPN 4 PN 28 kcal/kg/day EN EN (20 kcal/kg/day) Outcome Primary:8 28

18 SPN

19 SPN trial 3 overfeeding 4 underfeeding

20 PermiT trial N Engl J Med 2015;372: Design Randomised controlled, pragmatic, seven-center, unblined Patients ICU 48 Intervention/Control 40-60%(Permissive under feeding ) 46% (Standard Enteral feeding ) 71% ( g/kg/day) Outcome Primary:90 Secondary SOFA score ICU free K

21 90 ICU Permissive underfeeding

22 PermiT trial EDEN EN

23 Nutr Hosp2017;39(1):19-29 RCT Meta-analysis ICU EN Underfeeding Full feeding MEDLINE EMBASE SCOPUS CENTRAL Underfeeding (16-72%) Full feeding (71-93%) 60 ICU Underfeeding 2 moderate feeding(46%-72%) trophic feeding(16%-25%)

24 Trophic feeding Moderate feeding Full-feeding Underfeeding ICU

25 Design Patient Interventions Permissive Underfeeding IIT 2 2,RCT BS 110mg/dl ICU EN 240 Under feeding 60~70% EDEN SPN Permi T Open label RCT ALI 48h 1000 Trophic feeding 400kcal/day or 25% Two-center RCT ICU3 ENkcal 60% 153 SPN 4 PN Unblined RCT ICU 48h EN 894 Under feeding 40~60% Control Full feeding 90~100% Full feeding 25kcal/kg/day EN EN Standard feeding 70 ~100% Outcome Underfeeding free 60 ICU free SPN 90 UF Problem Limitation, Full feeding (80%),,

26 Problem Limitation Permissive Underfeeding IIT, EDEN SPN Permi T Full feeding (80%),, limitation Moderate feeding full feeding outcome Pilot study

27 Design Randomised controled, prospective, multicenter, double-blined, parallel-group Patients 2 EN ICU 112 Intervention/Control 1.5kcal/ml EN 1.0kcal/ml EN 1ml/kg(IBW)/h 10 max100ml/h Outcome Primary:EN (kcal/day) Secondary (EN+PN+ ) EN /IBW ICU

28 56 7 APACHE 23 nonoperative DM 23% BMI 27 IBW 67kg 1900kcal/day ( )

29 1.5kcal/ml EN total 1.0kcal/ml

30 A:ENkcal/day B:ENkcal/kg/day C:ENkcal/day- kcal D:EN+PN+glu ivkcal/day,en /kg/day 1.5kcal/ml 1.5kcal vs 1.0kcal EN 1832kcal vs 1259kca EN /kg/day: vs kcal 1.5kcal 89%

31 ICU ICU kcal/ml

32 Pilot study 1.5kcal/ml EN 1.0kcal/ml EN 50% Survival and functional outcome

33 N

34 PICO P I C O ICU 18 Energy-dense(1.5kcal/ml) 1ml/kg(IBW)/h Routine(1.okcal/ml) 1ml/kg(IBW)/h 90

35 Methods Trial design 46 ICU ANZIC(Australian and New Zealand Intensive Care Society)

36 Methods Trial design NPO Fresenius Kabi Deutschland Fresenius Kabi Deutschland Monash

37 Methods Patient population Patient Inclusion 1. ICU ICU 48

38 Methods Patient population Exclusion criteria ml/kg(IBW)/h EN ( ) TARGET study

39 Figure S1 ( ) routine nutrition or

40 Method nutrition Energy dense group 1.5kcal/ml Fresubin Energy Fiber Tube Feed Routine group 1.0kcal/ml Fresubin 1000 Complete Tube Feed IBW ( cm-152.4)kg IBW ( cm-152.4)kg Energy-dense routine permuted block randomization Web-based randomization system 24

41 Energy-dense Routine Calorie 1.5kcal/ml 1kcal/ml Fat 58g/L 27g/L Carbohydrate 180g/L 125g/L Protein 56g/L 55g/L Fiber 15g/L 20g/L Salt 2.5g/L 3.8g/L Water 78ml/100ml 83ml/100ml

42 Double blind

43 1ml/kg(IBW)/h 48 EN Overfeeding 100ml/h EN 180mg/dl

44 28 ICU EN 28 ICU EN

45 Methods outcome Primary Outcome 90 Secondary Outcome (90 ) ICU-free hospital-free 28 28

46 Primary Outcome 7 ( 65 or <65 ) ( sepsis vs. ) Australian and Newzealand Risk of Death Score 5 (ANZICS CORE) Body mass index(< )

47 Methods Statistical analysis TARGET TARGET ANZICS CORE % 80% %

48 O Brien-Fleming P modified intention-to-treat(itt) Per-protocol as-treated primary secondary 2 (Hodges-Lehman ) 95 t Wilcoxon

49 90 95% Log-binominal ( ) ü üicu APACHE SCORE übmi ü (Austraria or New Zealand) ü üicu ( ) 28

50 Log-binomial Modified poisson 90 Log-rank Kaplan-Meier 95% Cox ICU SPSS (Version22 ) Stata (Verision15.1)

51 Result

52

53

54 kg IBW 64kg BMI 29 ICU 7 7% APACHE score 22 ICU 14

55 line 1.5kcal EN1 (kcal/day) 1 IBW

56

57 65% 1.5kcal 103% 27% 1.0kcal 69% 18%

58 Primary Outcome Secondary Outcome

59 90 28 Per-protocol

60 90

61 Sub group Quintile for risk of death BMI 90

62 Discussion

63 RCT open-label RCT meta outcome 25-30kcal/kg/day

64 Outcome 1. BMI 2% BMI /3 BMI30 (11-14kcal/kg/day) hypocaloric eucaloric

65 1.5kcal 50% 1.5kcal overfeeding IBW (IBW:29.1kcal/kg/day ABW:23.1kcal/kg/day) Overfeeding

66 Limitation 1. 2.

67 3. EN ICU 24 EN 4 1.5kcal systematic 5

68 Conclusion

69 1.5kcal/ml (30kcal/kg/day) 1.0kcal/ml (20kcal/kg/day) BMI 1g/kg/day EN(+PN)

70 RCT BMI30 ICU 23 Refeeding Refeeding Clinical Nutrition xxx (2018) 1e32 Lancet Respir Med 2015;3: JC Outcome QOL ADL ADL