2019 ESPEN
1) Who should be considered for medical nutrition therapy?
Medical nutrition therapy shall be considered for all patients staying in the ICU, mainly for more than 48 h.
중증 환자의 기아 기간(duration of starvation)이 임상 결과에 대한 영향을 직접적으로 다루는 연구는 윤리적인 문제로 없다.
이전 권고사항대로 초기 영양 시작과 초기 EN 시작의 금기의 cut off는 48시간이다. (acute phase/early period에서의 영양 재개는 삼가한다.)
한 연구에서 영양 실조가 상태가 아닌 ICU 환자에서 PN을 지연에 대한 가능한 편익을 보여주었다.
뿐만 아니라 risk of refeeding syndrome 환자군에서는 careful and progressive re-introduction of nutrition을 한다.
2) When should nutrition therapy be initiated and which route should be used?
If oral intake is not possible, early EN (within 48 h) in critically ill adult patients should be performed/initiated rather than delaying EN.
If oral intake is not possible, early EN (within 48 h) shall be performed/initiated in critically ill adult patients rather than early PN.
In case of contraindications to oral and EN, PN should be implemented within three to seven days.
Early and progressive PN can be provided instead of no nutrition in case of contraindications for EN in severely malnourished patients.
To avoid overfeeding, early full EN and PN shall not be used in critically ill patients but shall be prescribed within three to seven days.
ICU 내원 첫 48시간이내(early phase) EN vs no nutrition, and EN vs PN에 대한 메타 분석이 있다. 하지만 후기(later time periods; days three to seven and beyond the first week) 기간에서의 영양에 대한 연구는 없다.
When comparing early EN vs early PN (including six studies in ICU patients and seven studies with also non-ICU patients included) our results showed a reduction of infectious complications with EN (RR 0.50, CI 0.37, 0.67, p = 0.005), as well as shorter ICU (RR -0.73, CI -1.30, 0.16, p = 0.01) and hospital stay (RR -1.23, CI -2.02, 0.45, p = 0.002; see Fig. 3 and Meta-analysis II in Supplemental Materials), whereas mortality was not different.
However, based on expert consensus, when a patient is determined to be at high nutrition risk (e.g., NRS 2002 ≥ 5) or severely malnourished, and EN is not feasible, the initiation of low-dose PN should be carefully considered and balanced against the risks of overfeeding and refeeding, which may outweigh the expected benefits.
종합하면, 영양 시작 시기, 경로 및 칼로리/단백질 목표는 더 이상 각각의 문제로 고려되지 않고 모든 측면을 고려한 보다 포괄적인 접근법으로 통합되어야 한다. 시작 시기와 경로를 정한 후, 에너지/단백질 목표량을 처음 48시간 이후에 점진적으로 증량하며 과잉(over-nutrition)을 주의한다. (e, the energy/protein goal should be achieved progressively and not before the first 48 h to avoid over-nutrition)
Full targeted medical nutrition therapy is considered to achieve more than 70% of the resting energy expenditure (REE), but not more than 100%.
3) When should we apply/implement supplemental PN?
In patients who do not tolerate full dose EN during the first week in the ICU, the safety and benefits of initiating PN should be weighed on a case-by-case basis.
PN should not be started until all strategies to maximize EN tolerance have been attempted.
ICU 내원 후 3일 이내 EN이 제공하는 칼로리가 에너지 요구량의 60% 미만일 때 최대 100%에 도달할 수 있도록 partial PN(supplementary PN)을 시작해야 한다. 2009 ESPNE 가이드라인에서는 입원 후 3일 이내 에너지 요구를 EN으로 충당하지 않은 중증 환자에서 supplemental PN을 시작해야 한다.
supplemental PN의 단점: Casaer et al. observed that early (supplemental or exclusive) PN is associated with increased morbidity including prolonged ICU dependency and mechanical ventilation, and increased infection rate and need for renal replacement therapy.
The optimal time point for supplemental PN aiming to achieve full caloric needs is not clear, but is suggested to be between days four and seven.
4) When should we apply/implement supplemental PN?
In patients who do not tolerate full dose EN during the first week in the ICU, the safety and benefits of initiating PN should be weighed on a case-by-case basis.
PN should not be started until all strategies to maximize EN tolerance have been attempted.
ASPEN/SCCM에서는 “patients with either a low or high nutritional risk, the use of supplemental PN should be considered only after seven to ten days if they are unable to meet >60% of energy and protein requirements by the enteral route alone“를 권고하고 있다.
이 권고안에 대해 ICU 입원 후 7-10일 전에 EN + supplemental PN을 개시하는 것이 임상 결과를 개선하지 못하며 심지어 해로운 결과를 초래할 수 있다는 평가에 기초한다. 특히, 우리는 8일차 이후 늦은 PN을 시작하거나 4일차부터 7일차까지의 늦은 PN 시작과 8일차부터 10일차까지의 효과를 비교하는 어떠한 연구도 알지 못한다.
It was suggested that early observations of increased infectious morbidity may have been related to the calorie load (overfeeding) more than being a consequence of the administration of supplemental PN.
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