aspen栄養ガイドライン - jseptic ｜特定非営利活 … system rctは減点方式...

ASPEN栄養ガイドライン 2016

東京慈恵会医科大学附属葛飾医療センター福島東浩

2016年4⽉12⽇

Crit Care Med. 2016 Feb;44(2):390-438. PMID: 26771786.

日集中医誌 J Jpn Soc Intensive Care Med 2016;23:185-281.

参考

GRADE system

RCTは減点方式

観察研究は加点方式

High

Low

High

Very Low

Moderate

Low

Very Low

Low

研究の質に応じて減点

研究の質に応じて加点

RCT, 観察研究がない場合はエキスパートによる見解

Definition

•  EN: Enteral Nutrition 経腸栄養

•  PN: Parenteral Nutrition 経静脈栄養

•  STD: Standard Therapy

•  IC: Indirect calorimetry 間接熱量測定法

•  REE: Resting energy expenditure 安静時エネルギー消費量

•  RQ: respiratory quotient 呼吸商

•  GRV: gastric residual volume 胃内残量

•  ALI: acute lung injury

•  MV: mechanical ventilation

INTRODUCTION

Introduction

Traditionally

Provide Exogenous Fuel

Preserve Lean Body

Nutrition Support

Introduction

Recently

Prevent oxidative cellular injury

Attenuate metabolic response to stress

Modulate immune response

Nutrition Therapy

　栄養評価

A. NUTRITION ASSESSMENT

A1. 栄養摂取が不十分な症例では栄養リスクを測定

A3b. 間接熱量測定法ができない場合、体重を基にした計算式を使用　25-30 kcal/kg/day

A3a. 間接熱量測定法を推奨


Nutritional Risk Score

[NRS -2002]

NUTRIC score

Nutritional Risk Score [NRS -2002]栄養状態の重症度疾患の重症度(≈ストレスによる代謝)

Absent Score 0 Normal nutritional status Absent

Score 0 Normal nutritional status

Mild Score 1

3か月の体重減少 >5% Mild Score 1

股関節骨折摂食量が平常の50–75%,１週間継続急性期を要する慢性疾患: 肝硬変

COPD

Moderate Score 2

2か月の体重減少 >5% Moderate Score 2

慢性維持透析, 糖尿病, 悪性腫瘍

BMI 18.5 – 20.5 impaired general condition 腹部手術, 脳卒中

摂食量が平常の50–75%, １週間継続重症肺炎, 悪性血液疾患

Severe Score 3

1か月の体重減少 >5% (3か月の体重減少≈>15%)

Severe Score 3

頭部外傷

骨髄移植 BMI <18.5 impaired general condition

集中治療患者 (APACHE 10 摂食量が平常の0-25%, １週間継続

Calculate the total score: 1. Find score (0–3) for Impaired nutritional status (only one: choose the variable with highest score) and Severity of disease (≈stress metabolism, i.e. increase in nutritional requirements). 2. Add the two scores (→ total score) 3. If age ≥70 years: add 1 to the total score to correct for frailty of elderly 4. If age-corrected total ≥3: start nutritional support

AdHocESPENWorkingGroup.ClinNutr2003;22:321–336

Nutritional Risk Score [NRS -2002] 過去のRCTからNRS, 栄養投与開始, 予後(length of stay, infection, mortalityなど), の関係を検証 Clin Nutr 2003; 22:321–336

栄養投与のcut off値

EN ≥3 PN ≥3.5

で予後が良好であった

PosiDveeffect

Noeffect

P=0.0006

NRS<3 NRS≥3

NUTRIC score (原法)

HeylandDK,CritCare2011;15:R268

variable range pointsAge <50 0

50≤,<75 1≥75 2

APACHEII <15 015≤,<20 120≤,<28 2≥28 3

SOFA <6 06≤,<10 1≥10 2

Co-morbidiDes 0-1 0≥2 1

DaysfromhospitaltoICUadmission

0≤,<1 0≥1 1

IL-6 0<,<400 0≥400 1

NUTRICscore―○0-5,---+6-10

100% calories

25% calories

Probability 28-days mortality

Score >=6 目標カロリーに近づくほど予測死亡率が低下

---6-10

―0-5

Revised NUTRIC Risk score

NUTRIC原法からIL-6を除外

目標カロリーに近づくほど予測死亡率が低下 Score >=6でより顕著

Probability 28-days mortality

ーO 0-5

ー+ 6-9

100% Target calories

25% Target calories

ClinNutr.2016Feb;35(1):158-62.

variable range points

Age <50 0

50≤,<75 1

≥75 2

APACHEII <15 0

15≤,<20 1

20≤,<28 2

≥28 3

SOFA <6 0

6≤,<10 1

≥10 2Co-morbidiDes 0-1 0

≥2 1

DaysfromhospitaltoICUadmission

0≤,<1 0≥1 1

IL-6 0<,<400 0≥400 1


Indirect Calorimeter 間接熱量測定法

計算式による熱量の算出


呼気中の酸素・二酸化炭素濃度や体積,尿中窒素排泄量を基に必要熱量を算出呼気ガス分析装置を使用 (詳細は清書を参照)

ミナト医科エアロモニタ　AE-310sCOSMED　fitmateGSTM



•  大掛かりな機器が必要(施設が制限される)

•  重症患者では様々な要因から計測精度が低下

NutrClinPract2014;29:44–55


A. NUTRITION ASSESSMENT J Am Diet Assoc. 2007 Mar;107(3):393-401 ７つのREE予測計算式とICで算出した熱量を比較 Retrospective cohort, 395patients,

どの式も精度は低く,様々な影響(重症度,薬剤,呼吸器など)の影響を受けやすい

簡便さから

ACCPの式[BW(kg) x 25 kcal/day]が有用

計算式による熱量の算出


A4. たんぱく質投与量：1.2-2.0 g/kg/day, 実測体重

A2. 伝統的な栄養の代替マーカー albumin, prealbumin, transferrin,retinol-binding protein

は栄養評価として使用しない

日本版重症患者の栄養療法ガイドライン

エネルギー消費量とエネルギー投与量

間接熱量計での測定結果，もしくは推算式による算出に基づいて設定することを強く推奨する(1D)

栄養状態の評価栄養療法開始前にスクリーニングによる栄養障害やリスクを同定するべきだが，信頼性の⾼い評価指標がない。(1D)

病歴や⼊院前の⾷事摂取や栄養状態，体重変化，併存疾患や合併症，理学所⾒，重症度(APACHEⅡスコアやSOFAスコア)，消化管機能などを総合的に評価する必要がある


　初期経腸栄養

B. INITIATE EN

24-48時間以内に開始

経口摂取ができない場合

経腸栄養を優先

B. INITIATE EN

EN vs. PN

Favors EN Favors PN

OR:0.56[0.39,0.79]

Infection

B2. 経静脈栄養PNより経腸栄養ENを優先 ↓

感染リスクが軽減


栄養投与ルート経腸栄養を優先することを強く推奨する(1A)

Ø  死亡率, 感染症発⽣率についてガイドライン作成委員会がそれぞれについてメタ解析を⾏った

–  死亡率については36編のRCTを対象とし, EN群とPN群とで死亡率に有意差を認めなかった [RR 1.03; 0.93-1.14，P =0.86]

–  感染症発⽣率について33編のRCTに対象とし, EN群で有意に低率だった[RR 0.66; 0.56-0.78，P＜0.0001]


B. INITIATE EN Mortality

OR:0.70[0.49,1.00]

本文より

Intensive Care Med 2009; 35:2018–2027

OR:0.34[0.14,0.85]

Favours Early Favours Late


Early EN vs. Late EN

早期経腸栄養死亡リスクが低い

B. INITIATE EN

OR:0.31[0.12,0.78]

本文 fig2

Intensive Care Med 2009; 35:2018–2027

Infection

OR:0.74[0.58,0.93]



Early EN vs. Late EN

早期経腸栄養感染リスクが低い

B. INITIATE EN

B4a. 誤嚥リスク, 腸管不耐性を認める場合胃腸下部への投与を推奨

B4b. 多くの重症患者の場合胃内への投与で大丈夫

B. INITIATE EN Jejunal tube

Tiger 2™, Cook

トゲ状

蠕動運動で自然に十二指腸へ進む(猫じゃらしの原理)

日本では未発売(2016年４月現在)

B. INITIATE EN Gastric vs. small bowel feedings, nutritional efficiency

Gastric vs. small bowel feedings, pneumonia.

OR: 11.06 [5.82, 16.30]

OR: 0.75 [5.82, 16.30]

Favours Gastric Favours small bowel

Favours small bowel Favours Gastric

Jejunal tubeの方が経腸栄養成功しやすい

Jejunal tubeの方が肺炎リスクが低い

本文より

本文より


十二指腸以遠の経腸栄養チューブ

内視鏡ないし造影下にて⾏う⼗⼆指腸以遠への栄養チューブ挿⼊はどちらも有効であり，各施設で慣れた⽅法で⾏うことを弱く推奨する Ø  造影下，もしくは内視鏡下での挿⼊。90%以上の⾼い成功率

Chest 1991;100:1643-6. Surg Endosc 1996;10:680-3.

盲⽬的に⾏う場合は空気を注⼊する⽅法を弱く推奨する胃蠕動が低下している症例では胃蠕動促進薬の使⽤を弱く推奨するØ  胃蠕動薬(エリスロマイシンやメトクロプラミド)は成功率を⾼める

[OR 2.26, 1.140,4.490，P＝0.02]Ø  空気注⼊する⽅法も成功率を⾼める[OR 3.46, 1.63,7.346，P＝0.001]

JPEN J Parenter Enteral Nutr 2015;39:521-30.

Ø  2％が気管内迷⼊し，1.2％の気胸が⽣じ，0.5％で死亡例JPEN J Parenter Enteral Nutr 2007;31:269-73.


疾患ごとの推奨

Initiate EN

Hemodynamic compromise or instability* (B) Should be withhold

Trauma Traumatic Brain Injury (M) Immediate [≤24-48hr]

Burn (M) Very early [≤4-6hr]

Sepsis (N) As soon as resuscitation is complete [≤24-48hr]

Postoperative major surgery (O) ≤24hr, when feasible

Obesity (Q) Early [24-48hr]

*hypotensive (MAP < 50 mm Hg), in patients for whom catecholamine agents are being initiated, or in patients for whom escalating doses are required to maintain hemodynamic stability.

L.ACUTEPANCREATITIS Mild Moderate - Severe

評価常に腸管不耐性を考慮しながら栄養の投与方法を検討

経路 Oral intake Naso-/oroenteric tube

種類時期投与量

• 特別食はいらない •  Clear liquidの必要なし •  7日以内に経口摂取できない

場合、特別食を検討

• 半消化態栄養剤 standard polymeric formula

•  Probioticsの使用を考慮 • 早期[24-48hr]から開始

•  Trophic rate

不耐性評価/対処

• 疼痛・嘔気・嘔吐がない • 膵酵素が正常

• 改善するような方法をとる Ø  単回から持続投与へ Ø  Feeding tubeの位置変える Ø  栄養剤の種類を変えるなど

•  経腸栄養が不適切な場合、１週間後にPN開始

半消化態栄養剤:ハイネ®(大塚製薬工場),ラコール®(大塚製薬工場),テルミール®(テルモ), エンシュア®(アボットジャパン),メイバランス®(明治)など

L.ACUTEPANCREATITIS

Hospital length of stay

Mean Difference -2.62 [-3.38, -1.186]

Sathiaraj et al. Aliment Pharmacol Ther. 2008 Sep 15;28(6):777-81. Single center, RCT 101 patients, mild acute pancreatitis, Clear liquid diet (CLD) vs. low fat soft diet (SD)

摂食中止に有意差なし (pain; p=0.85, nausea; p=0.12),　 SD群で初日の摂取熱量が有意に高い (137 vs. 262 kcal, p<0.0001)

Length of stay CLD SD p

Rajkumar 2013 6.9 4.2 <.0001

Sathiaraj 2008 6 4 <.0001Rajkumar.NutrClinPract.2013Jun;28(3):365-70.Sathiaraj.AlimentPharmacolTher.2008Sep15;28(6):777-81.

Mild pancreatitis

CLD: Clear liquid diet vs. SD: low fat soft diet

L.ACUTEPANCREATITIS

World J Surg. 2013;37:2053-60.

Single center prospective pilot trial

60 patients, Nasojejunal tube,

15-20 mL/kg/hr

Early EN (<48h)

vs. Late EN (≥day8)

Early EN, n=97

Late EN, n=100

p

Hospital stay 18.0days 18.5days 0.459

Infected necrosis 4.1% 18.0%0.002

Sepsis 2.1% 4.0%0.498

Mortality 0% 9%0.007

Early EN, n=30

Late EN, n=30

p

ICU stay 9days 12days 0.033

Pancreatic infection 10% 33%0.024

Mortality 7% 3%0.028

Pancreas. 2013 May;42:640-6.

Single center, Retrospective cohort,

197Patients, Nasojejunal tube

Early EN(≤48hr)

vs. Late EN(>48hr)

早期経腸栄養群の方が感染性膵壊死頻度低下,死亡頻度低下など予後がよい傾向

Moderate to Severe pancreatitis

L.ACUTEPANCREATITIS

Question:

Which is the most appropriate formula to use when initiating early EN in the patient with moderate to severe acute pancreatitis?

L2. We suggest using a standard polymeric formula to initiate EN in the

patient with severe acute pancreatitis. Although promising, the data are currently insufficient to recommend placing a patient with severe acute pancreatitis on an immune-enhancing formulation at this time. [Quality of Evidence: Very Low]

半消化態栄養剤:ハイネ®(大塚製薬工場),ラコール®(大塚製薬工場),テルミール®(テルモ),エンシュア®(アボットジャパン),メイバランス®(明治)など

SeverepancreaDDs半消化態栄養剤を使用

L.ACUTEPANCREATITIS

Mortality

InfecDon

Risk Ratio 2.17 [1.13, 4.17]

Risk Ratio 2.45 [1.61, 3.74]

Favors PN Favors jejunal EN

Favors PN Favors jejunal EN

ENの方が死亡リスク低い

ENの方が感染リスク低い

L3a. 経静脈栄養より経腸栄養を推奨

PN vs. jejunal EN

ただし循環や腸管不耐性の評価は常に行う本文より

本文より

L.ACUTEPANCREATITISCrit Care. 2013 Jun 20;17(3):R118. Meta-analysis, 3RCT, 157patients,

Naso-gastric vs. Naso-jejunal

Mortality

N-G, n=82 N-J, n=75 p感染性膵壊死 16 23 0.28

MOF 14 18 0.11

RR 0.69 [0.37, 1.29]

重症急性膵炎死亡リスク感染性膵壊死、多臓器不全の頻度

N-G, N-Jで変わらない

重症急性膵炎の予後は

胃内投与と十二指腸内投与で変わらない

L.ACUTEPANCREATITIS

L4.ModeratetoSeverepancreaDDs腸管不耐性を認めた場合, 改善させる方法をとること[feedingtubeの位置を変える,fat-freeに近い素材にする,単回から持続投与にする,など]

　経腸栄養投与量

C. DOSING OF EN

C2. ARDS, MV≥72hrの症例, trophic/fullどちらも適当

C1. 栄養リスクが低い時, 初めの１週間は特別な栄養投与は必要ない

C3. 栄養リスク高い症例, 重度低栄養症例

経腸栄養EN投与を早急に開始

24-48時間refeeding syndromeに注意入院初期の１週間は48-72時間で目標熱量の80%

C. DOSING OF ENThe EDEN trial PermiT Trial.

JAMA 2012;307:795–803. NEJM 2015;372:2398-408.

Setting/Design open-label, RCT, 44 ICU RCT, 7ICU

PatientsALI onset ≤48hr, MV received ≤72hr Pneumonia 65%, Sepsis 15%

ICU stay≥72hr, severe sepsis 30% MV 97%

APACHE APACHE III 90 APACHE II 20

N 1000 894

Study days Day 1-6 Day 1-14

Intervention Trophic 10-20kcal/kg/d Permissive underfeeding 40-60%

Full Energy 25-30kcal/kg/d Protein 1.2-1.6g/kg/d

STD feeding 70-100%

Caloric intake [% of target]

Trophic 400kcal [25%] Permissive 835kcal [46%]

Full 1300kcal [80%] STD 1299kcal [71%]

Result 死亡率, MV期間, 感染症予後に有意差なし

死亡率, 感染症予後に有意差なし

C. DOSING OF EN

たんぱく質投与量：1.2-2.0 g/kg/day, 実測体重

Clin Nutr. 2012 Aug;31(4):462-8. Setting/Methods: Prospective cohort study, 113 tertiary hospital ICU Patients: Severe sepsis 約90%, Burn 約10%, APACHE II 22

C. DOSING OF EN

Low Median High

Protein, g/kg/d 0.79 1.06 1.46

Energy, kcal/kg/d 21.7 24.7 27.2

Length of stay ICU 5days 10days 10days

ICU mortality 27% 24% 16%

JPEN J Parenter Enteral Nutr. 2012;36:60-68 Setting/Methods: Prospective cohort study Patients: 230/886 patients, surgical 20%, sepsis 15%, respiratory 20%, APACHE II 23

Protein, g/kg/d 0.83±0.23 1.06±0.14 1.21±0.15 1.31±0.18

Energy, kcal/kg/d 808±379 1094±436 876±433 1266±545

Length of MV 16.4±16.6 25.4±17.9 27.1±24.3 28.3±17.0

Length of stay ICU 18.8±18.0 28.0±18.3 28.8±24.5 31.7±19.6

28d mortality 20.4% 19.5% 12.5% 14.7%

1.2–1.5 g/kg/d の方が

0.8-1.0 kg/kg/dより予後が良い

1.5–2.0 g/kg/d では

予後は変わらないとの報告もある Nutrition. 2003 Nov-Dec;19:909-16.

たんぱく質投与量


エネルギー消費量とエネルギー投与量

間接熱量計での測定結果，もしくは推算式による算出に基づいて設定することを強く推奨する(1D)

経腸栄養の⽬標投与エネルギー量

重症化以前に栄養障害がない症例では，初期の1週間は消費エネルギーに⾒合うエネルギー投与量を⽬指さないことを弱く推奨する(2D)

Ø 重症化以前に栄養障害がある症例では，⾄適投与量は不明である。しかし，エネルギー負債が⼤きくなり過ぎない程度の投与量は必要である。



たんぱく質投与量⾄適蛋⽩投与量は不明である(unknown field).

エネルギー投与量が⽬標量に達している場合は,

1.2-2.0 g/kg(実測体重)/day の蛋⽩が喪失していることを考慮したうえで, 蛋⽩投与量を設定することを弱く推奨する.(1C)


疾患ごとの推奨栄養投与量

Energy [kcal/kg/day]

Protein [g/kg/day]

J. RENAL FAIRURE

AKI 25-30 1.2-2.0

CRRT 2.5たんぱく質制限しないできるだけ早急に投与

K. HEPTIC FAILURE たんぱく質制限しない

M. SURGICAL SUBSET

Trauma 1.2-2.0

Traumatic Brain Injury

25 1.5-2.5

BURN ICでの計測を推奨

N. SEPSIS10-20 kcal/hr 500 kcal/day

1.2-2.0

Q. OBESITY

BMI 30-50 11-14 [actual body] All classes of obesity IC 65-70% high-protein hypocaloric feeding

BMI 30-40 2.0 [actual body]

BMI >40 2.5 [actual body]

BMI >50 22-25 [ideal body] I. PULMONARY FAILURE 水分制限・熱量濃縮栄養剤を使用

　腸管不耐性と適正な経腸栄養

D. MONITORING TOLERANCE AND ADEQUACY OF EN

腸管不耐性GIintolerance

嘔吐 vomiDng 腸管拡張 abdomonaldistenDon

不快感 complaintsofdiscomfort 排液量過多 highNGoutput

胃内残量過多 highGRV 下痢 diarrhea

腸管運動減弱・排便減少 reducedpassageofflatusandstool

腹部X線所見の異常 abnormalabdominalradiographs


誤嚥リスク Risk for Aspiration

気道確保できない inability to protect the airway 　70歳以上 age over 70 years

経鼻からの腸管栄養 nasoenteric enteral device 　人工呼吸器管理 MV

意識低下 reduced level of consciousness 　不十分な口腔ケア poor oral care

仰臥位 supine position 　胃食道逆流 gastroesophageal reflex

神経障害 Neurologic deficit 　EN 間欠的投与 intermittent EN

不適切な看護比 inadequate nurse/patient ratio 　ICU外への転送 transport out of the ICU


D1. 無駄な絶飲食は避ける。絶飲食は低限に。


D2a. 胃内残量をルーティンに計測する必要はない D2b. 不耐性の所見がなく胃内残量<500mLの場合,

経腸栄養をやめるべきではない

NUTRIREA1 trial. JAMA. 2013 Jan 16;309(3):249-56 胃内残量の測定とVAP発生頻度を検証 Setting/Methods: Multicenter, France, 9 ICU, open label RCT Patients: ALI, MV 2days and more, 452 patients,

HR 1.06 (90% CI, 0.72-1.55; P = .80)

IntervenHonvsControl

VAP発生頻度

Intolerance monitor: Intervention; Record Vomiting Control; GRV >250mL, measure every 6hr

Intervention Control p

Vomiting 39.6% 27.0% 0.003

Intolerance 39.6% 63.5%


胃内残量の測定と嘔吐記録, VAP発⽣頻度変わらない

JPEN J Parenter Enteral Nutr 2002; 26:174–181 Early: 入室時から必要栄養量, Late: ４日目まで20%, ５日目から必要栄養量, 自然滴下 Begun: 60mL/4hour, 3 feeds → 120mL /4hours, 3feeds → Increase 60 mL every 3feeds残渣150mL以上の時は半減

急激な投与は肺炎リスク上げる


J Trauma. 2007 Jul;63(1):57-61. Design/Setting: Prospective RCT, trauma ICU Patients/Intervention: 164 trauma patients, MV >48hr, intermitted vs. continuous EN

持続投与の方が生存率高い

Early Late pVAP 49.3% 30.7% .020ICU stay, days 13.6 9.8 .043抗菌薬投与, days 12.4 7.5 <.001


RR 0.59 [0.43, 0.81]

Infection

Favors protocol Favors control

D3a. ENはプロトコールの基に施行 D3b. 容量を基, またはトップダウンの多角的戦力をもったプロトコールを

用いる

本文より


D4. 経腸栄養投与中は

誤嚥リスクを評価し, 誤嚥リスクを減らす方法をとるべき

D4a. 誤嚥ハイリスク症例では幽門部より以遠へのチューブ留置 D4b. 誤嚥ハイリスク症例では持続投与(間欠投与の中止)

D4d. VAP予防: 頭部挙上 30-45º

クロルヘキシジン口腔洗浄　１日２回

D4c. メトクロプラミド,エリスロマイシンの使用により

胃内残量は少なくなる

D. MONITORING TOLERANCE AND ADEQUACY OF ENWangL,eta.CochraneDatabaseSystRev.2016Jan8;1:CD009946.PMID:26743945.

RiskRaHo [95%CI] p

VAP 0.36 [0.25,0.50] <.00001Favorsemirecumbent Favorsupine

Semirecumbent position (30˚-60˚) vs. supine position (0˚-10˚)

45˚ vs. 25˚- 30˚

Favor25-30˚Favor45˚Risk Ratio [95% CI] p

VAP 0.74 [0.35, 1.56] .43

頭位30˚-60˚の方が VAPリスクが低い

25˚-30˚ vs. 45˚ VAPリスクは変わらない

Ventilator associated pneumonia: VAP


D6. 下痢を認めたからといって自動的に経腸栄養への介入は必要ない。しかし, 適切な評価/治療決定は行う

D5. 誤嚥マーカーのための食物の着色は必要ない


経腸栄養耐性の評価方法 Ø  患者の経腸栄養に対する耐性として，疼痛や腹部膨満感の訴え, 理

学所⾒，排ガス・排便，腹部X 線写真などをモニタリングする。

Ø  経腸栄養の不適切な中⽌を避ける。

Ø  不耐性を⽰す他の徴候がない場合，随時確認した胃内残量＜500mLであれば経腸栄養を中断しない。

Ø  不適切な栄養投与や⿇痺性イレウスの⻑期化を防ぐために，診断や処置に伴う絶⾷期間を最⼩限にとどめる。

以上のことをすべて弱く推奨する（2C）


　栄養成分/補助栄養

E. SELECTION OF APPROPRIATE ENTERAL FORMULATION

E1. 標準的な半消化態栄養剤等張栄養剤 (1 - 1.5 kcal/mL) を推奨

特別な栄養はルーティーンに使用しない

Disease specific (Diabetes, pancreatitis[L])

Organ specific (Pulmonary[E3,I], Renal[J], hepatic[K])

Immune-modulating (excluding postoperative patient[E2,O,M])

Antioxidants

主な補助栄養

免疫調節栄養(Immune-modulating formula): ω3-fatty acid, EPA, DHA, glutamine

抗酸化物質(Antioxidants): selenium, zinc, vitamin C, vitamin E

半消化態栄養剤:ハイネ®(大塚製薬工場),ラコール®(大塚製薬工場),テルミール®(テルモ), エンシュア®(アボットジャパン),メイバランス®(明治)など

E2. 免疫調整経腸栄養[アルギニン, EPA, DHA, グルタミン, 核酸]

ルーティン投与は行わない

F4. グルタミンの添加は推奨されない


SIGNET REDOX MetaPlusBMJ. 2011;342:d1542 NEJM. 2013;368:1489-97 JAMA. 2014;312:514-24.

Setting/Design 10 ICU, double blind RCT 14 ICU, double blind RCT 14 ICU, double blind RCT

PatientsGastrointestinal failure, TPN, ICU stay≥48hr Sepsis 60%, medical 25%

Organ failure≥2, MV, EN only 80% Medical 80%, Sepsis 70%

MV≥72hr, SPN 15% Medical: surgical: trauma 5:8:5

APACHE 20 25 Medical: surgical: trauma 25: 20: 17

N 502 1223 301

Intervention グルタミンセレン

グルタミン抗酸化物質プラセボ

免疫調節栄養標準⾼蛋⽩栄養

route PN PN+EN EN

Result 感染有病率, 死亡率有意差なし

死亡率改善なしグルタミンで予後悪化の可能性

死亡率改善なし内科疾患で死亡率悪化


E3.

ARDS症例に対する

抗炎症性脂質(ω3-脂肪酸,EPA,DHA)/抗酸化物質(selenium, zinc, vit C, vit E)投与

推奨にすることはできない

E. SELECTION OF APPROPRIATE ENTERAL FORMULATION OMEGA study

JAMA. 2011;306:1574-81.

Setting/Design Multicenter RCT, Double blind, 44 hospital (EDEN 2x2)

Patients ALI (developing ≤48hr, MV)　 (pneumonia 50%, sepsis 20%)

APACHE III 91-3

N 272

Intervention N-3 control 投与量 120mL q12h

内容

n-3 fatty acids, antioxidants, γ-linolenic acid

isocaloric, isovolemic

Energy kcal/day 480 474

Protein g/day 3.8 20

Result

N-3群で有意に•  MV期間が永い•  院内滞在期間変わらない

悪化を認めたため途中で中止

疾患ごとの推奨

免疫調節栄養抗炎症物質抗酸化物質

Quality of Evidence

Medical ICU (E) Not be used routinely

Moderate

ARDS (E) Cannot make recommendation

Low – Very Low

Severe Trauma Traumatic Brain Injury (M) Be considered Use Very Low

Sepsis (N) Not be used routinely

Cannot make Recommendation

Moderate

Surgical ICU (O) Routine use Moderate - Low

high-fat/low-carbohydrate Quality of Evidence

Pulmonary Failure (I) To manipulate the RQ and reduce CO2 production NOT be used Very Low

発酵性水溶性食物繊維: フルクトオリゴ糖, イヌリンなど ProbioDcs:発酵乳,乳酸菌飲料,生菌製剤など

F2. probioticsは安全に投与できるしかしルティーン投与を推奨するには至っていない

F1. 安定した症例では発酵性水溶性食物繊維の添加を推奨

下痢を認めた場合, 10-20g/24hr 分割して投与

F3. 抗酸化ビタミン, 微量ミネラルは安全に使用できる

E4a.腸管虚血や腸管運動停止リスク症例では不溶性食物繊維は使用しない E4b.難治性下痢, 吸収低下, 食物繊維に反応しない症例では低分子ペプチド

を推奨


n-3系多価不飽和脂肪酸 ARDS患者に関してはn-3系脂肪酸（EPA），γリノレン酸，抗酸化物質を強化した経腸栄養剤使⽤を弱く推奨（2B） Sepsis/severe sepsis/septic shockの患者に関してはn-3系脂肪酸(EPA)，γリノレン酸，抗酸化物質を強化した経腸栄養剤の使⽤を考慮することを弱く推奨（2B）

Ø  OMEGA studyでは早期と晩期の両⽅が混在,晩期のEN投与が初期6⽇間の⽬標熱量は240-360 kcal/day程度に制限, などの問題点あり

Ø  4つの⼩規模RCTで予後改善 Crit Care Med 1999;27:1409-20. Crit Care Med 2006;34:1033-8. Crit Care Med 2006;34:2325-33. J NutrDisord Ther

2012;26:109-29. Ø  2014年RCTではないか患者で死亡率有意に⾼い JAMA 2014;312:514-24 Ø  研究結果が混在するため推奨度を⼀段階下げた


　経静脈栄養

G.WHENTOUSEPN

G1. 栄養リスクの低い症例

経静脈栄養投与は7日目以降

G3. 経腸栄養で目標熱量に達していない場合[<60%]

経静脈栄養併用は7-10日後

G2. 栄養リスクの高く, 経腸栄養EN不適当な症例

経静脈栄養投与はICU入室後速やかに投与

E. SELECTION OF APPROPRIATE ENTERAL FORMULATION EPaNIC trial Early PN trial SPN study

NEJM 2011;365:506-17. JAMA.2013;309:2130-8. Lancet.2013;381:385-93.

EN + PN TPN EN + PN Setting /Design

Belgy, 7 ICU Open label RCT

ANZ, 31 ICU double blind RCT

Switzerland, 2 ICU double blind RCT

PatientsNRS≥3, ICU stay ≥2days 心臓外科術後60%

EN相対的禁忌 (実際40%がEN投与) ICU stay ≥2days 消化管術後60%

Day3 EN投与量≤60% ICU stay ≥5days

APACHE 23 20 22

N 4640 1372 153

Intervention Early PN Late PN Early PN STD EN EN + SPN PN初期投与 day1 day7 Day1 Day2 - Day4

目標熱量達成 day3 day8 day1 day7 Day4-8 [目標の77%]

Day4

Result

Early PN群で有意に•  ICU滞在期間 •  MV期間が永い•  感染割合高い

身体機能, 死亡割合

変わらない

Early PN群で有意に •  身体機能を保つ •  MV期間が短い

死亡率, 感染割合変わらない

SPN群で有意に感染症発症率が低い

G.WHENTOUSEPNSPN studyの疑問点 •  肺炎罹患率が、Day4-8ではEN群の方が高いの

にday9-28ではSPN群の方が高い。Day4-28では

変わっていない。 •  Primary endpoint がday4-28の感染症罹患率。計

算にDay4までのデータが入っていないのは驚く

べきことである •  Day28までの脱落者が多すぎ、理由も不明確。

データが不適切ではないか •  肺炎罹患率が高すぎないか？[ある施設では

0.16-0.35/1000 ventilator-days ] Lancet. 2013 May 18;381(9879):1716-7.

•  SPN群25-30 kcal/kg/day, たんぱく質1.2g/kg/day EN群20kca/kg/day, たんぱく質0.8g/kg/day 重症患者のunderfeedingを避けた方がいいとい

うことではないか Lancet.2013Feb2;381(9864):354-5.

Day4から計算

■ SPN ■ EN

Proportion without nosocomial infection

Day0 day9 day28

SPN 153 149 99

EN 153 147 71

G.WHENTOUSEPNCrit Care Med. 2011 Dec;39(12):2691-9. . Setting/Methods: A Multicenter observational study,29 countries, 226 ICU Patients: ICU stay ≥72hr, EN within 48hr, 2920patients, early EN: <48hr

ProporDonalive

●earlyEN■earlySPN▲lateSPN

Early EN Early SPN Late SPN p

Total calories 63.4% 81.2% 64.3%<.001

60days alive 72.2% 65.4% 64.7%.02

生存退院 HR p

Early EN Ref. <.0003

Early SPN0.75 [0.59-0.96]

Late SPN0.64 [0.51-0.81]SPN群の方が生存予後が悪い

H.WHENINDICATED,MAXIMIZEEFFICACYOFPN

H2. 栄養状態不良症例でのPN投与 ≤20 kcal/kg/day or ⽬標の80%, たんぱく質≥1.2 g/kg/day

H.WHENINDICATED,MAXIMIZEEFFICACYOFPNClin Nutr. 2011 Dec;30(6):730-7. Meta-analysis. 5RCT, 2010-11, using EN patients were excluded hypocaloric PN ≤20 kcal/kg/day vs. contorl: 25-30 kcal/kg/day

InfecHon

HospitalLenghofStay

RR0.21[0.06,0.72]

Meandifference-2.32[-3.72,-0.93]

Favourhypocalory Favourcontrol

PN単独では, Hypocalory PNの⽅が感染リスク, 在院⽇数ともに低い


静脈栄養の適応

重症化前に低栄養がない患者において, 初期1週間に経腸栄養が20 kcal/hr以上投与できれば, ⽬標量達成を⽬的とした静脈栄養を⾏わないことを弱く推奨する(2B) 静脈栄養の開始時期

持続的な経腸栄養によるエネルギー投与量が平均20 kcal/hr未満の症例での静脈栄養の開始時期は明確ではない静脈栄養の⽬標エネルギー投与量

急性期における静脈栄養の⾄適エネルギー投与量は明確ではない



Question:

When PN is needed in the adult critically ill patient, what strategies can be adopted to improve efficacy?

H1. Based on expert consensus, we suggest the use of protocols and nutrition support teams to help incorporate strategies to maximize efficacy and reduce associated risk of PN.

PN関連リスクを減らすため, プロトコール化や栄養管理チームを勧める

Bundle Statements Assess patients on admission to the ICU for nutrition risk, and calculate both energy and protein requirements to determine goals of nutrition therapy.

Initiate enteral nutrition (EN) within 24−48 hours following the onset of critical illness and admission to the ICU and increase to goals over the first week of ICU stay.

Take steps as needed to reduce risk of aspiration or improve tolerance to gastric feeding (use prokinetic agent, continuous infusion, chlorhexidine mouthwash, elevate the head of bed, and divert level of feeding in the gastrointestinal tract).

栄養リスクの評価, 必要な熱量とたんぱく質量を計算し、目標を決定

経腸栄養ENの初期投与は発症24-48時間以内

誤嚥リスク減少や胃の不耐性改善のための方法をとる[蠕動運動亢進薬,持続投与,クロルヘキシジンによる口腔洗浄,頭部挙上,消化管投与部位の変更]

Bundle Statements

Implement enteral feeding protocols with institution-specific strategies to promote delivery of EN.

Do not use gastric residual volumes as part of routine care to monitor ICU patients on EN.

Start parenteral nutrition early when EN is not feasible or sufficient in high-risk or poorly nourished patients.

胃内残量はルーティンに測定しない

経腸栄養が不適当, ハイリスク, 栄養状態不良のとき経静脈栄養PNを早期に開始

経腸栄養ENプロトコールの作成

本邦と他国との比較 International Nutrition Survey [INS]日集中医誌2014;21:243-52 Setting/Methods: 28country 175ICU (Japan 9ICU 193patient), observational study Patients: ICU≥72hr, MV (ICU入室前14時間前または入室後48時間以内に開始)

Japan Other Asia

All other site

N 193 614 3,522

BW, median (kg) 56.0 63.8 73

BMI 22.1 22.9 25.6

Diagnosis (medical)cardiovascular 15.5% 7.5% 8.7%

respiratory 19.7% 23.5% 24.1%

Open ICU 44.4% 36.7% 24.6%

52

28 32

0

10

20

30

40

50

60

Japan OtherAsia Otherallsites

TimetoiniHaHonofEN(hr)

Japan Other Asia All other site

CP Non-CP CP Non-CP CP Non-CP

Fasting patint 25.3% 10.9% 3.8% 2.3% 17.3% 5.9% CP: Cardiovascular patients

本邦と他国との比較 International Nutrition Survey [INS]日集中医誌2014;21:243-52 Setting/Methods: 28country 175ICU (Japan 9ICU 193patient), observational study Patients: ICU≥72hr, MV (ICU入室前14時間前または入室後48時間以内に開始)

栄養開始時期は世界に⽐べ遅い栄養充⾜率は世界に⽐べ少ない

♦日本

■OtherAsia△Allothersite

主要な臨床研究の概要

参考資料

The EDEN trial JAMA 2012; 307(8):795–803. Setting/Methods: randomized, ARDS network 44 ICU, open-label Patients: acute lung injury 1000 patients, BMI約30, Mechanical ventilation, Pneumonia 約65% Intervention: Trophic enteral feeding; 10-20 kcal/kg/d

vs. Full enteral feeding; 25-30 kcal/kg/d, protein 1.2-1.6 g/kg/d

Trophic Full p

60 days Mortality 23.2% 22.2% .77

Ventilator-free 14.9days 15.0days .89

VAP 7.3% 6.7%.72

Bacteremia 11.6% 9.3%.24

≤6 days Trophic Full

Caloric intake 400kcal 1300kcal

% of target 25% 80%

day6 day6

Trophic vs. full 予後変わらず

Protocol

83

The EDEN trial

PermiT Trial N Engl J Med. 2015 Jun 18;372(25):2398-408. Methods/Patients: 7 ICU, RCT, ICU stay≥72hr, 894 patients (APACHE II 20, severe sepsis 30%, MV 97%)

Intervention: Permissive underfeeding vs. STD feeding, EN

Permissive STD

Caloric intake 835kcal 1299kcal

% of target 46% 71%

Protein 57 g 59 g

% of target 68% 69%

Glucose, mmol/L 9.1 9.4

Permissive

STD

Permissive STD p

Death, 90days 27.2% 28.9% 0.58

CRBSI 2.5% 4.3% 0.13

VAP 18.1% 20.2% 0.43

UTI 10.0% 10.8% 0.73

Underfeeding vs. STD feeding 予後変わらず

day14 day14

CritCareMed2002;30:2407–2412

VAP発症率の低下 11.8→5.7/1000 ventilator days

1.  MV症例, 頭部挙上≥30°2.  経⿐挿管は避ける3.  経⿐胃管より経⼝胃管4.  抜管症例は速やかに胃管抜去5.  挿管チューブの事故/⾃⼰抜去を予防6.  ⾃⼰抜去防⽌のために適切な鎮静7.  胃内残量の測定8.  １⽇１回以上の⼝腔洗浄9.  ⼈⼯呼吸回路の⽔滴除去 10.  エアロゾル投与の際は valved t-adapters

または holding chambers fを使⽤11.  期間挿管は最⼩限に。NPPVを使⽤。12.  抗菌薬の過剰投与を避ける13.  クロルヘキシジンによる⼝腔洗浄

(⼼臓外科患者のみ)14.  肺炎球菌とインフルエンザの予防接種

VAP予防指針の作成指針導入


SIGNET trial. BMJ. 2011 Mar 17;342:d1542 Setting/Methods: Multicenter, 10 ICU, double blind RCT Patients: gastrointestinal failure, TPN, ICU stay≥48hr, 502 patients (APACHE 20, sepsis 60%, medical 25%) Intervention: Glutamine, Selenium, Glutamine + Selenium, Neither (PN)

Formulation ■ Glutamine ■ Selenium ■ Glutamine+Selenium ■ Neither

Glutamine, Selenium

予後に差なし

Glutamine Non- Glutamine Odds ratio Selenium Non-

Selenium Odds ratio

Mortality, 6mo 46% 42% 1.18 [0.82,1.70] 43% 45% 0.89 [0.62, 1.29]

New Infection, 14days 54% 52% 1.07 [0.75 1.53] 50% 55% 0.81 [0.57, 1.15]

ICU stay 15.0 13.4 0.96 [0.80, 1.14] 13.2 15.1 1.08 [0.91, 1.29]

Survival

SIGNET trial. BMJ. 2011 Mar 17;342:d1542 Setting/Methods: Multicenter, 10 ICU, double blind RCT Patients: gastrointestinal failure, TPN, ICU stay≥48hr, 502 patients (APACHE 20, sepsis 60%, medical 25%) Intervention: Glutamine, Selenium, Glutamine + Selenium, Neither (PN)

Formulation PN bag containing [2000 kcal, 1500mL]

Glutamine glutamine 20.2g + nitrogen 12.5g

Selenium Nitrogen 12.5g + 500µg selenium

Glutamine+Selenium glutamine 20.2g + 500µg selenium

Neither Nitrogen 12.5g Median times before Randomization: 2.6 days The median Duration of trial parenteral nutrition: 5.1 days

REDOXS trial N Engl J Med. 2013 Apr 18;368(16):1489-97 Setting/Methods: Multicenter, 14 ICU, double blind RCT Patients: Organ failure≥2, MV, 1223 patients, medical 80%, sepsis 30%, EN only 80%, APACHE 25

Intervention: Glutamine, Antioxidant, Placebo

Death Antioxidants + Antioxidants - Glutamine -specific Odds

Glutamine + 32.6% 32.2% 1.02 [0.72, 1.43]

Glutamine - 29.0% 25.3% 1.20 [0.84, 1.72]

Antioxidants -specific Odds 1.18 [0.83, 1.66] 1.40 [0.98, 2.00]

Glutamine+ Glutamine- p

Mortality 32.4% 27.2%.05

Odds ratio 1.28 [1.00, 1.64]P=0.02

Survival

Glutamine YESー　NO---

Glutamine, Antioxidants 死亡率改善なし Glutamineで悪化の可能性

REDOXS trialN Engl J Med. 2013 Apr 18;368(16):1489-97 Setting/Methods: Multicenter, 14 ICU, double blind RCT Patients: Organ failure≥2, MV, 1223 patients, medical 80%, sepsis 30%, EN only 80%, APACHE 25

Intervention: Glutamine, Antioxidant, Placebo

PN EN

Glutamine

dipeptide alanyl-glutamine 0.50 g/kg/day (glutamine 0.35g/kg/day)

alanyl-glutamine + glycine-glutamine dipeptides 42.5 g/day (glutamine 30g/day)

Antioxidant selenium 500µg

selenium 300µg zinc 20mg beta carotene 10mg vitamin E 500mg vitamin C 1500mg

Control placebo placebo

MetaPlus trial JAMA. 2014 Aug 6;312(5):514-24. Setting/Methods: Multicenter, 14 ICU, double blind RCT. Patients: EN, MV≥72hr, 301 patients, medical: Intervention: immune-modulating nutrients (IMHP) [n=152] vs. standard high-protein enteral nutrition (HP) [n=149]

N Mortality , 6Mo Infection, % ICU stay, days MV, days

IMHP HP IMHP HP p IMHP HP p IMHP HP p IMHP HP p

All 152 149 35% 29% .21 53% 52% >.99 18 18 .73 9 8 .84

Medical 54 55 54% 35%.04 39% 47% .44 14 15 .58 7 9 .19

Surgical 81 75 28% 29% .90 62% 51% .20 21 20 .87 11 7 .11

Trauma 55 54 15% 17% .76 58% 67% .43 25 23 .45 11 9 .71

免疫調節栄養投与で予後の改善なし内科疾患で悪化

MetaPlus trial JAMA. 2014 Aug 6;312(5):514-24. Setting/Methods: Multicenter, 14 ICU, double blind RCT. Patients: EN, MV≥72hr, 301 patients, medical: Intervention: immune-modulating nutrients (IMHP) [n=152] vs. standard high-protein enteral nutrition (HP) [n=149]

OMEGA study JAMA. 2011 Oct 12;306(14):1574-81. Setting/Design：Multicenter RCT (EDEN trial 2x2), double blinded, 44 hospital Patients：ALI (developing ≤48hr, MV), 272 patients　　 Intervention: 120mL q12hr n-3 (n-3 fatty acids, antioxidants, γ-linolenic acid) vs. control (isocaloric, isovolemic) 中間解析でn-3群が予後不良の可能性と判断され中断

N-3 control p

Ventilator-free, days 14.0 17.2 .02

Hospital mortality 25.1% 17.6% .11

ALIの予後改善認めず予後悪化の可能性あり

OMEGA study JAMA. 2011 Oct 12;306(14):1574-81. Setting/Design：Multicenter RCT (EDEN trial 2x2), double blinded, 44 hospital Patients：ALI (developing ≤48hr, MV), 272 patients　　 Intervention: 120mL q12hr

N-3 controlEnergy, kcal 480 474 Protein, g 3.8 20Carbohydrate, g 4.2 51.8Fat, g 44.6 22

EPA 6.84 0DHA 3.40 0GLA 5.92 0

Daily nutrition

Antioxidant N-3 controlVitamin C, mg 1000 76 Vitamin E, IU 440 12

Zinc, mg 24.2 5.6Selenium, µg 85.2 18

GLA: γ-linolenic acid

EPaNIC trialN Engl J Med. 2011 Aug 11;365(6):506-17. Setting/Methods: Multicenter, Belgy, 7 ICU, Open label RCT Patients: NRS≥3, ICU stay ≥2days 4640 patients (約60%が心臓外科手術術後患者) Intervention: Late PN group vs. Early PN group

目標カロリー達成 ■ Early PN: day3 ■ Late PN: day8

Early PN群 ICU滞在期間, MV期間が永い感染割合高い身体機能死亡割合変わらない

Late PN, N=680 Early PN, N=678 p

ICU 退室(≤8days) 75.2% 71.2% .007

身体機能6-MW 277m 283m .57

MV ≥2days 36.3% 40.2%.006

Death (≤90days) 11.2% 11.2%1.00

SSI 2.7 % 4.2 % .006

低血糖 3.5% 1.9% .001

PN開始 ■ Early PN: day1 ■ Late PN: day7

Protocol

EPaNIC trial

EPaNIC trial

Early PN trialJAMA. 2013 May 22;309(20):2130-8. ANZICS Clinical Trial Group. Setting/Methods: Multicenter, ANZ, 31 ICU, double blind RCT Patients: relative contraindication to EN, ICU stay ≥2days 1372 patients (60%が消化管手術術後患者, APACHE II 20, 40%にEN投与) Intervention: Early PN group vs. STD group

STD, N=680 Early PN, N=678 Difference p

⾝体機能 RAND-36 45.5(±26.8) 49.8(±27.6) Difference 4.3

(0.95 to 7.58) .01

MV 7.73 days (7.55 to 7.92)

7.26 days (7.09 to 7.44)

Mean Difference -0.47 (-0.82 to -0.11)

.01

Death (≤60days) 22.8% 21.5% Odds Ratio 0.93

(0.71 to 1.21) .60

SSI 3.96 % 3.23 % Risk Difference -0.73 (-0.604 to 4.57)

.56

● Early PN ○ STD

Early PN群身体機能を保つ MV期間が短い死亡割合感染割合変わらない

栄養投与された割合 Protein Energy

Early PN trialProtocol

Protocol

Early PN trial

SPN studyLancet. 2013 Feb 2;381(9864):385-93. EN vs. EN + supplemental PN (SPN) Setting/Methods: Switzerland, 2 ICU, double blind RCT, 間接熱量測定法 Patients: day3 でENでの栄養が目標の60%以下, ICU stay ≥5days 153 patients

Enteral delivery

Energy ≤60%

Day3

■ SPN ■ EN

感染症発症率に有意差(p=0.038) Day 9以降

Day9

Proportion without nosocomial infection

Enteral delivery

Day8Day4

Day 4-8, Mean delivery SPN EN p

Energy, kcal/kg/day 28 20 <.001

Proportion of energy, % 103 77 <.001

protein, g/kg/day 1.2 0.8 <.001

Parenteral delivery Day4

SPN studyProtocol

Meta-analysis. Am J Clin Nutr. 2001 Oct;74(4):534-42. 27studies, 1828patients

Meta-analysis. JAMA. 1998 Dec 16;280(23):2013-9. 26 RCT, 2211Patients, TPN vs. STD 22 study; major complication (心血管イベント, 感染など) RR 0.84 [0.64, 1.09]

Major Complication malnourished patients with PN

RR: 0.52 [0.30, 0.91]

栄養状態悪い患者では

PN投与群で合併症リスクが低い

protein-energy malnutritionSTD vs. PN, Mortality protein-energy malnutrition

Relative Risk: 3.0 [1.09, 8.56] n=2, subgroup analysis たんぱく質栄養状態悪い患者では

PN投与群で合併症リスクが低い G.WHENTOUSEPN

ガイドライン本文と要約 (抜粋)

参考資料

A. NUTRITION ASSESSMENT Question:

Does the use of a nutrition risk indicator identify patients who will most likely benefit from nutrition therapy?

A1. Based on expert consensus, we suggest a determination of

nutrition risk (for example, Nutritional Risk Score [NRS -2002], NUTRIC score) be performed on all patients admitted to the ICU for whom volitional intake is anticipated to be insufficient. High nutrition risk identifies those patients most likely to benefit from early EN therapy.

栄養リスクを評価 [ ex) NRS-2002, NUTRIC score ]

A. NUTRITION ASSESSMENT Question:

What additional tools, components or surrogate markers provide useful information when performing nutrition assessments in critically ill adult patients?

A2. Based on expert consensus, we suggest that nutritional assessment include an evaluation of comorbid conditions, function of the gastrointestinal (GI) tract, and risk of aspiration.

We suggest not using traditional nutrition indicators or

surrogate markers, as they are not validated in critical care.

伝統的な栄養の代替マーカーは使用しないEx) albumin, prealbumin, transferrin,retinol-binding protein


Question:

What is the best method for determining energy needs in the critically ill adult patient?

A3a. We suggest that indirect calorimetry (IC) be used to determine energy requirements, when available and in the absence of variables that affect the accuracy of measurement. [Very Low]

間接熱量測定法を推奨


A3b. Based on expert consensus, in the absence of IC, we suggest that a published predictive equation or a simplistic weight-

based equation (25–30 kcal/kg/day) be used to determine energy requirements. (See section Q for obesity recommendations.)

間接熱量測定法ができない場合、体重を基にした計算式を使用 25-30 kcal/kg/day


Question: Should protein provision be monitored independently from energy provision in critically ill adult patients? A4. Based on expert consensus, we suggest an ongoing evaluation of adequacy of protein provision be performed (see section C4)


B. INITIATE EN

Question:

What is the benefit of early EN in critically ill adult patients compared to withholding or delaying this therapy?

B1. We recommend that nutrition support therapy in he form of early

EN be initiated within 24–48 hours in the critically ill

patient who is unable to maintain volitional intake.

経口摂取ができない場合

経腸栄養EN 24-48時間以内に開始

B. INITIATE EN

Question:

Is there a difference in outcome between the use of EN or PN for adult critically ill patients?

B2. We suggest the use of EN over PN in critically ill patients who require nutrition support therapy.

経静脈栄養PNより経腸栄養ENを優先

B. INITIATE EN Question:

Is the clinical evidence of contractility (bowel sounds, flatus) required prior to initiating EN in critically ill adult patients?

B3. Based on expert consensus, we suggest that, in he majority of

MICU and SICU patient populations, while GI contractility factors should be evaluated when initiating EN , overt signs of contractility should not be required prior to initiation of EN .

経腸栄養EN開始のための腸管蠕動音の確認は必要ない

B. INITIATE EN Question: What is the preferred level of infusion of EN within the GI tract for critically ill patients? How does the level of infusion of EN affect patient outcomes?

B4a. We recommend that the level of infusion be diverted lower in the GI tract in those critically ill patients at high risk for aspiration (see section D4) or those who have shown intolerance to gastric EN (see section D2). [Quality of Evidence: Moderate to High]

B4b. Based on expert consensus we suggest that, in most critically ill patients, it is acceptable to initiate EN in the stomach.

誤嚥リスク, 腸管不耐性を認める場合胃腸下部への投与を推奨

多くの重症患者の場合胃内への投与で大丈夫

B. INITIATE EN

Question:

Is EN safe during periods of hemodynamic instability in adult critically ill patients?

B5. Based on expert consensus, we suggest that in the setting of

hemodynamic compromise or instability, EN should be withheld until the patient is fully resuscitated and/or stable. Initiation/reinitiation of EN may be considered with caution in patients undergoing withdrawal of vasopressor support.

循環動態が安定しない時, 経腸栄養ENはwithhold

L.ACUTEPANCREATITIS

Question:

Does disease severity in acute pancreatitis influence decisions to provide

specialized nutrition therapy?

L1a. Based on expert consensus, we suggest that he initial nutrition

assessment in acute pancreatitis evaluate disease severity to direct nutrition therapy. Since disease severity may change quickly, we suggest

frequent reassessment of feeding tolerance and need for specialized nutrition therapy.

常に耐性を評価しながら栄養方法を検討

L.ACUTEPANCREATITIS

Question:

Do patients with mild acute pancreatitis need specialized nutrition therapy?

L1b. We suggest NOT providing specialized nutrition therapy to

patients with mild acute pancreatitis, instead advancing to an oral diet as tolerated. If an unexpected complication develops or there is failure to advance to oral diet within 7 days, then specialized nutrition therapy should be considered. [Quality of Evidence: Very Low]

MildpancreaDDs特別食はいらない(clearliquidsで開始する必要もない)

経口食を進める７日以内に経口摂取失敗した場合、特別食を検討

L.ACUTEPANCREATITIS

Question:

Which patients require specialized nutrition therapy early after admission for acute pancreatitis?

L1c. We suggest that patients with moderate to severe acute pancreatitis should have a naso-/oroenteric tube placed and EN

started at a trophic rate and advanced to goal as fluid volume resuscitation is completed (within 24–48 hours of admission)

[Quality of Evidence: Very Low]

ModeratetoSeverepancreaDDs経腸栄養は早期(24-48hr)から開始

初期投与量はtrophicrate

L.ACUTEPANCREATITIS

Question:

Which is the most appropriate formula to use when initiating early EN in the patient with moderate to severe acute pancreatitis?

L2. We suggest using a standard polymeric formula to initiate EN in the

patient with severe acute pancreatitis. Although promising, the data are currently insufficient to recommend placing a patient with severe acute pancreatitis on an immune-enhancing formulation at this time. [Quality of Evidence: Very Low]

半消化態栄養剤:ハイネ®(大塚製薬工場),ラコール®(大塚製薬工場),テルミール®(テルモ),エンシュア®(アボットジャパン),メイバランス®(明治)など

SeverepancreaDDs半消化態栄養剤を使用

L.ACUTEPANCREATITIS

Question:

Should patients with severe acute pancreatitis receive EN or PN?

L3a. We suggest the use of EN over PN in patients with severe acute pancreatitis who require nutrition therapy. [Quality of Evidence: Low]

経静脈栄養より経腸栄養を推奨

L.ACUTEPANCREATITIS

Question:

Should patients with severe acute pancreatitis be fed into the stomach or small bowel?

L3b. We suggest that EN be provided to the patient with severe acute pancreatitis by either the gastric or jejunal route, as there is no difference in tolerance or clinical outcomes between these two levels of infusion. [Quality of Evidence: Low]

重症急性膵炎の予後は胃内投与と十二指腸内投与で変わらない

L.ACUTEPANCREATITIS

Question:

In the presence of intolerance, what strategies can be used to enhance tolerance to EN in patients with severe acute pancreatitis?

L4. Based on expert consensus, we suggest that, in patients with moderate to severe acute pancreatitis who have intolerance to EN,

measures should be taken to improve tolerance.

ModeratetoSeverepancreaDDs腸管不耐性を認めた場合, 改善させる方法をとること

[feedingtubeの位置を変える,fat-freeに近い素材にする,単回から持続投与にする,など]

L.ACUTEPANCREATITIS

Question:

Should patients with severe acute pancreatitis receive probiotics?

L5. We suggest that the use of probiotics be considered in patients with severe acute pancreatitis who are receiving early EN.

[Quality of Evidence: Low]

Question:

When is it appropriate to use PN in patients with severe acute pancreatitis?

L6.

Based on expert consensus, we suggest that, for the patient with severe acute

pancreatitis, when EN is not feasible, use of PN should be considered after one week from the onset of the pancreatitis episode.

C. DOSING OF EN

Question:

What population of patients in the ICU setting does not require nutrition support therapy over the first week of hospitalization?

C1. Based on expert consensus, we suggest that patients who are at low nutrition risk with normal baseline nutrition status and low disease severity (for example, NRS -2002 ≤ 3 or NUTR IC score ≤ 5) who cannot maintain

volitional intake do NOT require specialized nutrition therapy over the first week of hospitalization in the ICU.

栄養リスクが低い時, 初めの１週間は特別な栄養投与は必要ない

C. DOSING OF EN

Question:

For which population of patients in the ICU setting is it appropriate to provide trophic EN over the first week of hospitalization?

C2. We recommend that either trophic or full nutrition by EN is appropriate for patients with acute respiratory distress syndrome (ARDS)/

acute lung injury (ALI) and those expected to have a duration of mechanical ventilation ≥ 72 hours, as these two strategies of feeding

have similar patient outcomes over the first week of

hospitalization. [Quality of Evidence: High]

ARDS, MV≥72hrの症例, trophic/fullどちらも適当

C. DOSING OF EN

Question: What population of patients in the ICU requires full EN (as close as possible to target nutrition goals) beginning in the first week of hospitalization? How soon should target nutrition goals be reached in these patients? C3. Based on expert consensus, we suggest that patients who are at high nutrition risk (for example, NRS -2002 > 5 or NUTR IC score ≥ 5, without interleukin-6) or severely malnourished should be advanced toward goal as quickly as tolerated over 24–48 hours while monitoring for refeeding syndrome. Efforts to provide > 80% of estimated or calculated goal energy and protein within 48–72 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization.

C. DOSING OF EN

Question: What population of patients in the ICU requires full EN (as close as possible to target nutrition goals) beginning in the first week of hospitalization? How soon should target nutrition goals be reached in these patients? C3. Based on expert consensus, we suggest that patients who are at high nutrition risk (for example, NRS -2002 > 5 or NUTR IC score ≥ 5, without interleukin-6) or severely malnourished should be advanced toward goal as quickly as tolerated over 24–48 hours while monitoring for refeeding syndrome. Efforts to provide > 80% of estimated or calculated goal energy and protein within 48–72 hours should be made in order to achieve the clinical benefit of EN over the first week of hospitalization.

栄養リスク高い症例, 重度低栄養症例

経腸栄養EN投与を早急に開始

24-48時間refeeding syndromeに注意入院初期の１週間は48-72時間で目標熱量の80%

C. DOSING OF EN

Question:

Does the amount of protein provided make a difference in clinical outcomes of adult critically ill patients?

C4. We suggest that sufficient (high-dose) protein should be provided.

Protein requirements are expected to be in the range of

1.2–2.0 g/kg actual body weight per day, and may likely be even higher in burn or multitrauma patients (see sections M and P).


Q. OBESITY IN CRITICAL ILLNESS

Question:

In adult obese ICU patients, does use of highprotein, hypocaloric feeding improve clinical outcomes compared with use of high-protein, eucaloric feeding?

Q4. Based on expert consensus, we suggest that high-protein hypocaloric feeding be implemented in the care of obese ICU patients to preserve lean body mass, mobilize adipose stores, and minimize the metabolic complications of overfeeding.

たんぱく質投与量は多く、熱量は少なく

Q. OBESITY IN CRITICAL ILLNESS

Question:

In adult obese ICU patients, what are the appropriate targets for energy and protein intake to achieve nitrogen equilibrium and meet metabolic requirements?

Q5. Based on expert consensus, we suggest that, for all classes of obesity, the goal of the EN regimen should not exceed 65–70% of target energy requirements as measured by IC. If IC is unavailable, we suggest using the weight-based equation 11–14 kcal/kg actual body weight/day for patients with BMI in the range 30–50 and 22–25 kcal/kg ideal body weight/day for patients with BMI > 50. We suggest that protein should be provided in a range from 2.0 g/kg ideal body weight/ day for patients with BMI 30–40 up to 2.5 g/kg ideal body weight/day for patients with BMI ≥ 40.

Question:

In adult obese ICU patients, what are the appropriate targets for energy and protein intake to achieve nitrogen equilibrium and meet metabolic requirements?

Q5. Based on expert consensus, we suggest that, for all classes of obesity, the goal of the EN regimen should not exceed 65–70% of target energy requirements as measured by IC. If IC is unavailable, we suggest using the weight-based equation 11–14 kcal/kg actual body weight/day for patients with BMI in the range 30–50 and 22–25 kcal/kg ideal body weight/day for patients with BMI > 50. We suggest that protein should be provided in a range from 2.0 g/kg ideal body weight/ day for patients with BMI 30–40 up to 2.5 g/kg ideal body weight/day for patients with BMI ≥ 40.

Q. OBESITY IN CRITICAL ILLNESS 肥満症例の栄養投与量

Energy [kcal/kg/day]

Protein [g/kg/day]

BMI 30-5011-14

[actual body]

All classes of obesity IC 65-70%

BMI 30-40 2.0

BMI >40 2.5

BMI >5022-25

[ideal body]

J.RENALFAILURE

Question:

In adult critically ill patients with acute kidney injury (AKI), what are the indications for use of specialty enteral formulations? What are appropriate energy and protein recommendations to reduce morbidity in AKI?

J1. Based on expert consensus, we suggest that ICU patients with acute renal failure (ARF) or AKI be placed on a standard enteral formulation,

and standard ICU recommendations for protein (1.2 – 2 g/kg actual body weight per day) and energy (25–30 kcal/kg/day) provision should be followed. If significant electrolyte abnormalities develop, a specialty formulation designed for renal failure (with appropriate electrolyte profile) may be considered.

AKI症例⽬標熱量 25-30 kcal/kg/day たんぱく質 1.2-2.0 g/kg/day

J.RENALFAILURE

Question:

In adult critically ill patients with AKI receiving hemodialysis or CRRT, what are appropriate targets for protein intake to support increased nitrogen losses?

J2. We recommend that patients receiving hemodialysis or CRRT receive increased protein, up to a maximum of 2.5 g/kg/day. Protein should NOT be restricted in patients with renal insufficiency as a means to avoid or delay initiating dialysis therapy. [Quality of Evidence: Very Low]

CRRT症例たんぱく質 2.5 g/kg/day

たんぱく質は制限しない

I.PULMONARYFAILURE

Question:

What is the optimal carbohydrate-to-fat ratio for the adult ICU patient with pulmonary failure?

I1. We suggest that specialty high-fat/low-carbohydrate formulations designed to manipulate the respiratory quotient and

reduce CO2 production NOT be used in ICU patients with acute respiratory failure (not to be confused with recommendation E3). [Quality of Evidence: Very Low]

CO2を減らす目的に高脂肪/低炭水化物製剤を使用しない

I.PULMONARYFAILURE

Question:

Does use of energy-dense EN formulas to restrict fluid administration benefit the adult ICU patient with acute respiratory failure?

I2. Based on expert consensus, we suggest that fluid-restricted energy-dense EN formulations be considered for patients with acute respiratory failure (especially if in a state of volume overload)

水分制限・熱量濃縮栄養製剤を推奨

I.PULMONARYFAILURE

Question:

Should serum phosphate concentrations be monitored when EN or PN is initiated in the ICU patient with respiratory failure?

I3. Based on expert consensus, we suggest that serum phosphate concentrations should be monitored closely, and phosphate replaced appropriately when needed.

血清リン濃度を測定


Question:

How should tolerance of EN be monitored in the adult critically ill N1. population?

D1. Based on expert consensus, we suggest that patients should be monitored

daily for tolerance of EN . We suggest that inappropriate cessation of EN should be avoided. We suggest that ordering

a feeding status of nil per os (NPO) for the patient surrounding the time of diagnostic tests or procedures should be minimized to limit propagation of ileus and to prevent inadequate nutrient delivery.

無駄な絶飲食は避ける

絶飲食は低限に


Question: Should GRVs be used as a marker for aspiration to monitor ICU patients on EN?

D2a. We suggest that GRVs not be used as part of routine care to monitor ICU patients on EN .

D2b. We suggest that, for those ICUs where GRVs are still utilized, holding EN for GRVs < 500 mL in the absence of other signs of intolerance (see section D1) should be avoided. [Quality of Evidence: Low]

胃内残量を

ルーティンに計測する必要はない

不耐性の所見がなく胃内残量<500mLの場合,

経腸栄養をやめるべきではない

D. MONITORING TOLERANCE AND ADEQUA CY OF EN

Question:

Should EN feeding protocols be used in the adult ICU setting?

D3a. We recommend that enteral feeding protocols be designed and implemented to increase the overall percentage of goal calories provided. [Quality of Evidence: Moderate to High]

D3b. Based on expert consensus, we suggest that use of a volume-based feeding protocol or a top-down multi-strategy protocol be considered.

ENはプロトコールの基に施行容量を基, またはトップダウンの多角的戦力をもったプロトコールを用いる


Question:

How can risk of aspiration be assessed in critically ill adults patients receiving EN, and what measures may be taken to reduce the likelihood of aspiration pneumonia?

D4. Based on expert consensus, we suggest that patients placed on EN should be assessed for risk of aspiration, and that steps to reduce risk of aspiration and aspiration pneumonia should be proactively employed.

経腸栄養投与中は

誤嚥リスクを評価すべき

誤嚥リスクを減らす方法をとるべき

Question:

How can risk of aspiration be assessed in critically ill adults patients receiving EN, and what measures may be taken to reduce the likelihood of aspiration pneumonia?

D4a. We recommend diverting the level of feeding by post-pyloric enteral access device placement in patients deemed to be at high risk for aspiration (see also section B4) [Quality of Evidence: Moderate to High]

D4b. Based on expert consensus, we suggest that for high-risk patients or

those shown to be intolerant to bolus gastric EN , delivery of EN should be switched to continuous infusion.


誤嚥ハイリスク症例では以下を考慮

Ø 幽門部より以遠へのチューブ留置

Ø 持続投与(間欠投与の中止) B. 参照


D4c. We suggest that, in patients at high risk of aspiration,

agents to promote motility, such as prokinetic medications (metoclopramide or erythromycin), be initiated where clinically feasible. [Quality of Evidence: Low]

メトクロプラミド,エリスロマイシンの使用により胃内残量少なくなる


D4d. Based on expert consensus, we suggest that nursing directives to reduce risk of aspiration and VAP be employed.

In all intubated ICU patients receiving EN , the head of the bed should

be elevated 30–45º and use of chlorhexidine mouthwash twice a day should be considered.

VAP予防

Ø 頭部挙上 30-45º Ø クロルヘキシジン口腔洗浄　１日２回


Question: Are surrogate markers useful in determining aspiration in the critical care setting?

D5. Based on expert consensus, we suggest that neither blue food coloring nor any coloring agent be used as a marker for aspiration of EN . Based on expert consensus, we also suggest that glucose oxidase strips not be used as surrogate markers for aspiration in the critical care setting. Question: How should diarrhea associated with EN be assessed in the adult critically ill population?

D6. Based on expert consensus, we suggest that EN NOT be automatically interrupted for diarrhea but rather that feeds be continued while evaluating the etiology of diarrhea in an ICU patient to determine appropriate treatment.

誤嚥マーカーのための食物の着色は必要ない

下痢を認めたからといって自動的に経腸栄養への介入は必要ない

しかし, 適切な評価/治療決定は行う


Question:

Which formula should be used when initiating EN in the critically ill patient?

E1. Based on expert consensus, we suggest using a standard polymeric formula when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in a MICU and disease-specific formulas in the SICU.

E1. 標準的な半消化態栄養剤

等張栄養剤 (1 - 1.5 kcal/mL) を推奨


Question:

Which formula should be used when initiating EN in the critically ill patient?

E1. Based on expert consensus, we suggest using a standard polymeric formula

when initiating EN in the ICU setting. We suggest avoiding the routine use of all specialty formulas in critically ill patients in a MICU and disease-specific formulas in the SICU.

特別な栄養はルーティーンに使用しない

Disease specific (Diabetes, pancreatitis[L])

Organ specific (Pulmonary[E3,I], Renal[J], hepatic[K])

Semi-elemental, elemental

Immune-modeling (excluding postoperative patient[E2,O,M])


Question:

Do immune-modulating enteral formulations have an impact on clinical outcomes for the critically ill patient regardless of the ICU setting?

E2. We suggest immune-modulating enteral formulations (arginine with other agents, including eicosapentaenoic acid [EPA], docosahexaenoic acid [DHA], glutamine, and nucleic acid) should not be used routinely in the MICU. Consideration for these formulations should be reserved for patients with TBI and perioperative patients in the SICU (see sections O and M). [Quality of Evidence: Very Low]

免疫調整経腸栄養 [アルギニン, EPA, DHA, グルタミン, 核酸] ルーティン投与は行わない


Question:

Should EN formulas with fish oils (FOs), borage oil and antioxidants be used in patients with ALI or ARDS?

E3. We cannot make a recommendation at this time regarding the

routine use of an enteral formulation characterized by an anti-inflammatory lipid profile (e.g., omega-3 FOs, borage oil) and antioxidants, in

patients with ARDS and severe ALI, given conflicting data.

[Quality of Evidence: Low to Very Low]

ARDS症例に対する抗炎症性脂質(ω3-脂肪酸,EPA,DHA)/抗酸化物質(selenium, zinc, vit C, vit E)投与

推奨にすることはできない

I.PULMONARYFAILURE

Question:

What is the optimal carbohydrate-to-fat ratio for the adult ICU patient with pulmonary failure?

I1. We suggest that specialty high-fat/low-carbohydrate formulations designed to manipulate the respiratory quotient and

reduce CO2 production NOT be used in ICU patients with acute respiratory failure (not to be confused with recommendation E3). [Quality of Evidence: Very Low]

CO2を減らす目的に高脂肪/低炭水化物製剤を使用しない

I.PULMONARYFAILURE

Question:

Does use of energy-dense EN formulas to restrict fluid administration benefit the adult ICU patient with acute respiratory failure?

I2. Based on expert consensus, we suggest that fluid-restricted energy-dense EN formulations be considered for patients with acute respiratory failure (especially if in a state of volume overload).

水分制限・熱量濃縮された栄養製剤を推奨

I.PULMONARYFAILURE

Question:

Should serum phosphate concentrations be monitored when EN or PN is initiated in the ICU patient with respiratory failure?

I3. Based on expert consensus, we suggest that serum phosphate concentrations should be monitored closely, and phosphate replaced appropriately when needed.

血清リン濃度を測定


Question:

In adult critically ill patients, what are the indications, if any, for enteral formulations containing soluble fiber or small peptides?

E4a. We suggest that a commercial mixed fiber formula not be used routinely in the adult critically ill patient prophylactically to promote bowel regularity or prevent diarrhea. [Quality of Evidence: Low]

E4b. Based on expert consensus, we suggest considering use of a commercial

mixed fiber-containing formulation if there is evidence of persistent diarrhea. We suggest avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. We

suggest considering use of small peptide formulations in the patient with

persistent diarrhea, with suspected malabsorption, ischemia, or lack of response to fiber.　


Question:

In adult critically ill patients, what are the indications, if any, for enteral formulations containing soluble fiber or small peptides?

E4a. We suggest that a commercial mixed fiber formula not be used routinely in the adult critically ill patient prophylactically to promote bowel regularity or prevent diarrhea. [Quality of Evidence: Low]

E4b. Based on expert consensus, we suggest considering use of a commercial

mixed fiber-containing formulation if there is evidence of persistent diarrhea. We suggest avoiding both soluble and insoluble fiber in patients at high risk for bowel ischemia or severe dysmotility. We

suggest considering use of small peptide formulations in the patient with

persistent diarrhea, with suspected malabsorption, ischemia, or lack of response to fiber.　

E4a.腸管虚血や腸管運動停止リスク症例では不溶性食物繊維は使用しない E4b.難治性下痢, 吸収低下, 食物繊維に反応しない症例では低分子ペプチド

を推奨

F. ADJUNCTIVE THERAPY

Question:

Should a fiber additive be used routinely in all hemodynamically stable ICU patients on standard enteral formulas? Should a soluble fiber supplement be provided as adjunctive therapy in the critically ill patient who develops diarrhea and is receiving a standard non-fiber-containing enteral formula?

F1. Based on expert consensus, we suggest that a fermentable soluble fiber (e.g., fructo-oligossaccharides [FOSs], inulin) additive be

considered for routine use in all hemodynamically stable medical and surgical

ICU patients placed on a standard enteral formulation. We suggest that 10–20 grams of a fermentable soluble fiber supplement be given in divided doses over 24 hours as adjunctive therapy if there is evidence of diarrhea.

安定した症例では発酵性水溶性食物繊維の添加を推奨下痢を認めた場合, 10-20g/24hr 分割して投与

発酵性水溶性食物繊維: フルクトオリゴ糖, イヌリン


Question:

Is there a role for probiotic administration in critically ill patients? Is there any harm in delivering probiotics to critically ill patients?

F2. We suggest that, while the use of studied probiotics species and strains appear to be safe in general ICU patients, they should

be used only for select medical and surgical patient populations for which RCTs have documented safety and outcome

benefit. We cannot make a recommendation at this time for the routine use of probiotics across the general population of ICU patients. [Quality of Evidence: Low]

probioticsは安全に投与できるしかしルティーン投与を推奨するには至っていない

Probiotics:発酵乳,乳酸菌飲料,納豆,生菌製剤


Question:

Does the provision of antioxidants and trace minerals affect outcome in critically ill adult patients?

F3. We suggest that a combination of antioxidant vitamins and trace minerals in doses reported to be safe in critically ill patients be provided to those patients who require specialized nutrition therapy [Quality of Evidence: Low]

抗酸化, 微量ミネラルは安全に使用できる


Question:

Should enteral glutamine be provided to any subsets of patients in the adult ICU setting?

F4. We suggest that supplemental enteral glutamine NOT be added to an EN regimen routinely in critically ill patients. [Quality of Evidence: Moderate]

ルーティンのグルタミンの添加は推奨されない

G.WHENTOUSEPN

Question:

When should PN be initiated in the adult critically ill patient at low nutrition risk?

G1. We suggest that, in the patient at low nutrition risk (for example, NRS -2002 ≤ 3 or NUTRIC score ≤ 5), exclusive PN be withheld over the first 7 days following ICU admission if the patient cannot maintain volitional intake and if early EN is not feasible. [Quality of Evidence: Very Low]

栄養リスクの低い症例

経静脈栄養投与は7日目以降

G.WHENTOUSEPN

Question:

When should PN begin in the critically ill patient at high nutrition risk?

G2. Based on expert consensus, in the patient determined to be at high nutrition risk (for example, NRS -2002 ≥5 or NUTRIC score ≥6) or severely malnourished, when EN is not feasible, we

suggest initiating exclusive PN as soon as possible following ICU admission.

栄養リスクの高く, 経腸栄養EN不適当な症例

経静脈栄養投与はICU入室後速やかに投与

G.WHENTOUSEPN

Question:

What is the optimal timing for initiating supplemental PN when EN does not meet energy or protein goals in the patient at low or high nutrition risk?

G3. We recommend that, in patients at either low or high nutrition risk, use of

supplemental PN be considered after 7 to 10 days if unable to meet > 60% of energy and protein requirements by the enteral route alone.

Initiating supplemental PN prior to this 7–10 day period in critically

ill patients on some EN does not improve outcomes and may be detrimental to the patient. [Quality of Evidence: Moderate]

経腸栄養で目標熱量に達していない場合[<60%]

経静脈栄養併用は7-10日後

SPN studyの結果は重要視されていない


Question:

When PN is needed in the adult critically ill patient, what strategies can be adopted to improve efficacy?

H1. Based on expert consensus, we suggest the use of protocols and nutrition support teams to help incorporate strategies to maximize efficacy and reduce associated risk of PN.

PN関連リスクを減らすため, プロトコール化や栄養管理チームを勧める


Question:

In the appropriate candidate for PN (high risk or severely malnourished), should the dose be adjusted over the first week of hospitalization in the ICU?

H2. We suggest that hypocaloric PN dosing (≤ 20 kcal/kg/day

or 80% of estimated energy needs) with adequate protein (≥ 1.2 g protein/kg/day) be considered in appropriate

patients (high risk or severely malnourished) requiring PN,

initially over the first week of hospitalization in the ICU. [Quality of Evidence: Low]

栄養状態不良症例でのPN投与 ≤20 kcal/kg/day or ⽬標の80%, たんぱく質≥1.2 g/kg/day


Question: Should soy-based IV fat emulsions (IVFE) be provided in the first week of ICU stay? Is there an advantage to using alternative IVFE (i.e., medium-chain triglycerides [MCT], olive oil [OO], FO, mixture of oils) over traditional soybean oil (SO)-based lipid emulsions in critically ill adult patients?

H3a. We suggest withholding or limiting SO-based IVFE during the first week following initiation of PN in the critically ill patient to a maximum of 100 g/week (often divided into 2 doses/week) if there is concern for essential fatty acid deficiency. [Quality of Evidence: Very Low]H3b Alternative IVFE may provide outcome benefit over soy-based IVFE; however, we cannot make a recommendation at this time due to lack of availability of these products in the U.S. When these alternative IVFEs (SMOF, MCT, OO and FO) become available in the United States, based on expert opinion, we suggest that their use be considered in the critically ill patient who is an appropriate candidate for PN.


Question: Is there an advantage to using standardized commercially available PN (premixed PN) versus compounded PN admixtures?

H4. Based on expert consensus, use of standardized commercially available PN versus compounded PN admixtures in the ICU patient has no advantage in terms of clinical outcomes.


Question:

What is the desired target blood glucose range in adult ICU patients?

H5. We recommend a target blood glucose range of 140– or 150–180 mg/dL for the general ICU population; ranges for specific patient populations (post-cardiovascular surgery, head trauma) may differ and are beyond the scope of this guideline.

[Quality of Evidence: Moderate]


Question:

Should parenteral glutamine be used in the adult ICU patient?

H6. We recommend that parenteral glutamine supplementation

NOT be used routinely in the critical care setting.

[Quality of Evidence: Moderate]

aspen栄養ガイドライン - jseptic ｜ 特定非営利活 … system rctは減点方式...

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aspen栄養ガイドライン - jseptic ｜特定非営利活 … system rctは減点方式...