文献 早期経腸栄養 感染症罹患率減少効果

Intensive Care Med. 2017 Mar;43(3):380-398.

doi: 10.1007/s00134-016-4665-0. 

Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines.

Reintam Blaser A1,2, Starkopf J3,4, Alhazzani W5,6, Berger MM7, Casaer MP8, Deane AM9, Fruhwald S10, Hiesmayr M11, Ichai C12, Jakob SM13, Loudet CI14, Malbrain ML15, Montejo González JC16, Paugam-Burtz C17, Poeze M18, Preiser JC19, Singer P20,21, van Zanten AR22, De Waele J23, Wendon J24, Wernerman J25, Whitehouse T26, Wilmer A27, Oudemans-van Straaten HM28; ESICM Working Group on Gastrointestinal Function.

 

Abstract

PURPOSE: 

To provide evidence-based guidelines for early enteral nutrition (EEN) during critical illness.

METHODS: 

We aimed to compare EEN vs. early parenteral nutrition (PN) and vs. delayed EN. We defined "early" EN as EN started within 48 h independent of type or amount. We listed, a priori, conditions in which EN is often delayed, and performed systematic reviews in 24 such subtopics. If sufficient evidence was available, we performed meta-analyses; if not, we qualitatively summarized the evidence and based our recommendations on expert opinion. We used the GRADE approach for guideline development. The final recommendations were compiled via Delphi rounds.

RESULTS: 

We formulated 17 recommendations favouring initiation of EEN and seven recommendations favouring delaying EN. We performed five meta-analyses: in unselected critically ill patients, and specifically in traumatic brain injury, severe acute pancreatitis, gastrointestinal (GI) surgery and abdominal trauma. EEN reduced infectious complications in unselected critically illpatients, in patients with severe acute pancreatitis, and after GI surgery. We did not detect any evidence of superiority for early PN or delayed EN over EEN. All recommendations are weak because of the low quality of evidence, with several based only on expert opinion.

CONCLUSIONS: 

We suggest using EEN in the majority of critically ill under certain precautions. In the absence of evidence, we suggest delaying EN in critically ill patients with uncontrolled shock, uncontrolled hypoxaemia and acidosis, uncontrolled upper GI bleeding, gastric aspirate >500 ml/6 h, bowel ischaemia, bowel obstruction, abdominal compartment syndrome, and high-output fistula without distal feeding access.