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2018.04.24 ICU Journal Club / Lancet 2018; 391: 133–43.
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Page 1: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

2018.04.24��ICU Journal Club��/����

Lancet 2018; 391: 133–43.

Page 2: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Introduction

Page 3: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

���(EN)�������•=DM&2@�N�"E�83-KH��7→�A�6�)�B4�ICU<)!���SI(/→9!�*���7��+LR>��$���E5

• ICU�,30–70%�T? G�0��J;5 OF→VAP�>�Q�:��'C

•.1�����,=�#%� P

Chest 2006; 129: 960–67. Intensive Care Med 2009; 35: 2018–27. ,etc.

Acta Anaesthesiol Scand 2014; 58: 914–22.Crit Care 2005; 9: R218–25.,etc.

Crit Care Med 2009; 37: 171–76. Intensive Care Med 2011; 37: 35–45. ,etc.

Page 4: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

��1�"�)2���1�84/6.

Design9meta analysisIncluded studies96RCTs, 234�Primary Outcome9���, QOL, &��!Secondary Outcome9�, '�, �,

#%�, sepsis, MODS

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$�0�-/(OR 0.34, 95%CI 0.14-0.85)

Intensive Care Med (2009) 35:2018–2027

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��3/2ICU� ,624�(��

2014.06.24���57��

Page 5: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

M�feeding intolerance(FI)��>-�6�=B��� ���(��1>NFI�HEL�;>OFI8K�I4�,/��������D)':�G?�� ��!#!� �&"%��$�*<

PubMed�MEDLINE�Web of Science�J���5A�� 9CF�0@?27→FI�>����72�3.�+B

Acta Anaesthesiol Scand 2014; 58: 914–22.

Page 6: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• 5����outcome�'���→�������FI�")�!#������• FI (*$�ICU%����&���

Page 7: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• EN�3�0��:"5 or <���� �9���

•�;��-�EN ��$618�4(#!���=2�ICU�'�+.>��,����7*�/)����&%����

Page 8: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Am J Crit Care 2010, 19:261–268

485<;=���+-EN-��

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2���-��� �,$ �!#��3%*1�"1174�

2017.07.11��.0��

Page 9: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

����4.>�FZ48%?��SEN>�HK6PJDORC�7T);

Primary outcome`ICU+�&?]�VKA�(�-

���EN]>�HK6OA�(�-G*�

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Am J Crit Care 2010, 19:261–268

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Page 10: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Crit Care Med 2016, 44:390–438.

�ASPEN2016�(.*427n{ %��$ZF��lG8�MAP<50mmHg�Qd�$Zf����GKof&:Q�$���(.*427c�&~�$Zf��EN@O&q�$�

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Intensive Care Med 2017;43:380-398

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pUk;P 2016;23:185-281.

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Page 11: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Methods

Page 12: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 13: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

�N&�24E*�QY�T<8-%A1�3�i O!)IM��Sg�KjBa{WN9����M9�nt6yM9�_aP;0�z�/azZX9b,>^ v� hc vxs ou���(fV O!)L2FxU7 1c����94T r:���lq�Jk`ENPN�m'������!D5� ?"PN� .+(w�]e�� $pV����@\H�R�=d#[VCG�RP)

Page 14: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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• 6YQV0�&�+�� ������:E�5C�;@C�U>7� �����

Page 15: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation
Page 16: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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• 0B+-�Day7"M����9')S�7�Day8".����EN�@G

• VQ�! ��H=�U �2DK�:$+RF<>��;/�Day8��I%PN&

Page 17: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 18: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 19: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

������Primary outcome�28D)KR

�Secondary outcome �SOFA����7-�?P����T�?P����,T�U>�<�WB6/N�(Q�FJ�$@9� ����+S�$;Lac9�Bil�AST/ALT�=VOLN�%#N+S�H����E! ;�A3�90D)KR�ICU)KR��C)KR�ICU8'! �"1!G�8'! �2M�*5:�����D0�ICU�4.��4���&I.

Page 20: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

����• NUTRIREA-1��%(����PN�28#�%(�37%�EN���%(���5%� •)�������(�4.9%�Power 80%����2854��$'���• Intention-to-treat��• 1000��2000��"*���!������&

Page 21: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. Ø _`a^P8\[M�$9RCT(9$9b

Ø 48%?������]8NM�51450�

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Page 22: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Ø NUTRIREA-2��������$�!�")���� ��%�������NUTRIREA-1���#(*� �&'��� �����

Page 23: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• Primary outcome�p ≦ 0.049�5'3=����7+(2�95% ,?%#�9*• Secondary outcome�p ≦ 0.05�5'3=����7+(2•������<-�:4��������A/<-�1 0(IQRs)�;$(SD)•A/����Student t(2�Wilcoxon ��������� (2@>•!&�������6.�8"�)�

Page 24: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Results

Page 25: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

2410 ��!"�

2013)3�22(�2015)6�30(�10885 �',

2�+�%��!��&��������',��� #�������*$��%�

Page 26: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 27: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 28: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 29: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 30: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 31: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation
Page 32: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 33: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

�Primary outcome�28��������

Page 34: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

�Secondary outcome�90��ICU�����!� ���ICU�� ���� ���� �� ���������������� �� ���

Page 35: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

�Secondary outcome���� ������

Page 36: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 37: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 38: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

� �����1�������

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Page 39: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

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Page 40: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• 286%;>�?�=�#��

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Page 41: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Discussion

Page 42: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

CALORIES trial

'F�DC=?+<�H-%^_X�����PN�EN���[����

���"�J8E���"�� W1.,RCT-,�2011R6022P�2014R302PB>�&2ICU 338EL@�183#A�2P#A�%^_X�T] SN�

ICUQ:369,#O�3P#A�M5�\G(Q�PN EN�����Y6$*�V

Q:��369,#O�%^_X)7�5P,/IZU�!���25kcal/kg(;4K=)/day

N Engl J Med 2014;371:1673-84

Page 43: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Primary outcome

30�������� ��

2014.11.25�������

Page 44: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Secondary outcome

PN������� �����

2014.11.25�����# �

��������90�� $���16������!���#�"����

Page 45: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

NUTRIREA-2���• NUTRIREA-2��K980��# ��M��I(=@]�;�EJ�ICU.C�OY��G���61

• >W\�CALORIES?7�SR�5,

• NUTRIREA-2��EN�����%$���&!�BLD^�� ��H������EN�>W\�M��Z*�)3�"���������:���

• <4�N/XRCT���VFQ�EN�U-���2[+T�P�%$�EN�')3�����ICU.C�A�� N Engl J Med 2015; 372: 2398–408.

Page 46: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• NUTRIREA-2�3a+0)!/�FID9�=K<�?5�TB�����(#�1��H�-/'%1&�@>���

• FI9E�?5�=K<(24C_)Q7�6Y<(V4C_)Q7�Z���

• 9E�*�$�L8�U�������3aS",�)�FID9�?5�B� �Ob�F`

• \@>���PN9E�6Y<�;G�]���JB�EN�M�P����

• ^X 0.��Day0�Day7�Day8�W:�NR�[A

Page 47: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• NUTRIREA-2��EN>�[6<A�8U[fIS�W���M��

•l>��:U7V���20kcal/kg/day�!-+��O��

•AFaY�/^�����(,!-+��EN�07�����" '* .�TQ�KL��@3

•]!-+�EN�R16GeS����[6<A�+%#�C��2bU�����NUTRIREA-2�`i?m���Zh��B;���E��\H�ck

• EN�dX�5N�gP_�PN�& ).$�EN�=j��5N�EN4J�& ).$��D9�

Page 48: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• CALORIES/*�9D��ICU&62�=7�A!.��� �

•���� �$5���PN�<%��EN�&64->2�+1�0����

• PN�'E�ICU�":&6B@����3?��(G�,����

•����RCT�PN�(G��&62�8C)H������8CF�(G�� �#;4�

Page 49: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Limitation

Page 50: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Q2)L�C,(@4�A.C7→MD�84%(2410>)�-������C,(@�2'�2)��P9 ��������6��*<�-����2'�$0����5���

R*<�ICU !"#�K3%������→:O�?;=�K3%�I&H�

Primary outcome(28F8JN) �/+E����K3%�1G���B�$0���

Page 51: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

`N.6DZO�?K+'&(%L3����→EN4I� "Q=V�S68XY/�$�0XP�"�N.6DZO�U9%�!��U���� ��+'&(%@!��

a8XV�T7V�\AY/��→-]>_JO4I�T7\A�,<%:�� �%HE��2;�*�)����5RDZO�90WG[^���F�����T7\A��B1�M���C�!$#

Page 52: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Conclusion

Page 53: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

•���� 7�/�*+C���3('&$#B8�-1", ���42����?<�5%�AC>��EN�PN���D.9 @����

•5%PN�;!�:�����5%EN�0�#)=1�����6 ��

Page 54: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Critical appraisal

Page 55: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

�����• Intention-to-treat;`�]�N\+! '�N�• "�.51/3�JZ+! '�TP+! '�9p_• %5&�305*�yg��(9u-4)$�h8>t)• n6Cq�si6���[<�f�• /�'1!5o_��x���R���• ENF�#42��(5,$XaY��\��l}H����r=�� ����• ENF�j@�md^z�S~�f�PNF�k�|wz�S~�f�• LQ����Vv��I:���E�• cAWMhU�7D→?b]�PNF���f�GO���KB�e�{6R���9p_�

Page 56: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

�����•B�L�'7�8$'7�J?�1���•E2A-(��•PN����20-25kcal/kg/day�Day1 F=���C� ;•%5�86%�3D�H>/�Q30%�3D�)G&/�0R���• BMI 28�+KMO•����@6T�<9���:��•,"I �S*��20kcal/kg/day���!#�����@6T�����.4I

Page 57: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

Personal opinion

Page 58: 2018.04.24 ICU Journal Club · 2018-05-10 · Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation

• Permissive underfeeding�<\��!��LP9K�kd%.,�20-25kcal/kg/day�V>EN$7H����O4;DePW5�����6`R�!�tLPN>�^n%.,�$C������EN�PN�b8cp�

•hA?��:UP�aS�l/E�M����t:UmgXG�Qf�[T�;r�PN��%)�)-:U=��:UP,'&�3 !����!�tEN�s]W���VAPW5�!#������tZ_iYqmg�Z;j2Fo0J�� Bacterial translocation$mg�!���EN�+,(*�:UP$B������O4;DePW5�1@��!�I#"!�


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