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This article was published on October 22, 2018, at NEJM.org.
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Crit Nutr 2009;28:387-400
�*�(��,�.3+��38)1"&��5Hypocarolic enteral nutrition6 2-9
Crit Care Med 2009;37:1757-61
ESPEN vs. ASPEN/SCCM EPaNIC trial
*Design+ Randomised controlled, Prospective, Multicenter*Patients+ ICU0� -)�('�1��NRS≧31��44640�5*Intervention/Control+ICU� �48�&��0PN��%�"(Early-initiation")ICU� �7�2PN3��-/,"(Late-initiation")*Outcome+Primary:ICU���&Secondary:�� ���)�#$���&)ICU���&)���!��&/.
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(Design)<X< factorial, Randomised controlled(Patients)18���.���+6.1mmol/L(110mg/dl)��1���%��1ICU �240�(Intervention/Control)��386960%-70%(permissive underfeeding�)→59.0&16.1%
90%-100%(target feeding�)→71.4&22.8%�����4.4-6.1mmol/L:IIT�;/10-11.1mmol/L(CIT�)�"2!44795(PU+IIT,PU+CIT,TG+IIT,TG+CIT)0�,- *(Outcome)Primary=28����Secondary:ICU����'�$�#'180����'������#
Am J Clin Nutr 2011;93:569-77
����Permissive underfeeding��������
Primary outcome�� ����������
90-100%����������Underfeeding(60%-70%)��� !
• ������� � �60%-70%(permissive underfeeding�)→59.0�16.1%90%-100%(target feeding�)→71.4�22.8%
• � �������� ��
,Design- Randomised, open-lavel, Multiple-center,Patients- ALI��48�(��1+������.�#/501000�2 ,Intervention/Control-�400 kcal/�+�$'225%+ 6�(��(Trophic-feeding�)��;25kcal/kg/�→��';�1300 kcal/�+�$'280%(Full-feeding�),Outcome-Primary:28��312����*!�((VFDs)Secondary;�$6897:�&�+60����+")4ICU free�(+�%���
VFD����������
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• �������80% �������
Design! Two-center, Randomised controlled Patients! ICU��3��&����(+-/536$��)60%���� Intervention/Control!20-30ml/h&EN ����3��*&251064&���SPN�94��#,��('-+"PN��728 kcal/kg/day8EN�9%)**EN.��(20 kcal/kg/day) Outcome!Primary:8��#,28��*&)����
SPN(supplemental PN) trial
Lancet 2013;381:385-93
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PermiT trial
N Engl J Med 2015;372:2398-408
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400kcal/day or
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,!PVTZ40~60%
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,!PVTZ90~100%
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,!PVTZ70 ~100%
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Problem
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I Energy-dense(1.5kcal/ml)1ml/kg(IBW)/h
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Methods Trial design• ,.&*��������
• #/%',-"�)+/$/,.(�46�ICU
• 2016�6���2017�11������
• ANZIC(Australian and New Zealand Intensive Care Society)�� ��
•��������!� �� ��
Methods Trial design• NPONP79��R�BE⇒���<M1#>X`VK18>6!�'K�5JL;�CI?
•�&�K+-$= RFresenius Kabi DeutschlandNP��⇒Fresenius Kabi DeutschlandK�0,A�'�J�'R4�C\S`Z[WT
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Methods Patient populationPatient Inclusion1. ICU"��� �&18���
2. ���'������
3. ����(�%&��&�$�% 12����
4. ICU!48����#�������� �'&
Methods Patient populationExclusion criteria1. >@,IK_LZ�Y,IaE�PT12*F��>C
2. A��M1ml/kg(IBW)/hYEN:.a;�V 'PQ��(1��GY�B"=)
3. A��\,I�M5�W,I38M�BV 'PQ��
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Figure S1
Method nutrition�!�
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• Energy-dense2675'routine2675*�$9:9)(.,#permuted block randomization/��
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Energy-dense Routine
Calorie 1.5kcal/ml 1kcal/ml
Fat 58g/L 27g/L
Carbohydrate 180g/L 125g/L
Protein 56g/L 55g/L
Fiber 15g/L 20g/L
Salt 2.5g/L 3.8g/L
Water 78ml/100ml 83ml/100ml
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• 28"��[ICU��E�6VENe�=WPUJc��Z\�Q&He�C
Methods outcome?Primary Outcome@WXSV��90 ��K$�$�
?Secondary Outcome@*�#9(90 NGJ8�)90 9K'�K$�(28 -�M:#9�K$�$�WXSV�Z28 -NGKICU-freeAOBLhospital-free#9WXSV�Z28 -NGK2�RUYT�6I#9�����.)>!��>�7K1�"+%Q�CFBO �
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• Primary Outcome(��(%*!�����(582')7&(1784.",#$* �
� (≧65� or <65�)
��(��!sepsis!������!��3/49���vs.���:)
Australian and Newzealand Risk of Death Score'+-�����620(5���(ANZICS CORE)
Body mass index(<18.5!18.5;24.9!25.0;29.9!≧30.0)
Methods Statistical analysis• 2:38%�9#0B3-ATARGETKWR8�&%�PSV7>@�"
• TARGET�" !(�5ANZICS CORE��� MWJQWH.?8NWJC<57,QWHSEV890����C20-30%5��⇒��80% 4,��7>@3.8-4.3%8*-/$);A5��1,GVPTGEIC3774�5�
•'�/ !6GVPTGEI9,OFUWDLP�+=�+%�7>@��2A5��1,4000�7��
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• LVPT?,Umodified intention-to-treat(ITT)Z���4Per-protocolHas-treated# ?,UprimaryosecondaryT�<Q(=/&�U>�NMH?,U�$KOfpcZWRS(=
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• 2;ET�U��o�E(Hodges-Lehman%�C)o95qG�EQ@DB9�'S�KPUt-�WKJUWilcoxonTF��-�Z�4^e`lp�'S�KPU^\��-�Z�4
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Result
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• Outcome>"�?& �+(<KMJQTN)�:CFD<387
1. �=0�.��4�2�$:CFD<3875;⇒�.��>*�>� <��?<27BBMI:��
�>2%>�$4BMI18.5��⇒5EA:>�.��>�!3D?-�6E927
2. �>1/34BMI30��>%��$:187⇒IGLOGS:?�HRPT(11-14kcal/kg/day)U/'��.4��⇒hypocaloricCeucaloricC'�,4#�6EE@"�?FD<387
•�G(�8�=_OA9c$N �Jb��a\]DVi⇒��b25^e �Jb�S\[1.5kcal<^�S\[⇒�=0aLX]cO'E�f?C*�aeL�Yi�>�Qh
• �*�TRgZ50%/`in4Mb;@$N�j�.⇒!��b3�W_1.5kcal<^boverfeedingbmlkjFUi[dP1% B7c�)IghIBWj�.(IBW:29.1kcal/kg/day ABW:23.1kcal/kg/day)
⇒OverfeedingjFU[V_^&�,c�<^�c`S\[�H�+: P�����8-"KP�#0��,6�<^�c`X
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Limitation
3. ENK�-FICU�9�24 7�I0� J��F6�AND⇒ENJ��QVUX�5J�!��K�=,"I�:BH>ED
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Conclusion
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• OutcomeP��#J�- VTMB
⇒QOLRADL+PLCD_
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Clinical Nutrition xxx (2018) 1e32
Lancet Respir Med 2015;3:943-52→ 2016.02.23OJC�!