DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“

Gunnar Elke; Wolfgang H. Hartl; K. Georg Kreymann; Michael Adolph; Thomas W. Felbinger; Tobias Graf; Geraldine de Heer; Axel R. Heller; Ulrich Kampa; Konstantin Mayer; Elke Muhl; Bernd Niemann; Andreas Rümelin; Stephan Steiner; Christian Stoppe; Arved Weimann; Stephan C. Bischoff

doi:10.1055/a-0713-8179

Aktuelle Ernährungsmedizin, Table of Contents

Aktuelle Ernährungsmedizin 2018; 43(05): 341-408
DOI: 10.1055/a-0713-8179

Leitlinie

DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“

S2k-Leitlinie (AWMF-Registernummer 073-004) der Deutschen Gesellschaft für Ernährungsmedizin (DGEM^[a]) in Zusammenarbeit mit der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI^[b]) sowie den Fachgesellschaften Deutsche Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI^[c]), Deutsche Gesellschaft für Chirurgie (DGCH^[d]), Deutsche Gesellschaft für Internistische Intensivmedizin und Notfallmedizin (DGIIN^[e]), Deutsche Gesellschaft für Kardiologie (DGK^[f]), Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie (DGTHG^[g]) und Deutsche Sepsis-Gesellschaft (DSG^[h])DGEM Guideline “Clinical Nutrition in Critical Care Medicine”S2k-Guideline (AWMF Registry Number 073-004) of the German Society for Nutritional Medicine (DGEM^a) in Cooperation with the German Interdisciplinary Association of Intensive and Emergency Medicine (DIVI^b) and the Medical Societies German Society of Anaesthesiology and Intensive Care Medicine (DGAI^c), German Society of Surgery (DGCH^d), German Society of Medical Intensive Care and Emergency Medicine (DGIIN^e), German Cardiac Society (DGK^f), German Society for Thoracic and Cardiovascular Surgery (DGTHG^g) and German Sepsis Society (DSG^h)

Gunnar Elke

¹Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel

,

Wolfgang H. Hartl

²Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München – Klinikum der Universität, Campus Großhadern, München

,

K. Georg Kreymann

³Flemingstraße 2, 22299 Hamburg

,

Michael Adolph

⁴Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen

,

Thomas W. Felbinger

⁵Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching, Neuperlach und Schwabing, Städtisches Klinikum München GmbH, München

,

Tobias Graf

⁶Universitäres Herzzentrum Lübeck – Medizinische Klinik II/Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck

,

Geraldine de Heer

⁷Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg

,

Axel R. Heller

⁸Klinik für Anästhesiologie und Operative Intensivmedizin, Universität Augsburg, Augsburg

,

Ulrich Kampa

⁹Klinik für Anästhesiologie und Intensivmedizin, Ev. Krankenhaus Hattingen, Hattingen

,

Konstantin Mayer

¹⁰Zentrum für Innere Medizin, Medizinische Klinik II, Universtitätsklinikum Gießen und Marburg, University of Giessen Lung Center, Standort Gießen, Gießen

,

Elke Muhl

¹¹Eichhörnchenweg 7, 23627 Gross Grönau

,

Bernd Niemann

¹²Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen

,

Andreas Rümelin

¹³Klinik für Anästhesie und operative Intensivmedizin, HELIOS St. Elisabeth-Krankenhaus Bad Kissingen, Bad Kissingen

,

Stephan Steiner

¹⁴Abteilung für Kardiologie, Pneumologie und Internistische Intensivmedizin, St. Vincenz-Krankenhaus, Limburg

,

Christian Stoppe

¹⁵Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen

,

Arved Weimann

¹⁶Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie , Klinikum St. Georg gGmbH, Leipzig

,

Stephan C. Bischoff

¹⁷Institut für Ernährungsmedizin, Universität Hohenheim, Stuttgart

› Author Affiliations

Abstract

Zusammenfassung

Fragestellung Die enterale und parenterale Ernährungstherapie kritisch kranker Patienten kann u. a. durch den Zeitpunkt des Beginns, die Wahl des Applikationswegs, die Menge und Zusammensetzung der Makro- und Mikronährstoffzufuhr sowie der Wahl spezieller, immunmodulierender Nährsubstrate variieren. Die Durchführung der Ernährungstherapie nimmt Einfluss auf den klinischen Ausgang dieser Patienten. Ziel der vorliegenden Leitlinie ist es, aktualisierte konsensbasierte Empfehlungen zur klinischen Ernährung kritisch kranker, erwachsener Patienten, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden, zu geben.

Methodik Die früheren Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) wurden in Einklang mit den aktuellen Richtlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) als S2k-Leitlinie aktualisiert. Entsprechend der S2k-Klassifikation dieser Leitlinie enthalten die dargestellten Empfehlungen keine Angabe von Evidenz- und Empfehlungsgraden, da keine systematische Aufbereitung der Evidenz zugrunde gelegt wurde. Als Grundlage für die Empfehlungen wurden insbesondere die seit Erscheinen der letzten DGEM-Leitlinien Intensivmedizin publizierten randomisiert-kontrollierten Studien und Metaanalysen, Beobachtungsstudien mit angemessener Fallzahl und hoher methodologischer Qualität (bis Mai 2018) sowie aktuell gültige Leitlinien anderer Fachgesellschaften herangezogen und kommentiert. Die Empfehlungsstärke ist rein sprachlich beschrieben. Jede Empfehlung wurde mittels Delphi-Verfahren abschließend bewertet und konsentiert.

Ergebnisse Die Leitlinie beschreibt einführend die pathophysiologischen Konsequenzen einer kritischen Erkrankung, welche den Metabolismus und die Ernährbarkeit der Patienten beeinflussen können, ferner die Definitionen unterschiedlicher Erkrankungsphasen im Krankheitsverlauf und sie diskutiert methodologische Aspekte zu ernährungsmedizinischen Studien. In der Folge werden 69 konsentierte Empfehlungen zu wesentlichen, praxisrelevanten Elementen der klinischen Ernährung kritisch kranker Patienten gegeben, darunter die Beurteilung des Ernährungszustands, die Indikation für die klinische Ernährungstherapie, der Beginn und Applikationsweg der Nahrungszufuhr, die Menge und Art der zugeführten Substrate (Makro- und Mikronährstoffe) sowie ernährungstherapeutische Besonderheiten bei adipösen kritisch kranken Patienten und Patienten mit mechanischen Unterstützungssystemen.

Schlussfolgerung Mit der Leitlinie werden aktuelle Handlungsempfehlungen zur enteralen und parenteralen Ernährung erwachsener Patienten geben, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden. Die Gültigkeit der Leitlinie beträgt voraussichtlich 5 Jahre (2018 – 2023).

Abstract

Purpose Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of delivery, the amount and composition of macro- and micronutrients, and the choice of special, immune-modulating substrates. Variations of clinical nutrition affect outcome. The present guideline provides updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device to maintain organ function.

Methods The recent guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification no systematic review of the available evidence was required to make recommendations, which therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The grading of each recommendation is solely described linguistically. Each recommendation was finally validated and consented through a Delphi process.

Results In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease stages during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition therapy, the timing and route of nutrition, and the amount and composition of substrates (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with mechanical support devices.

Conclusion The current guideline provides up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018 – 2023).

Schlüsselwörter

medizinische Ernährungstherapie - enterale Ernährung - parenterale Ernährung - kritische Erkrankung - Leitlinie - Adipositas

Keywords

medical nutrition therapy - enteral nutrition - parenteral nutrition - critical illness - guideline - obesity

Full Text

References

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