Insulinresistenz: Bedeutung in Anästhesie und Intensivmedizin – Wie viel Kalorien und Insulin braucht der kritisch Kranke?

Zusammenfassung

Metabolismus und Ernährungstherapie des kritisch kranken Patienten sind dynamische Parameter im Verlauf der schweren Erkrankung, die Einfluss auf den Blutzuckerspiegel nehmen. Nachdem zunächst ein Vorteil hinsichtlich des Überlebens einer intensivierten Insulintherapie in einer Studie gezeigt wurde, konnte dies in den folgenden großen Studien nicht mehr bestätigt werden. Es wurde sogar eine erhöhte Sterblichkeit berichtet. Die Hyperglykämie des Intensivpatienten sollte vor dem Hintergrund des Stress-Stoffwechsels betrachtet werden und ist möglicherweise ein adaptiver Prozess. Neben der endogenen Stressantwort verändern auch exogene Maßnahmen, wie die Therapie mit Katecholaminen und Glukokortikoiden, die Wirkung von Insulin und den Glukosemetabolismus. Hypo- und hyperkalorische Ernährung können ebenfalls die Wirksamkeit der Insulintherapie beeinflussen. Ziel der Ernährungstherapie sollte eine an den Zustand des Patienten angepasste Kalorienzufuhr sein und sowohl eine hyperkalorische Versorgung als auch ein Energiedefizit vermeiden. Unter diesen Rahmenbedingungen sollte die Insulintherapie so eingesetzt werden, dass der gewählte Zielkorridor des Blutzuckers erreicht werden kann, ohne zu einer Steigerung des Risikos für Hypoglykämien zu führen.

Abstract

Metabolism and nutrition of the critical ill are dynamic parameters of the severe disease influencing the blood glucose concentration. After the finding of increased survival in an initial study in tight glucose control, further large multicenter trials could not show such a benefit and even an increased mortality has been found. Hyperglycemia may be a feature of the stress metabolism and is possibly an adaptive process. Next to the endogenous response, therapy with catecholamines and glucosteroids impacts the response to insulin and the glucose metabolism. Hypo- and hypercaloric nutrition also interact with the insulin therapy. Nutritional therapy should be adapted to the actual state of the patient avoiding hypercaloric feeding and an energy deficit. Using this framework, therapy with insulin may be used to achieve a targeted range of glucose avoiding an increased risk of hypoglycaemia.

Insulin - Ernährung - Kalorienziel - Blutzuckersteuerung

insulin - nutrition - caloric goal - glycemic control

Kernaussagen

• Am Beginn der Ernährungstherapie ist die Energiezufuhr hypokalorisch, allerdings sollte das Kaloriendefizit nicht aus den Augen verloren werden.

• Die aktuellen Leitlinien lehnen eine hyperkalorische Ernährung in der akuten Phase ab.

• In experimentellen Studien sind auch negative Wirkungen von hyperkalorischer Ernährung und Hyperinsulinämie beschrieben.

• Das Konzept der enteralen und metabolischen Toleranz beschreibt die Anpassung der Ernährung an den aktuellen Zustand des Patienten.

• Durch Nutzung von Protokollen kann die Qualität der Ernährung gesteigert werden.

• Eine Einstellung des Blutzuckers in den Bereich 80–110 mg/dl führte in Studien zu einer deutlichen Steigerung der Hypoglykämien.

• Eine Hyperglykämie im Stress beruht auf einem Missverhältnis zwischen Glukosefreisetzung und Insulinwirkung und ist möglicherweise ein adaptiver Prozess.

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