Ernährung bei Intensivpatienten

Zusammenfassung

Der prognostische Einfluss einer adäquaten Energie- und Proteinzufuhr ist gerade für den mangelernährten Intensivpatienten aktuell erneut gezeigt worden. Konsens besteht über die Vorteile einer frühzeitigen enteralen Ernährung. Das Bestehen einer gastrointestinalen Intoleranz schafft beim kritisch Kranken häufig jedoch erhebliche Probleme und auch Risiken bei der Durchführung. Für den Fall einer unzureichenden enteralen Kalorienzufuhr wird die Zeitspanne bis zum Beginn einer totalen oder kombiniert enteralen und parenteralen Ernährung kontrovers diskutiert. Da beim kritischen Kranken ungünstige Effekte nicht ausgeschlossen werden können, muss die Gabe von immunomodulierenden Substraten besonders vorsichtig erfolgen. Empfohlen wird die Implementierung eines leitlinienbasierten Ernährungsprotokolls. Hierbei bezieht die vorliegende Übersicht die aktuellen Leitlinien der Europäischen Gesellschaft für klinische Ernährung und Metabolismus (ESPEN) von 2009, der Amerikanischen Gesellschaft für Parenterale und Enterale Ernährung (ASPEN) von 2009 und der Deutschen Sepsis-Gesellschaft (DSG) von 2010 ein.

Abstract

The prognostic impact of inadequate energy and protein supply in malnourished intensive care patients has been recently reemphasized. Consent exists about the beneficial effects of early enteral nutrition in the critically ill. However, gastrointestinal intolerance of the critically ill may be a major problem for the feasibility of enteral nutrition bearing additional risks. In case adequate enteral nutrition cannot be realized, there is controversy about the appropriate time to start total parenteral or combined enteral / parenteral nutrition. Due to potential adverse effects immune-enhancing substrates have to be cautiously administered. For standardization implementation of a guideline based nutritional protocol is recommended. The review refers to the recent guidelines of the European Society for Clinical Nutrition and Metabolism (2009), the American Society for Parenteral and Enteral Nutrition (ASPEN) (2009) and the German Sepsis Society (DSG) (2010).

Schlüsselwörter

Enterale Ernährung - parenterale Ernährung - metabolisches Risiko

Keywords

nutritional support - enteral nutrition - parenteral nutrition - nutritional risk

Literatur

• 1 Akinnusi M E, Pineda L A, EL Solh A A. Effect of obesity on intensive care morbidity and mortality: A meta-analysis.  Crit Care Med. 2008;  36 151-158
• 2 Alberda C, Gramlich L, Jones N. et al . The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study.  Intensive Care Med. 2009;  35 1728-1737
• 3 Al Saady N M, Blackmore C M, Bennett E D. High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially ventilated patients.  Intensive Care Med. 1989;  15 290-295
• 4 Angstwurm M W, Engelmann L, Zimmermann T. et al . Selenium in Intensive CAre (SIC): results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock.  Crit Care Med. 2007;  35 118-126
• 5 Bakalar B, Duska F, Pachl J. et al . Parenterally administered dipeptide alanyl-glutamine prevents worsening of insulin sensitivita in multiple trauma patients.  Crit Care Med. 2006;  34 381-386
• 6 Barr J. et al . Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol.  Chest. 2004;  2 1446-1457
• 7 Battistella F D, Widergren J T, Anderson J T. et al . A prospective, randomized trial of intravenous fat emulsion administration in trauma victims requiring total parenteral nutrition.  J Trauma. 1997;  43 52-58
• 8 Baue A E, Durham R, Faist E. Systemic inflammatory response syndrome (SIRS), multiple organ dysfunction syndrome (MODS), multiple organ failure (MOF): are we winning the battle?.  Shock. 1998;  10 79-89
• 9 Berg A, Bellander B M, Wanecek M. et al . Intravenous glutamine supplementation to head trauma patients leaves cerebral glutamate concentration unaffected.  Intensive Care Med. 2006;  32 1741-1746
• 10 Berger M M, Chiolero R L. Enteral nutrition and cardiovascular failure: from myths to clinical practice.  JPEN J Parenter Enteral Nutr. 2009;  33 702-709
• 11 BesselinkMG, van Santvoort H C, Buskens E. et al . Probiotic prophylaxis in predicted severe acute pancreatitis: a randomised, double-blind, placebo-controlled trial.  Lancet. 2008;  371 651-659
• 12 Braga M, Ljungqvist O, Soeters P. et al . ESPEN Guidelines in Parenteral Nutrition: Surgery.  Clin Nutr. 2009;  28 379-386
• 13 Brunkhorst F M, Engel C, Boos F. et al . Intensive insulin therapy and pentastarch resuscitation in severe sepsis.  N Engl J Med. 2008;  358 125-139
• 14 Casaer M P, Mesotten D, Hermans G. et al . Early versus late parenteral nutrition in critically ill adults.  N Engl J Med. 2011;  365 506-517
• 15 Déchelotte P, Hasselmann M, Cynober L. et al . L-alanyl-L-glutamine dipeptide-supplemented total parenteral nutrition reduces infectious complications and glucose intolerance in criticall ill patients: the French controlled, randomized, double-blind, multicenter study.  Crit Care Med. 2006;  34 598-604
• 16 Doig G S, Heighes P T, Simpson F, Sweetman E A. Early enteral nutrition reduces mortality in trauma patients requiring intensive care: A meta-analysis of randomised controlled trials.  Injury. 2011;  42 50-56
• 17 Eliasen M M, Brabec M, Gerner C. et al . Reduced stress tolerance of glutamine-deprived human monocytic cells is associated with selective down-regulation of Hsp70 by decreased mRNA stability.  J Mol Med. 2006;  84 147-158
• 18 Falcao de Arruda I S, de Aguilar-Nascimento J E. Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients.  Clin Sci (Lond). 2004;  106 287-292
• 19 Felbinger T W, Sachs M Prognostische Bedeutung der Mangelernährung in der Intensivmedizin.. In: Weimann A, Schütz T, Lochs H Krankheitsbedingte Mangelernährung – eine Herausforderung für unser Gesundheitswesen.. Lengerich: Pabst; 2010: 60-65
• 20 Felbinger T W. Kombinierte enterale und parenterale Ernährung – Ernährung des kritisch Kranken.  Intensivmed. 2011;  48 109-116

• 21 Gadek J E, DeMichele S J, Karlstad M D. et al . Effect of enteral feeding with eicosapentenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral nutrition in ARDS study group.  Crit Care Med. 1999;  27 1409-1420
• 22 Grau T, Bonet A, Minambres E. et al . The effect of L-alanyl-L-glutamine dipeptide supplemented total parenteral nutrition on infectious morbidity and insulin sensitivity in critically ill patients.  Crit Care Med. 2011;  39; Epub ahead of print
• 23 Griesdale D EC, de Souza R J, van Dam R M. et al . Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR data.  CMAJ. 2009;  180 821-827
• 24 Grimm H, Tibell A, Norrlind B. et al . Immunoregulation by parenteral lipids: impact of the n-3 to n-6 fatty acid ratio.  J Parenter Enteral Nutr. 1994;  18 417-421
• 25 Hamani D, Kuhn M, Charrueau C. et al . Interactions between omega3 polyunsaturated fatty acids and arginine on nutritional and immunological aspects in severe inflammation.  Clin Nutr. 2010;  29 654-662
• 26 Heighes P T, Doig G S, Sweetman E A, Simpson F. An overview of evidence from systematic reviews evaluating early enteral nutrition in critically ill patients: more convincing evidence is needed.  Anaesth Intensive Care. 2010;  38 167-174
• 27 Herve P, Simonneau G, Girard P. et al . Hypercapnic acidosis induced by nutrition in mechanically ventilated patients: glucose versus fat.  Crit Care Med. 1985;  13 537-540
• 28 Heller A R, Rössler S, litz R J. et al . Omega-3-fatty acids improve the diagnosis-related clinical outcome.  Crit Care Med. 2006;  34 972-979
• 29 Heyland D K, Dhaliwal R, Drover J W. et al . Canadian Clinical Practice Guidelines for nutrition support in mechanically ventilated critically ill adult patients.  JPEN J Parenter Enteral Nutr. 2003;  27 355-373
• 30 Heyland D K, Dhaliwal R, Suchner U, Berger M M. Antioxidant nutrients: A systematic review of trace elements and vitamins in the critically ill patient.  Intensive Care Med. 2005;  31 327-337
• 31 Heyland D K, Dhaliwal R, Day A G. et al . Reducing Deaths due to Oxidative stress (the redoxs study); Rationale and study design for a randomized trial of glutamine and antioxidant supplementation in critically ill patients.  Proc Nutr Soc. 2006;  65 250-263
• 32 Kreymann K G, Berger M M, Deutz N EP. et al . ESPEN Guidelines Enteral Nutrition: Intensive Care.  Clin Nutr. 2006;  25 210-223
• 33 Kreymann G, Adolph M, Mueller M J. Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. Energy intake and energy expenditure. Guidelines on parenteral nutrition. Chapter 3.  Ger Med Sci. 2009;  7; Doc25
• 34 Lighart-Melis G C, van de Poll M C, Dejong C H. et al . The route of administration (enteral or parenteral) affects the conversion of isotopically labeled L-(2 – 15N) glutamine into citrulline and arginine in humans.  JPEN J Parenter Enteral Nutr. 2007;  31 343-350
• 35 Luiking Y C, Poeze M, Dejong C H. et al . Sepsis: an arginine deficiency state.  Crit Care Med. 2004;  32 2135-2145
• 36 Marik P E, Zaloga G P. Immunonutrition in critically ill patients: a systematic review and analysis of the literature.  Intensive Care Med. 2008;  34 1980-1990
• 37 Marik P E, Zaloga G P. Immunonutrition in high-risk surgical patients: a systematic review and analysis of the literature.  JPEN J Parenter Enteral Nutr. 2010;  34 378-386
• 38 McClave S A, Martindale R G, Vanek V W. et al . Guidelines for the provision and assessment of nutrition support therapy in the adult critically patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).  JPEN J Parenter Enteral Nutr. 2009;  33 277-316
• 39 Menne R, Adolph M, Brock E. et al . Cost analysis of parenteral nutrition regimens in the intensive care unit: three-compartment bag system vs multibottle system.  JPEN J Parenter Enteral Nutr. 2008;  32 606-612
• 40 Moore F A, Moore E E. The evolving rationale for early enteral nutrition based on paradigms of multiple organ failure: a personal journey.  Nutr Clin Pract. 2009;  24 297-304
• 41 Montejo J C, Minambres E, Bordejé L. et al . Gastric residual volume during enteral nutrition in ICU patients: the REGANE study.  Intensive Care Med. 2010;  36 1386-1393
• 42 Moss G. The etiology and prevention of feeding intolerance paralytic ileus – revisiting an old concept.  Ann Surg Innov Res. 2009;  3 3
• 43 Nolopp M, Weimann A. Enterale Ernährung bei hämodynamischer Instabilität. Lose Blattreihe Intensivmedizin Landsberg: Ecomed. im Druck
• 44 Peterson S J, Tsai A A, Scala C M. et al . Adequacy of oral intake in critically ill patients 1 week after extubation.  J Am Diet Assoc. 2010;  110 427-433
• 45 Petros S, Engelmann L. Enteral nutrition delivery and energy expenditure in medical intensive care patients.  Clin Nutr. 2006;  25 51-59
• 46 Pichard C, Schwarz G, Frei A, Kyle U. et al . Economic investigation of the use of three-compartment total parenteral nutrition bag: prospective randomized unblended controlled study.  Clin Nutr. 2000;  19 245-251
• 47 Pichard C, Thibault R, Heidegger C P, Genton L. Enteral and parenteral nutrition for critically ill patients: A logical combination to optimize nutritional support.  Clin Nutr. 2009;  4 (Suppl 1) 3-7
• 48 Pontes-Arruda A, Aragao J M, Albuquerque J D. Effects of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in mechanically ventilated patients with severe sepsis and septic shock.  Crit Care Med. 2006;  34 2325-2333
• 49 Pontes-Arruda A, Demichele S, Seth A, Singer P. The use of an inflammation-modulating diet in patients with acute lung injury or acute respiratory distress syndrome: a meta-analysis of outcome data.  JPEN J Parenter Enteral Nutr. 2008;  32 596-605
• 50 Poulard F, Dimet J, Martin-Lefevre L. et al . Impact if not measuring residual gastrioc volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study.  JPEN J Parenter Enteral Nutr. 2010;  34 125-130
• 51 Rayes N, Hansen S, Seehofer D. et al . Early enteral supply of fiber and Lactobacilli versus conventional nutrition: a controlled trial in patients with major abdominal surgery.  Nutrition. 2002;  18 609-615
• 52 Rayes N, Seehofer D, Theruvath T. et al . Supply of pre- and probiotics reduces bacterial infection eates after liver transplantation- a randomized double-blind trial.  Am J Transplantat. 2005;  5 125-130
• 53 Reintam A, Parm P, Kitus R. et al . Gastrointestinal failure score in critically ill patients: a prospective observational study.  Crit Care. 2008;  12 R90
• 54 Reinhart K, Brunkhorst F M, Bone H G. et al . Prävention, Diagnose, Therapie und Nachsorge der Sepsis – erste Revision der S“k-Leitlinien der Deutschen Sepsis-Gesellschaft e. V. (DSG) und der Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin (DIVI).  Intensivmed. 2010;  47 185-207
• 55 Schulman A S, Wilcutts K F, Clarifge J A. et al . Does the addition of glutamine to enteral feeds affect patient mortality?.  Crit Care Med. 2005;  33 2501-2506
• 56 Simpson F, Doig G S. Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle.  Intensive Care Med. 2005;  31 12-23
• 57 Singer P, Theilla M, Fisher. et al . Benefit of an enteral diet enriched with eicosapentaenoic acid and gamma-linolenic acid in ventilated patients with acute lung injury.  Crit Care Med. 2006;  34 1033-1038
• 58 Singer P, Berger M M, Van den Berghe G. et al . ESPEN Guidelines on Parenteral Nutrition: Intensive Care.  Clin Nutr. 2009;  28 387-400
• 59 Singleton K D, Wischmeyer P E. Glutamine’s protection against sepsis and lung injury is dependant on heat shock protein 70 expression.  Am J Physiol Regul Integr Comp Physiol. 2007;  292 R1839-R1845
• 60 Takala J, Ruokonen E, Webster N R. et al . Increased mortality associated with growth hormone treatment in critically ill adult patients.  N Engl J Med. 1999;  341 785-792
• 61 Ukleja A. Altered GI motility in critically Ill patients: current understanding of pathophysiology, clinical impact, and diagnostic approach.  Nutr Clin Pract. 2010;  25 16-25
• 62 Van den Berg B, Bongaard J M, Hop W C. High fat. Low carbohydrate, enteral feeding in patients weaning from the ventilator.  Intensive Care Med. 1994;  20 470-475
• 63 Van den Berghe G, Wouters P, Weekers F. et al . Intensive insulin therapy in the critically ill patients.  N Engl J Med. 2001;  345 1359-1367
• 64 Van de Poll M C, Siroen M P, van Leeuwen P A. et al . Interorgan amino acid exchange in humans: consequences for arginine and citrulline metabolism.  Am J Clin Nutr. 2007;  85 167-172
• 65 Villet S, Chiolero R L, Bollmann M D. et al . Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients.  Clin Nutr. 2005;  24 502-509
• 66 Visser J, Labadarios D, Blaauw R. Micronutrient supplementation for critically adults: A systematic review and meta-analysis.  Nutrition. 2011;  27 745-758
• 67 Weimann A. Omega-3-fatty acid supplemented parenteral nutrition in the critically ill – another step forward on the great journey.  Crit Care Med. 2006;  34 1253-1255
• 68 Weimann A, Ebener C H, Holland-Cunz S. et al . Surgery and transplantation – Guidelines on parenteral nutrition, Chapter 18.  GMS Ger Med Sci. 2009;  7 Doc10 (20 091 118)
• 69 Weimann A. Immunmodulation durch Ernährung – neue Befunde.  Aktuel Ernährungsmed. 2008;  33 101-105
• 70 Ziegler T R, Ogden L G, Singleton K D. et al . Parenteral glutamine increases serum heat shock protein 70 in critically ill patients.  Intensive Care Med. 2005;  31 1079-1086