Vorstellung eines pragmatischen Konzeptes zur bedarfsadaptierten Ernährungstherapie des kritisch kranken Patienten

 

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Zusammenfassung

Hintergrund Die korrekte Anpassung der Ernährungstherapie des kritisch kranken Patienten stellt eine Herausforderung für jeden Intensivmediziner dar. Vor allem eine Überernährung muss hierbei in den ersten Tagen der kritischen Erkrankung unbedingt vermieden werden. Bisher publizierte Arbeiten zu dieser Thematik sind oft komplex und teilweise widersprüchlich, was die praktische Umsetzung weiter erschwert. Unser Ziel ist daher die Vorstellung eines einfachen und praktikablen Ernährungskonzepts, welches neben pathophysiologischen Grundlagen auch die Implementierung der neueren wissenschaftlichen Literatur und der aktuellen Leitlinien beinhaltet.

Ergebnisse Unser Ernährungsalgorithmus beruht auf den Veränderungen des Metabolismus kritisch kranker Patienten und bezieht daher die endogene Substratproduktion mit ein. In der Akutphase führen die Ausschöpfung vorhandener Leberglykogenreserven sowie eine gesteigerte Glukoneogenese in Verbindung mit einer peripheren Insulinresistenz in der Regel zu einer ausgeprägten Hyperglykämie. Sofern keine Kontraindikationen vorliegen, wird die Ernährungstherapie frühzeitig mit zunächst nur geringer Zufuhr begonnen (10 – 20 ml/h). In den folgenden Stunden und Tagen wird die (par)enterale Zufuhr abhängig von der aktuellen individuellen metabolischen Toleranz – erkennbar anhand von Blutzuckerwerten sowie notwendiger Insulindosierung – schrittweise erhöht (oder reduziert), bis das angestrebte Ernährungsziel erreicht ist.

Zusammenfassung Unser Konzept erweitert bisher publizierte Ernährungsalgorithmen, indem es eine praktikable Handlungsanweisung unter Beachtung der endogenen Substratproduktion bietet. Durch Einbeziehung von einfachen, günstigen und ubiquitär verfügbaren Parametern ermöglicht es eine frühe, bedarfsadaptierte Ernährung, die das Risiko einer Überernährung minimiert.

Abstract

Background The correct adaptation of a nutrition support for the critically ill adult patient is a challenge for every intensivist. Especially an overfeeding in the first days of critical illness must be avoided. Previously published papers on this topic are oftentimes complex and in part contradictory, thus making the practical implementation even more difficult. Our aim is to present a simple and feasible nutrition concept, which is based on pathophysiological reasoning and implements the recent scientific literature and actual nutrition guidelines.

Results Our nutrition algorithm is based on pathophysiological changes in metabolism during critical illness and takes into account the endogenic nutrient supply. An emptying of the liver glycogen reserves and increased gluconeogenesis linked with a peripheral insulin resistance lead to an excessive hyperglycemia in the acute phase. If there are no contraindications, artificial nutrition support will be started early with initially only moderate intake (10 – 20 ml/h). Depending on the metabolic tolerance (based on blood glucose level and needed insulin dosage) in the following hours and days, the (par-)enteral nutrition support will be increased (or decreased) stepwise until the individually set feeding goal is reached.

Conclusion Our algorithm expands the recently published nutrition algorithms by providing a feasible concept, that takes into account the endogenic substrate production. By using simple, cheap and ubiquitous available parameters it allows an early and demand-based feeding, which minimizes the risk of overfeeding.

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