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DOI: 10.1055/s-2008-1067545
© Georg Thieme Verlag KG Stuttgart · New York
Ernährung des kritisch kranken adipösen Patienten
Nutritional Support in the Critically Ill Obese PatientPublication History
Publication Date:
20 November 2008 (online)
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Zusammenfassung
Das Körpergewicht des Patienten ist auch bei der Ernährungstherapie des Intensivpatienten zu berücksichtigen. Grundsätzlich ist festzustellen, dass viele ernährungsmedizinische Leitlinien (DGEM, ESPEN) auch bei diesem besonderen Krankengut ihre Gültigkeit besitzen. Wahrscheinliche Ausnahmen stellen die Kalorienzufuhr und die Eiweißzufuhr dar, deren Umfang modifiziert werden muss. Eine Abschätzung des tatsächlich vorhandenen Kalorienumsatzes kann nur annäherungsweise mittels speziell adaptierter Formeln (z. B. modifizierte Harris-Benedict-Formel) durchgeführt werden, erfolgt idealerweise aber mittels indirekter Kalorimetrie. Problematisch ist jedoch die isokalorische Zufuhr der tatsächlich berechneten Kalorienmenge. Hier besteht ein hohes Risiko für Nebenwirkungen (Leberverfettung, Hyperglykämie) und es sind technische Probleme (große Applikationsvolumina bei enteraler Ernährung) zu erwarten. Somit hat sich auf der Basis weniger Phase-I-ähnlicher Studien ein hypokalorisches Konzept durchgesetzt. Das es Hinweise für eine dysproportional gesteigerte Eiweißkatabolie bei kritisch kranken Adipösen gibt, sollte gleichzeitig auf eine besonders eiweißreiche Diät geachtet werden. Möglicherweise besteht auch ein erhöhter Glutaminbedarf, der insbesondere bei parenteraler Ernährung zu berücksichtigen wäre. Grundsätzlich ist unser ernährungsmedizinisches Wissen hinsichtlich der Behandlung des adipösen Intensivpatienten bisher nur bruchstückhaft. Spezielle Aspekte der Ernährungstherapie (z. B. bei schwerer Sepsis oder Langzeitbeatmung) sind bei diesem speziellen Krankengut bisher nicht untersucht; es ist fraglich, ob jemals Empfehlungen möglich sein werden, deren Nutzen sich anhand von harten Prognosevariablen (Letalität) eindeutig belegen lässt.
Abstract
Body weight is an important determinant of nutritional therapy during critical illness. It is highly likely that many evidence-based recommendations which were published recently by a variety of national and international nutritional societies (DGEM, ESPEN) are also valid for obese, critically ill patients. However, there are some exceptions which comprise the magnitudes of caloric and protein supply. Magnitudes of the latter have to be specifically adjusted to the body weight of an obese patient. It is possible to roughly estimate actual energy expenditure by specific modified formulas which are all based on the classic Harris-Benedict equation. However, due to large inter-and intraindividual variations indirect calorimetry remains the method of choice to determine energy requirements. Nevertheless, problems may arise during isocaloric administration of calculated energy needs. Problems are of technical nature during enteral application of large volumes, but also include hyperglycemia and fatty liver degeneration. Based on a few phase I-like studies, a hypocaloric concept is currently recommended for feeding critically ill obese patients. Since there is evidence for an exaggerated protein catabolism in these patients, application of higher than usual amounts of protein is essential. Possibly, also requirements for specific amino acids such as glutamine may be increased. Current knowledge on nutrition of critically ill obese patients is far from being complete. Thus far, several aspects of nutritional therapy (e. g. during severe sepsis or prolonged artificial ventilation) have not yet been examined. It is questionable whether there will be ever specific recommendations which have been derived from data on solid clinical outcome parameters such as mortality.
Schlüsselwörter
Adipositas - Intensivpatient - hypokalorische Ernährungstherapie - Glutamin
Key words
obesity - nutrition - critical illness - glutamine
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Prof. Dr. Wolfgang H. Hartl
Chirurgische Klinik und Poliklinik, Campus Großhadern, LMU-München
Marchioninistraße 15
81377 München
Email: Wolfgang.hartl@med.uni-muenchen.de