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Aktuelle Ernährungsmedizin 2005; 30(3): 117-123
DOI: 10.1055/s-2005-866824
Originalbeitrag
© Georg Thieme Verlag KG Stuttgart · New York

Künstliche Ernährung des kritisch kranken Patienten - eine Diskussion der kanadischen Leitlinien

Artificial Nutrition of the Critically Ill Patient - A Critical Appraisal of the Canadian GuidelinesW.  Scheppach1 , U.  Suchner2 , M.  Keymling3
  • 1Medizinische Universitätsklinik Würzburg
  • 2Fresenius Kabi Deutschland GmbH, Bad Homburg
  • 3Medizinische Klinik II, Klinikum Meiningen GmbH
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Publication History

Publication Date:
13 May 2005 (online)

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Zusammenfassung

Die kanadischen Leitlinien scheinen den Paradigmenwechsel in der künstlichen Ernährung kritisch kranker Patienten zu „besiegeln”. Vor diesem Hintergrund ist besonders die Empfehlung zum bevorzugten Einsatz der enteralen Ernährung zu verstehen, welche stets bei Patienten mit funktionstüchtigem Gastrointestinaltrakt eingesetzt werden sollte. Die parenterale Ernährung wird nicht mehr als Standardverfahren, sondern eher als supplementierende Ernährungsstrategie im Falle einer unzureichenden enteralen Substratzufuhr angesehen. Zur Umsetzung dieses Konzeptes wird gefordert, die frühzeitige Platzierung von Jejunalsonden (d. h. innerhalb von 24 - 48 Stunden nach stationärer Aufnahme) zum Routineverfahren zu erheben, soweit dies die Infrastruktur der Krankenhäuser unter Nutzung aller verfügbarer Optionen zulässt. Die jejunale Applikation geringer Volumina von Sondenkost (beginnend mit 10 - 20 ml/h) sollte unmittelbar nach stationärer Aufnahme begonnen werden, sofern keine absoluten Kontraindikationen vorliegen. Dabei ist es die Intention, den Darm mit Substraten zu versorgen, um die Integrität der Schleimhautbarriere zu erhalten. Die Applikationsrate sollte kontinuierlich gesteigert werden, wobei die Gesamtenergiezufuhr 20 - 25 kcal/kg Körpergewicht nicht überschreiten sollte. Die Frage, ab wann eine ergänzende parenterale Ernährung initiiert werden muss, bleibt jedoch auch weiterhin umstritten. Nach Auffassung der Autoren hängt die Entscheidung zur kombinierten enteralen/parenteralen Ernährung weniger von der zu erwartenden enteralen Nahrungskarenz (mehr als oder weniger 10 Tage) als vielmehr vom Ausmaß der gastrointestinalen Toleranz gegenüber enteraler Nährlösungen, von der Ausprägung einer vorbestehenden Fehlernährung sowie vom Grad des Aggressionsstoffwechsels ab.

Abstract

Apparently, the Canadian Clinical Practice Guidelines mark a change of paradigm as far as nutritional support strategies for critically ill patients are concerned. The recommendation to rather apply enteral and not parenteral nutrition in patients with a functional gastrointestinal tract has to be considered a key issue of these guidelines. The role of parenteral feeding steps down from a standard to a supplementary procedure in cases of insufficient enteral intake. The early placement of a nasojejunal tube (i. e., within 24 - 48 h after admission) should become a routine procedure in ICU's of tertiary centers. Low volume jejunal feeding (starting with 10 - 20 ml/h) should be initiated immediately after admission, provided that there are no contraindications. By „feeding the gut” via the enteral route the feeding strategy aims at maintaining intestinal barrier integrity. The enteral infusion rate should then be raised gradually, but should not provide more than 20 - 25 kcal per kg of body weight („feed the patient”). The question when to start supplementary parenteral nutrition remains a matter of debate. The decision whether or not combined enteral and parenteral nutrition strategies will be commenced depend on the degree of gastrointestinal intolerance to enteral feeds, the severity of preexisting malnutrition, and the level of hypermetabolism.

Schlüsselwörter

Kanadische Leitlinien - Intensivpflichtigkeit - enterale Ernährung - parenterale Ernährung

Key words

Canadian guidelines - critical illness - enteral nutrition - parenteral nutrition

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Prof. Dr. med. Wolfgang Scheppach

Schwerpunkt Gastroenterologie · Medizinische Universitätsklinik

Josef-Schneider-Straße 2

97080 Würzburg

Email: scheppach_w@klinik.uni-wuerzburg.de

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