Empfehlungen und Innovationen in der Ernährungsmedizin für kritisch Kranke

Die medizinische Ernährungstherapie ist ein zentraler Bestandteil der Therapie auf Intensivstationen und spielt eine entscheidende Rolle für die Prognose kritisch kranker Patient*innen. Eine individualisierte Ernährungsstrategie ist essenziell, um den besonderen Bedürfnissen kritisch kranker Patient*innen gerecht zu werden und mögliche Komplikationen zu minimieren.

Abstract

Medical Nutrition Therapy (MNT) is a key component of treatment in intensive care units (ICU) and plays a crucial role in the prognosis of critically ill patients. An individualized nutrition strategy is essential to meet the specific needs of critically ill patients and to minimize potential complications.

Recommendations for MNT differ between the guidelines of the German Society for Nutritional Medicine (DGEM), the European Society for Clinical Nutrition and Metabolism (ESPEN), and the American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.), making its implementation in clinical practice challenging. Therefore, the first part of this article provides a pragmatic summary of the current recommendations for everyday clinical practice. The second part focuses on recent data and how these might influence current paradigms of MNT for critically ill patients, with particular emphasis on phase-appropriate macronutrient delivery and combinations of nutrition with other interventions.

Kernaussagen

• Die Ernährung kritisch Kranker ist eine adjuvante medizinische Therapie, die individuelle Planung und sorgfältige Adaptation an den aktuellen gastrointestinalen und metabolischen Status der Intensivpatient*innen benötigt.

• In den letzten Jahren haben große multizentrische Studien hierbei einen Paradigmenwechsel bewirkt.

• Angesichts der aktuellen Datenlage erscheint es ratsam, bei ITS-Aufnahme den Ernährungsstatus abzuschätzen und möglichst die Körperzusammensetzung zu bestimmen.

• Die MNT sollte innerhalb der ersten 24–48 h starten; bei den meisten Patient*innen ist mit einer enteralen Standardsondenkost zu beginnen.

• Die initiale Laufrate ist niedrig zu wählen (sowohl bei enteraler als auch parenteraler Ernährung).

• Verschiedene Routen der Ernährungszufuhr können kombiniert werden, um die Versorgung mit der individuell angepassten Therapie sicherzustellen.

• Mindestens 1-mal pro Schicht sind die aufgenommene Nahrungsmenge und die gastrointestinale Toleranz zu evaluieren und die Therapie daran anzupassen.

• Es sollte ein interdisziplinärer und multiprofessioneller Therapieansatz verfolgt werden.

Schlüsselwörter

medizinische Ernährungstherapie - Ernährung - kritische Erkrankungen - Intensivpatient - Makronährstoff - Mikronährstoff - Übersichtsarbeit

Keywords

medical nutrition therapy - nutrition - critical illness - intensive care patient - macronutrient - micronutrient - review article

Publikationsverlauf

Artikel online veröffentlicht:
24. März 2025

• Literatur

• 1 Elke G, Hartl WH, Kreymann KG. et al. Clinical Nutrition in Critical Care Medicine – Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33: 220-275
• 2 Singer P, Blaser AR, Berger MM. et al. ESPEN practical and partially revised guideline: Clinical nutrition in the intensive care unit. Clin Nutr 2023; 42: 1671-1689
• 3 McClave SA, Taylor BE, Martindale RG. et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill 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 2016; 40: 159-211
• 4 Compher C, Bingham AL, McCall M. et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: The American Society for Parenteral and Enteral Nutrition. JPEN. J Parenter Enteral Nutr 2022; 46: 12-41
• 5 Weimann A, Hartl WH, Adolph M. et al. [Assessment and technical monitoring of nutritional status of patients in intensive and intermediate care units : Position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive and Emergency Medicine (DIVI)]. Med Klin Intensivmed Notfmed 2022; 117 (Suppl. 2) 37-50
• 6 Elke G, Hartl WH, Kreymann KG. et al. DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“. S2k-Leitlinie (AWMF-Registernummer 073–004). Aktuel Ernahrungsmed 2018; 43: 341-408
• 7 Mogensen KM, Robinson MK, Casey JD. Nutritional Status and Mortality in the Critically Ill. Crit Care Med 2015; 43: 2605-2615
• 8 Moisey LL, Mourtzakis M, Cotton BA. Skeletal muscle predicts ventilator-free days, ICU-free days, and mortality in elderly ICU patients. Crit Care 2013; 17: R206
• 9 Weijs PJ, Looijaard WG, Dekker IM. Low skeletal muscle area is a risk factor for mortality in mechanically ventilated critically ill patients. Crit Care 2014; 18: R12
• 10 Elke G, Hartl WH, Adolph M. et al. Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI). Med Klin Intensivmed Notfmed 2023; 118 (Suppl. 1) 1-13
• 11 Detsky AS, McLaughlin JR, Baker JP. What is subjective global assessment of nutritional status. JPEN J Parenter Enteral Nutr 1987; 11: 8-13
• 12 Kondrup J, Allison SP, Elia M. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003; 22: 415-421
• 13 Valentini LV, Volkert D, Schütz T. Guideline of the German Society for Nutritional Medicine (DGEM) DGEM Terminology for Clinical Nutrition. Aktuel Ernahrungsmed 2013; 38: 97-111
• 14 Hill A, Heyland DK, Elke G. et al. Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial. Nutr Res Rev 2020; 33: 312-320
• 15 Hill A, Heyland DK, Ortiz Reyes LA. et al. Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2022; 46: 395-410
• 16 Pearce CB, Duncan HD. Enteral feeding. Nasogastric, nasojejunal, percutaneous endoscopic gastrostomy, or jejunostomy: its indications and limitations. Postgrad Med J 2002; 78: 198-204
• 17 Heyland DK, Schroter-Noppe D, Drover JW. et al. Nutrition support in the critical care setting: current practice in canadian ICUs – opportunities for improvement?. JPEN J Parenter Enteral Nutr 2003; 27: 74-83
• 18 Hill A, Heyland DK, Ortiz Reyes LA. et al. Combination of enteral and parenteral nutrition in the acute phase of critical illness: An updated systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2022; 46: 395-410
• 19 Reintam Blaser A, Starkopf J, Alhazzani W. et al. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med 2017; 43: 380-398
• 20 Estrada-Orozco K, Cantor-Cruz F, Larrotta-Castillo D. et al. Central venous catheter insertion and maintenance: Evidence-based clinical recommendations. Rev Colomb Obstet Ginecol 2020; 71: 115-162
• 21 Pittiruti M, Hamilton H, Biffi R. et al. ESPEN Guidelines on Parenteral Nutrition: central venous catheters (access, care, diagnosis and therapy of complications). Clin Nutr 2009; 28: 365-377
• 22 Radke DI, Pulletz S, Hartl W. et al. Überwachung von Ernährungstherapie und Kalorienzufuhr: Herausforderungen und Lösungsansätze. Anasthesiol Intensivmed Notfallmed Schmerzther 2025; 60: 142-154
• 23 Westman EC. Is dietary carbohydrate essential for human nutrition. Am J Clin Nutr 2002; 75: 951-953
• 24 Barazzoni R, Deutz NE, Biolo G. Carbohydrates and insulin resistance in clinical nutrition: Recommendations from the ESPEN expert group. Clin Nutr 2017; 36: 355-363
• 25 Leutenegger AF, Goschke H, Stutz K. Comparison between glucose and a combination of glucose, fructose, and xylitol as carbohydrates for total parenteral nutrition of surgical intensive care patients. Am J Surg 1977; 133: 199-205
• 26 Keller U. [The sugar substitutes fructose and sorbite: an unnecessary risk in parenteral nutrition]. Schweiz Med Wochenschr 1989; 119: 101-106
• 27 Ladefoged K, Berthelsen P, Brøckner-Nielsen J. Fructose, xylitol and glucose in total parenteral nutrition. Intensive Care Med 1982; 8: 19-23
• 28 Cuthbertson DP, Angeles Valero Zanuy MA, León Sanz ML. Post-shock metabolic response. 1942. Nutr Hosp 2001; 16: 176-182
• 29 Kreymann G, Grosser S, Buggisch P. Oxygen consumption and resting metabolic rate in sepsis, sepsis syndrome, and septic shock. Crit Care Med 1993; 21: 1012-1019
• 30 Koletzko B, Jauch KW, Krohn K, Verwied-Jorky S. Leitlinie Parenterale Ernährung der Deutschen Gesellschaft für Ernährungsmedizin e. V. (DGEM)*. Aktuel Ernährungsmed 2007; 32 (Suppl. 1) S1-S2
• 31 Charriere M, Ridley E, Hastings J. et al. Propofol sedation substantially increases the caloric and lipid intake in critically ill patients. Nutrition 2017; 42: 64-68
• 32 Reimund JM, Rahmi G, Escalin G. Efficacy and safety of an olive oil-based intravenous fat emulsion in adult patients on home parenteral nutrition. Aliment Pharmacol Ther 2005; 21: 445-454
• 33 Elke G, van Zanten AR, Lemieux M. et al. Enteral versus parenteral nutrition in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care 2016; 20: 117
• 34 Berger MM, Shenkin A, Schweinlin A. et al. ESPEN micronutrient guideline. Clin Nutr 2022; 41: 1357-1424
• 35 Elke G, Hartl WH, Adolph M. et al. [Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units: Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]. Med Klin Intensivmed Notfmed 2023; 118 (Suppl. 1) 1-13
• 36 Hill A, Meyer M-T. Ernährung auf der Intensivstation. Intensiv 2024; 32: 245-254
• 37 Nakamura K, Kihata A, Naraba H. et al. beta-Hydroxy-beta-methylbutyrate, Arginine, and Glutamine Complex on Muscle Volume Loss in Critically Ill Patients: A Randomized Control Trial. JPEN J Parenter Enteral Nutr 2020; 44: 205-212
• 38 de Azevedo JRA, Lima HCM, Frota P. et al. High-protein intake and early exercise in adult intensive care patients: a prospective, randomized controlled trial to evaluate the impact on functional outcomes. BMC Anesthesiol 2021; 21: 283
• 39 Zhang Q, Zhou J, Zhu D, Zhou S. Evaluation of the effect of high protein supply on diaphragm atrophy in critically ill patients receiving prolonged mechanical ventilation. Nutr Clin Pract 2022; 37: 402-412
• 40 Dresen E, Weissbrich C, Fimmers R. et al. Medical high-protein nutrition therapy and loss of muscle mass in adult ICU patients: A randomized controlled trial. Clin Nutr 2021; 40: 1562-1570
• 41 Arabi YM, Aldawood AS, Al-Dorzi HM. et al. Permissive Underfeeding or Standard Enteral Feeding in High- and Low-Nutritional-Risk Critically Ill Adults. Post Hoc Analysis of the PermiT Trial. Am J Respir Crit Care Med 2017; 195: 652-662
• 42 Reignier J, Plantefeve G, Mira JP. et al. Low versus standard calorie and protein feeding in ventilated adults with shock: a randomised, controlled, multicentre, open-label, parallel-group trial (NUTRIREA-3). Lancet Respir Med 2023; 11: 602-612
• 43 Bels JLM, Thiessen S, van Gassel RJJ. et al. PRECISe study team. Effect of high versus standard protein provision on functional recovery in people with critical illness (PRECISe): an investigator-initiated, double-blinded, multicentre, parallel-group, randomised controlled trial in Belgium and the Netherlands. Lancet 2024; 404: 659-669
• 44 McClave SA, Taylor BE, Martindale RG. et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parent Enter Nutr 2016; 40: 159-211
• 45 Pardo E, Lescot T, Preiser JC. et al. Association between early nutrition support and 28-day mortality in critically ill patients: the FRANS prospective nutrition cohort study. Crit Care 2023; 27: 7
• 46 International working group for patient’s right to nutritional care, ASPEN, ESPEN, FELANPE, PENSA. The International Declaration on the Human Right to Nutritional Care “Vienna Declaration”. 2022 Zugriff am 11. Oktober 2024 unter: https://www.espen.org/files/Vienna-Declaration-2022.pdf
• 47 Heyland DK, Patel J, Compher C. et al. The effect of higher protein dosing in critically ill patients with high nutritional risk (EFFORT Protein): an international, multicentre, pragmatic, registry-based randomised trial. Lancet 2023; 401: 568-576
• 48 Stoppe C, Patel JJ, Zarbock A. et al. The impact of higher protein dosing on outcomes in critically ill patients with acute kidney injury: a post hoc analysis of the EFFORT protein trial. Crit Care 2023; 27: 399
• 49 Abdelrahim RA, Mekala SRR, Polepalli KV. et al. Nutritional Ketosis as a Therapeutic Approach in Critical Illness: A Systematic Review. Cureus 2024; 16: e65455
• 50 Hirschberger S, Schmid A, Kreth S. [Immunomodulation by nutritional intervention in critically ill patients]. Anaesthesiologie 2023; 72: 229-244
• 51 Rahmel T, Effinger D, Bracht T. et al. An open-label, randomized controlled trial to assess a ketogenic diet in critically ill patients with sepsis. Sci Transl Med 2024; 16: eadn9285
• 52 Stoppe C, McDonald B, Meybohm P. et al. Effect of High-Dose Selenium on Postoperative Organ Dysfunction and Mortality in Cardiac Surgery Patients: The SUSTAIN CSX Randomized Clinical Trial. JAMA Surg 2023; 158: 235-244
• 53 Heyland DK, Wibbenmeyer L, Pollack JA. et al. A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries. N Engl J Med 2022; 387: 1001-1010
• 54 Society of Critical Care Medicine. Critical Care Statistics: Society of Critical Care Medicine; 2024 [updated May 15]. Zugriff am 28. Januar 2025 unter: https://www.sccm.org/Communications/Critical-Care-Statistics
• 55 Hill A, Heyland DK, Elke G. et al. Meeting nutritional targets of critically ill patients by combined enteral and parenteral nutrition: review and rationale for the EFFORTcombo trial. Nutr Res Rev 2020; 33: 312-320
• 56 Hill A, von Dossow V, Heyland DK. et al. Preoperative Nutritional Optimization and Physical Exercise for Patients Scheduled for Elective Implantation for a Left-Ventricular Assist Device – The PROPER-LVAD Study. Surgeries 2022; 3: 284-296
• 57 Hill A, Arora RC, Engelman DT, Stoppe C. Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers. Crit Care Clin 2020; 36: 593-616
• 58 Macht M, Wimbish T, Clark BJ. et al. Postextubation dysphagia is persistent and associated with poor outcomes in survivors of critical illness. Crit Care 2011; 15: R231
• 59 Schönhofer B, Geiseler J, Dellweg D. et al. [Prolonged Weaning – S2k-Guideline Published by the German Respiratory Society]. Pneumologie 2019; 73: 723-814