S3-Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) in Zusammenarbeit mit der GESKES und der AKE

Zusammenfassung

Fragestellung: Unter künstlicher Ernährung können bestimmte Komplikationen auftreten. Um deren Häufigkeit zu minimieren, sind spezifische Überwachungsmaßnahmen erforderlich. Ziel der vorliegenden Leitlinie ist es, diesbezüglich evidenzbasierte Empfehlungen zu geben.

Methodik: Die bestehende Leitlinie der deutschen ernährungsmedizinischen Fachgesellschaft (DGEM) wurde in Einklang mit den Richtlinien der AWMF und des ÄZQ aktualisiert und erweitert.

Ergebnisse: Die Leitlinie beinhaltet 13 konsentierte Empfehlungen zur spezifischen Überwachung von Patienten, die künstlich ernährt werden. Speziell eingegangen wird auf Probleme bei der Menge der zugeführten Substrate, auf klinische Dysfunktionen des oberen und unteren Gastrointestinaltrakts (einschließlich eines erhöhten gastralen Residualvolumens, GRV) und auf Glukose- und Fettverwertungsstörungen. Generell sollte die Menge der tatsächlich zugeführten Substrate/Flüssigkeiten engmaschig überwacht und dokumentiert werden. Unter enteraler Ernährung ist speziell bei kritisch kranken Patienten in der Akutphase eine klinische Überwachung der gastrointestinalen Funktionen (Abdominalbefund, Darmtätigkeit) unerlässlich, die bei chirurgischen Patienten auch die Messung des GRV miteinbeziehen sollte. Speziell bei Diabetikern bzw. im Rahmen eines Postaggressionssyndroms ist ferner eine regelmäßige Messung der Glukose- und Triglyzeridkonzentration erforderlich, wobei bestimmte Grenzwerte (400 mg/dL [4,6 mmol/L] bzw. 200 mg/dL [11,0 mmol/L]) nicht überschritten werden sollten.

Schlussfolgerung: Überwachungsmaßnahmen sind unerlässlicher Bestandteil der künstlichen Ernährung. Inhalt und Intensität hängen von der Modalität und von der Art bzw. vom Stadium der Grunderkrankung ab. Spezifische Grenzwerte/Toleranzschwellen sind zu beachten.

Abstract

Purpose: Artificial nutrition may be associated with specific complications. To minimize their frequency, surveillance measures are indispensable. Based on sound scientific evidence the new guideline wants to present corresponding recommendations.

Methods: In accordance with the principles of the AWMF and the AEZQ, the existing guideline of the German Society of Nutritional Medicine was revised and updated.

Results: The guideline presents 13 consensus-based recommendations concerning the specific surveillance of patients requiring artificial nutrition. We closely address problems related to the adequacy of nutritional support, malfunction of the upper and lower gastrointestinal tract (including an increased gastric residual volume, GRV), and glucose and fat malassimilation. Generally the amount of substrates actually consumed by or delivered to the patient should closely be monitored and documented. In critically ill patients fed enterally, clinical monitoring of gastrointestinal functions (abdominal findings, bowel movements etc.) is indispensable and should be intensified during the acute phase. Surgical patients may profit from an additional measurement of GRV. Diabetic patients and patients during the acute phase of a disease additionally require regular measurements of triglyceride and glucose concentrations. For those parameters it is recommended to respect specific upper limits (400 mg/dL [4.6 mmol/L] and 200 mg/dL [11.0 mmol/L], respectively).

Conclusion: Surveillance measures are an integral part of artificial nutrition. Way and intensity of surveillance measures are guided by the modality of artificial nutrition, and by the type and stage of the underlying disease. Specific upper limits/threshold concentrations should be respected.

Schlüsselwörter

künstliche Ernährung - enterale Ernährung - Gastrointestinaltrakt - Substratzufuhr - gastrales Residualvolumen - Triglyzeridkonzentration - Glukosekonzentration - Diabetes

Keywords

artificial nutrition - enteral nutrition - gastrointestinal tract - substrate supply - gastric residual volume - triglyceride concentration - glucose concentration

^* DGEM Steering Committee: Bischoff SC, Lochs H, Weimann A, Adolph M, Ockenga J, Sieber C

• Literatur

• 1 Hartl WH, Jauch KW, Parhofer K et al. Working group for developing the guidelines for parenteral nutrition of The German Association for Nutritional Medicine. Complications and monitoring – Guidelines on Parenteral Nutrition, Chapter 11. Ger Med Sci 2009; 7 Doc17
• 2 Stingel K, Schütz T, Koller M et al. Leitlinie der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) – Methodik zum Leitlinien-Update Klinische Ernährung. Aktuel Ernahrungsmed 2013; 38: 90-100
• 3 Koller M, Schutz T, Valentini L et al. Outcome models in clinical studies: Implications for designing and evaluating trials in clinical nutrition. Clin Nutr 2013; 32: 650-657
• 4 McClave SA, Martindale RG, Vanek VW 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 2009; 33: 277-316
• 5 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
• 6 Fruhwald S, Holzer P, Metzler H. Gastrointestinal motility in acute illness. Wien Klin Wochenschr 2008; 120: 6-17
• 7 Lopez-Herce J. Gastrointestinal complications in critically ill patients: what differs between adults and children?. Curr Opin Clin Nutr Metab Care 2009; 12: 180-185
• 8 Gomes GF, Pisani JC, Macedo ED et al. The nasogastric feeding tube as a risk factor for aspiration and aspiration pneumonia. Curr Opin Clin Nutr Metab Care 2003; 6: 327-333
• 9 McClave SA, DeMeo MT, DeLegge MH et al. North American Summit on Aspiration in the Critically Ill Patient: consensus statement. JPEN J Parenter Enteral Nutr 2002; 26: 80-85
• 10 Lewis SJ, Heaton KW. Stool form scale as a useful guide to intestinal transit time. Scand J Gastroenterol 1997; 32: 920-924
• 11 O’Keefe GE, Shelton M, Cuschieri J et al. Inflammation and the host response to injury, a large-scale collaborative project: patient-oriented research core – standard operating procedures for clinical care VIII – Nutritional support of the trauma patient. J Trauma 2008; 65: 1520-1528
• 12 Bankhead R, Boullata J, Brantley S et al. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr 2009; 33: 122-167
• 13 McClave SA, Snider HL, Lowen CC et al. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN J Parenter Enteral Nutr 1992; 16: 99-105
• 14 Landzinski J, Kiser TH, Fish DN et al. Gastric motility function in critically ill patients tolerant vs intolerant to gastric nutrition. JPEN J Parenter Enteral Nutr 2008; 32: 45-50
• 15 Metheny NA, Stewart J, Nuetzel G et al. Effect of feeding-tube properties on residual volume measurements in tube-fed patients. JPEN J Parenter Enteral Nutr 2005; 29: 192-197
• 16 McClave SA, Snider HL. Clinical use of gastric residual volumes as a monitor for patients on enteral tube feeding. JPEN J Parenter Enteral Nutr 2002; 26: S43-48; discussion S49-50
• 17 Heyland DK, Dhaliwal R, Drover JW 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
• 18 Montejo JC, Minambres E, Bordeje L et al. Gastric residual volume during enteral nutrition in ICU patients: the REGANE study. Intensive Care Med 2010; 36: 1386-1393
• 19 McClave SA, Lukan JK, Stefater JA et al. Poor validity of residual volumes as a marker for risk of aspiration in critically ill patients. Crit Care Med 2005; 33: 324-330
• 20 Pinilla JC, Samphire J, Arnold C et al. Comparison of gastrointestinal tolerance to two enteral feeding protocols in critically ill patients: a prospective, randomized controlled trial. JPEN J Parenter Enteral Nutr 2001; 25: 81-86
• 21 Desachy A, Clavel M, Vuagnat A et al. Initial efficacy and tolerability of early enteral nutrition with immediate or gradual introduction in intubated patients. Intensive Care Med 2008; 34: 1054-1059
• 22 Reignier J, Mercier E, Le Gouge A et al. Effect of not monitoring residual gastric volume on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feeding: a randomized controlled trial. JAMA 2013; 309: 249-256
• 23 Metheny NA, Schallom L, Oliver DA et al. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care 2008; 17: 512-519; quiz 520
• 24 Elpern EH, Stutz L, Peterson S et al. Outcomes associated with enteral tube feedings in a medical intensive care unit. Am J Crit Care 2004; 13: 221-227
• 25 Umbrello M, Elia G, Destrebecq AL et al. Tolerance of enteral feeding: from quantity to quality of gastric residual volume?. Intensive Care Med 2009; 35: 1651-1652
• 26 Mentec H, Dupont H, Bocchetti M et al. Upper digestive intolerance during enteral nutrition in critically ill patients: frequency, risk factors, and complications. Crit Care Med 2001; 29: 1955-1961
• 27 Metheny NA, Clouse RE, Chang YH et al. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med 2006; 34: 1007-1015
• 28 Poulard F, Dimet J, Martin-Lefevre L et al. Impact of not measuring residual gastric volume in mechanically ventilated patients receiving early enteral feeding: a prospective before-after study. JPEN J Parenter Enteral Nutr 2010; 34: 125-130
• 29 Kuppinger DD, Rittler P, Hartl WH et al. Use of gastric residual volume to guide enteral nutrition in critically ill patients: A brief systematic review of clinical studies. Nutrition 2013; 29: 1075-1079
• 30 Guenter P. Safe practices for enteral nutrition in critically ill patients. Crit Care Nurs Clin North Am 2010; 22: 197-208
• 31 Jeejeebhoy KN. Total parenteral nutrition: potion or poison?. Am J Clin Nutr 2001; 74: 160-163
• 32 Lekka ME, Liokatis S, Nathanail C et al. The impact of intravenous fat emulsion administration in acute lung injury. Am J Respir Crit Care Med 2004; 169: 638-644
• 33 Tripathy D, Mohanty P, Dhindsa S et al. Elevation of free fatty acids induces inflammation and impairs vascular reactivity in healthy subjects. Diabetes 2003; 52: 2882-2887
• 34 Hermansen K, Dinesen B, Hoie LH et al. Effects of soy and other natural products on LDL:HDL ratio and other lipid parameters: a literature review. Adv Ther 2003; 20: 50-78
• 35 Gura K, Strijbosch R, Arnold S et al. The role of an intravenous fat emulsion composed of fish oil in a parenteral nutrition-dependent patient with hypertriglyceridemia. Nutr Clin Pract 2007; 22: 664-672
• 36 Suchner U, Katz DP, Furst P et al. Effects of intravenous fat emulsions on lung function in patients with acute respiratory distress syndrome or sepsis. Crit Care Med 2001; 29: 1569-1574
• 37 Smyrniotis VE, Kostopanagiotou GG, Arkadopoulos NF et al. Long-chain versus medium-chain lipids in acute pancreatitis complicated by acute respiratory distress syndrome: effects on pulmonary hemodynamics and gas exchange. Clin Nutr 2001; 20: 139-143
• 38 Waitzberg DL, Lotierzo PH, Logullo AF et al. Parenteral lipid emulsions and phagocytic systems. Br J Nutr 2002; 87 (Suppl. 01) S49-57
• 39 Calder PC. Long-chain n-3 fatty acids and inflammation: potential application in surgical and trauma patients. Braz J Med Biol Res 2003; 36: 433-446
• 40 Mayer K, Fegbeutel C, Hattar K et al. Omega-3 vs. omega-6 lipid emulsions exert differential influence on neutrophils in septic shock patients: impact on plasma fatty acids and lipid mediator generation. Intensive Care Med 2003; 29: 1472-1481
• 41 Tsuang W, Navaneethan U, Ruiz L et al. Hypertriglyceridemic pancreatitis: presentation and management. Am J Gastroenterol 2009; 104: 984-991
• 42 Ewald N, Hardt PD, Kloer HU. Severe hypertriglyceridemia and pancreatitis: presentation and management. Curr Opin Lipidol 2009; 20: 497-504
• 43 Hartl W, Jauch K, Parhofer K et al. Komplikationen und Monitoring. Aktuel Ernahrungsmed 2007; 32 (Suppl. 01) S60-S68
• 44 Alberti KG, Zimmet P, Shaw J et al. The metabolic syndrome – a new worldwide definition. Lancet 2005; 366: 1059-1062
• 45 Grundy SM, Brewer Jr HB, Cleeman JI et al. Definition of metabolic syndrome: Report of the National Heart, Lung, and Blood Institute/American Heart Association conference on scientific issues related to definition. Circulation 2004; 109: 433-438
• 46 Ryden L, Standl E, Bartnik M et al. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: executive summary. The Task Force on Diabetes and Cardiovascular Diseases of the European Society of Cardiology (ESC) and of the European Association for the Study of Diabetes (EASD). Eur Heart J 2007; 28: 88-136
• 47 Van den Berghe G, Wouters P, Weekers F et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001; 345: 1359-1367
• 48 Mesotten D, Swinnen JV, Vanderhoydonc F et al. Contribution of circulating lipids to the improved outcome of critical illness by glycemic control with intensive insulin therapy. J Clin Endocrinol Metab 2004; 89: 219-226
• 49 Schetz M, Vanhorebeek I, Wouters PJ et al. Tight blood glucose control is renoprotective in critically ill patients. J Am Soc Nephrol 2008; 19: 571-578
• 50 Mirtallo JM, Dasta JF, Kleinschmidt KC et al. State of the art review: Intravenous fat emulsions: Current applications, safety profile, and clinical implications. Ann Pharmacother 2010; 44: 688-700
• 51 Finney SJ, Zekveld C, Elia A et al. Glucose control and mortality in critically ill patients. JAMA 2003; 290: 2041-2047
• 52 Malmberg K. Prospective randomised study of intensive insulin treatment on long-term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 1997; 314: 1512-1515
• 53 Meier JJ, Deifuss S, Gallwitz B et al. Influence of impaired glucose tolerance on long-term survival after acute myocardial infarction. Dtsch Med Wochenschr 2002; 127: 1123-1129
• 54 Norhammar AM, Ryden L, Malmberg K. Admission plasma glucose. Independent risk factor for long-term prognosis after myocardial infarction even in nondiabetic patients. Diabetes Care 1999; 22: 1827-1831
• 55 Parsons MW, Barber PA, Desmond PM et al. Acute hyperglycemia adversely affects stroke outcome: a magnetic resonance imaging and spectroscopy study. Ann Neurol 2002; 52: 20-28
• 56 Umpierrez GE, Isaacs SD, Bazargan N et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002; 87: 978-982
• 57 Weir CJ, Murray GD, Dyker AG et al. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997; 314: 1303-1306
• 58 Zindrou D, Taylor KM, Bagger JP. Admission plasma glucose: an independent risk factor in nondiabetic women after coronary artery bypass grafting. Diabetes Care 2001; 24: 1634-1639
• 59 Bochicchio GV, Salzano L, Joshi M et al. Admission preoperative glucose is predictive of morbidity and mortality in trauma patients who require immediate operative intervention. Am Surg 2005; 71: 171-174
• 60 Capes SE, Hunt D, Malmberg K et al. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet 2000; 355: 773-778
• 61 Capes SE, Hunt D, Malmberg K et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001; 32: 2426-2432
• 62 Rosmarin DK, Wardlaw GM, Mirtallo J. Hyperglycemia associated with high, continuous infusion rates of total parenteral nutrition dextrose. Nutr Clin Pract 1996; 11: 151-156
• 63 Kaminski Jr MV. A review of hypersomolar hyperglycemic nonketotic dehydration (HHND): etiology, pathophysiology and prevention during intravenous hyperalimentation. JPEN J Parenter Enteral Nutr 1978; 2: 690-698
• 64 NICE-SUGAR Study Investigators. Finfer S, Chittock DR, Su SY et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283-1297
• 65 Van den Berghe G, Wilmer A, Hermans G et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006; 354: 449-461
• 66 Vlasselaers D, Milants I, Desmet L et al. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet 2009; 373: 547-556
• 67 Haga KK, McClymont KL, Clarke S et al. The effect of tight glycaemic control, during and after cardiac surgery, on patient mortality and morbidity: A systematic review and meta-analysis. J Cardiothorac Surg 2011; Jan 10; 6: 3. Doi:
• 68 Gandhi GY, Murad MH, Flynn DN et al. Effect of perioperative insulin infusion on surgical morbidity and mortality: systematic review and meta-analysis of randomized trials. 7. Mayo Clin Proc 2008; 83: 418-430
• 69 Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Intern Med 2004; 164: 2005-2011
• 70 Kansagara D, Fu R, Freeman M et al. Intensive insulin therapy in hospitalized patients: a systematic review. Ann Intern Med 2011; 154: 268-282
• 71 Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 2008; 300: 933-944
• 72 Griesdale DE, de Souza RJ, van Dam RM et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ 2009; 180: 821-827
• 73 Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest 2010; 137: 544-551
• 74 Friedrich JO, Chant C, Adhikari NK. Does intensive insulin therapy really reduce mortality in critically ill surgical patients? A reanalysis of meta-analytic data. Crit Care 2010; 14: 324
• 75 Hermans G, Schetz M, Van den Berghe G. Tight glucose control in critically ill adults. JAMA 2008; 300: 2725; author reply 2726 – 2727
• 76 Gunst J, Van den Berghe G. Blood glucose control in the intensive care unit: benefits and risks. Semin Dial 2010; 23: 157-162
• 77 Van den Berghe G, Mesotten D, Vanhorebeek I. Intensive insulin therapy in the intensive care unit. CMAJ 2009; 180: 799-800
• 78 Kuppinger D, Hartl WH. In search of the perfect glucose concentration for hospitalized patients: a brief review of the meta-analyses. Nutrition 2013; 29: 708-712
• 79 Qaseem A, Humphrey LL, Chou R et al. Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2011; 154: 260-267
• 80 Van den Berghe G. Insulin therapy for the critically ill patient. Clin Cornerstone 2003; 5: 56-63
• 81 Mizock BA. Blood glucose management during critical illness. Rev Endocr Metab Disord 2003; 4: 187-194
• 82 Zoungas S, Patel A, Chalmers J et al. Severe hypoglycemia and risks of vascular events and death. N Engl J Med 2010; 363: 1410-1418