Der adipöse Patient auf der Intensivstation^[*] – Was ist anders?

Zusammenfassung

In vielen Ländern kommt es in den letzten Jahren zu einem erheblichen Anstieg der Menschen mit starkem Übergewicht - insbesondere bei den jüngeren Altersgruppen bis 35 Jahre. Entsprechend nimmt auch die Anzahl der Intensivpatienten, die unter einer erheblichen Adipositas leiden, kontinuierlich zu. Bei diesen Patienten sind einige Besonderheiten zu beachten. Unterschiede zu Normalgewichtigen betreffen z.B. die Atemphysiologie: Durch die Adipositas kommt es zu einer Abnahme der Lungenvolumina und zu einer deutlichen Steigerung der Atemarbeit und des Sauerstoffverbrauchs.Klinisch relevante Veränderungen finden auch an den oberen Atemwegen und am Hals statt. Deshalb ist eine Maskenbeatmung, eine Intubation oder eine operative Atemwegssicherung deutlich schwieriger als bei Normalgewichtigen. Adipöse Intensivpatienten sind also primär als Patienten mit schwierigem Atemweg anzusehen. Darüber hinaus können bei stark Adipösen auch Arzneimittelverteilung, -abbau und Ausscheidung anders als bei Normalgewichtigen sein. Das ist bei der Medikamentendosierung zu beachten. Trotz Übergewicht können adipöse Patienten bei Aufnahme auf die Intensivstation mangelernährt sein. Auch bei dieser Patientengruppe sollte eine Ernährung möglichst früh und enteral begonnen werden. Zwar geht Adipositas wegen einer Vielzahl an Komorbiditäten mit einer erhöhten Sterblichkeit einher, doch zahlreiche Studien belegen: Selbst extreme Adipositas erhöht die Mortalität im Vergleich zu normalgewichtigen Intensivpatienten nicht.

Abstract

In many countries over the past years there has been a marked increase in the number of people with severe overweight - especially among the younger age groups up to 35 years. Accordingly, the number of intensive care patients suffering additionally from a significant obesity is also increasing continuously. Some particular features of these patients need to be observed. Differences to normal-weight patients involve, for example, respiratory physiology: the obesity leads to a decrease of lung volumeand to a marked increase in breathing work as well as oxygen consumption. Clinically relevant changes occur in the upper airways and neck. Thus, mask ventilation, intubation or surgical interventions to secure the airways are clearly more difficult than in normal-weight patients. Obese intensive care patients are therefore primarily to be considered as patients with difficultairway conditions. In addition in cases of extreme obesity, drug distribution, degradation and excretion can differ from those of normal-weight patients. This must be taken into account for medication dosing. In spite of the overweight, obese patients may be undernourished upon admission to the ICU. Thus, for this group of patients also, enteral nutrition should be startedas early as possible. Although obesity is accompanied by a higher mortality on account of the many possible comorbidities, numerous studies have confirmed that even extreme obesity does not increase the mortality rate in comparison with that of normal-weight patients.

Kernaussagen

• Die Prävalenz der Adipositas nimmt mit dem Alter zu. In den letzten Jahren stieg sie aber insbesondere bei den jüngeren Altersgruppen bis 35 Jahre an.

• Durch die Adipositas kommt es zu einer Abnahme der Lungenvolumina und zu einer deutlichen Steigerung der Atemarbeit und des Sauerstoffverbrauchs.

• Adipöse Intensivpatienten sind primär als Patienten mit schwierigem Atemweg anzusehen.

• Bei stark adipösen Patienten können Arzneimittelverteilung sowie der Arzneimittelabbau und die Ausscheidung verändert sein.

• Auch bei adipösen Intensivpatienten sollte man möglichst früh und möglichst enteral mit der Ernährung beginnen.

• Selbst bei extremer Adipositas ist die Mortalität im Vergleich zu normalgewichtigen Intensivpatienten nicht erhöht.

Schlüsselwörter:

Adipositas - Atemwegssicherung - Beatmung - Medikamentendosierung - Ernährung

Key words:

obesity - airway management - ventilation - medication dosages - nutrition

^* Erstveröffentlichung des Beitrags in: Intensivmed.up2date 2014; 10: 37–50

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