Glukosemanagement in der Intensivmedizin

Der vorliegende Artikel gibt einen Überblick zu pathophysiologischen, methodologischen und klinischen Aspekten des Glukosemanagements in der Intensivmedizin und informiert als evidenzbasiertes Update über die aktuelle Studienlage und Leitlinienempfehlungen bei erwachsenen kritisch kranken Patienten.

Abstract

Stress induced hyperglycemia as a consequence of the metabolic changes during critical illness is associated with increased morbidity and mortality and should thus be considered as a common and serious complication. Glucose management has become an integral part of adjuvant therapy in the critically ill patient over the past decade. Apart from treating uncontrolled hyperglycemia, results of various randomized-controlled clinical trials have put hypoglycemia as a side-effect of tight glycemic control, and glycemic variability into the focus. Meanwhile, moderate glucose control with a target range of 140 – 200 mg/dl (7,7 – 11,0 mMol/l) and avoidance of hypoglycemia and high glucose variability is considered as a “gold-standard” in the general intensive care unit population. Nutrition therapy interacts with glucose management and we suggest adaptation according to closely monitored individual metabolic tolerance of the patient. The following article summarizes the pathophysiological rationale and clinical and methodological aspects of glucose management in the intensive care unit setting. It further informs as an evidence based update on current literature and guideline recommendations in the adult critically ill patient.

Kernaussagen

• Zu den Dysglykämien gehören Hypoglykämien, Hyperglykämien und erhöhte Blutglukosevariabilität.

• Stresshyperglykämie ist das führende Symptom der metabolischen Änderungen bei einer kritischen Erkrankung.

• Stresshyperglykämie ist eine häufige Komplikation, die mit einem schlechteren Outcome assoziiert ist und aus peripherer Insulinresistenz sowie gesteigerter endogener Substratproduktion resultiert.

• Eine kontinuierliche Insulintherapie zur Behandlung der Stresshyperglykämie wird empfohlen.

• Konsens aktueller Leitlinienempfehlungen ist die moderate Glukosekontrolle mit einem zwischen den verschiedenen Fachgesellschaften leicht variierenden Zielbereich.

• Die aktuelle S3-Leitlinie der DGEM empfiehlt einen Blutglukosezielbereich von 140 – 200 mg/dl.

• Die Blutglukosemessung sollte mit einem Blutgasanalysator oder im Zentrallabor aus einer arteriellen Vollblutprobe durchgeführt werden.

• Oxygenierung, pH-Wert, Hämatokrit, Veränderungen der Gewebeperfusion und bestimmte Medikamente können je nach Art des verwendeten Messverfahrens Einfluss auf Messungen der Blutglukose nehmen.

• Blutglukosemessungen sollten mindestens alle 6 – 8 h, unter laufender intravenöser Insulintherapie mindestens alle 3 – 4 h und bei ausgeprägter Blutglukosevariabilität mindestens 2-stündlich durchgeführt werden.

• Schwere Hypoglykämien sind als häufigste Nebenwirkung einer intensivierten Insulintherapie zu vermeiden, ebenso eine hohe Blutglukosevariabilität.

• Die Glukosekontrolle sollte als Bestandteil eines multimodalen Behandlungskonzepts der metabolischen Therapie die leitliniengerechte Ernährungstherapie und Frühmobilisation berücksichtigen.

• Im Sinne eines individualisierten Therapieansatzes sollte die exogene Substratzufuhr an die metabolische Toleranz des Patienten adaptiert werden, um eine Aggravierung der Stresshyperglykämie durch Hyperalimentation zu vermeiden.

Schlüsselwörter

Stresshyperglykämie - Hyperglykämie - Hypoglykämie - Intensivmedizin - Glukosekontrolle - kritisch kranker Patient

Keywords

stress hyperglycemia - hyperglycemia - hypoglycemia - intensive care medicine - glucose control - critically ill patient

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