Die Rolle der Ernährung beim herzchirurgischen Patienten – eine Übersicht

Zusammenfassung

Der präoperative Ernährungsstatus und die perioperative Ernährungsstrategie spielen eine wichtige Rolle für das Outcome herzchirurgischer Patienten – dennoch gibt es nur wenige Studien zu Ernährungskonzepten für diese Patientengruppe. In diesem Beitrag werden die Ursachen der Mangelernährung, der Einfluss der Ernährungstherapie auf den herzchirurgischen Patienten und Strategien zur Verbesserung der Ernährung beschrieben.

Abstract

Cardiac surgery patients regularly experience a systemic inflammation response to the surgery and a postoperative stay in the intensive care unit. Nutritional support is one strategy to improve the outcome of cardiosurgical patients. A preoperatively diagnosed malnutrition contributes to a higher morbidity and mortality in this patient group. Preoperative fasting, glucose-free infusions during long and invasive operations and delayed postoperative nutrition therapy aggravate the nutrition situation. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking.

This article outlines the main causes for malnutrition in cardiosurgical patients and summarizes possibilities to identify patients at high nutritional risk, who are most likely to profit from aggressive nutritional therapy. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy based on current recommendations of ASPEN, ESPEN and an international multidisciplinary consensus group is presented. The amount and kind of nutrition, as well as the best time to initiate nutrition support, ways to monitor nutrition therapy and the potential use of pharmaconutrition to modulate the inflammatory response to cardiopulmonary bypass are presented to benefit patients undergoing cardiac surgery.

Kernaussagen

• Ein regelmäßiges und frühzeitiges Screening auf Malnutrition sollte in die klinische Routine implementiert werden.

• Für die Behandlung im klinischen Alltag sollten standardisierte Ernährungsprotokolle verwendet werden.

• Wenn möglich sollte eine präoperative Optimierung der Ernährung erwogen werden.

• Langes präoperatives Fasten sollte vermieden werden.

• Eine Ernährungstherapie sollte in folgender Reihenfolge priorisiert werden: oral > enteral > parenteral.

• Der Beginn einer Ernährungstherapie sollte innerhalb von 24 Stunden postoperativ initiiert werden.

• Ernährungsziele sind 25 – 30 kcal/kg Energie und 1,2 – 2 g Protein pro kg Idealgewicht und Tag.

• Die Toleranz einer enteralen Ernährung kann durch angepasste Analgesie, Prokinetika, Beatmungs- und Volumentherapie sowie Mobilisation verbessert werden.

• Bei herzchirurgischen Eingriffen mit ausgeprägter Immunreaktion sollten immunmodulierende Nährstoffe in Erwägung gezogen werden.

Schlüsselwörter

Herzchirurgie - Ernährung - Pharmakonutrition - Malnutrition - Outcome

Key words

cardiac surgery, nutrition, pharmaconutrition, malnutrition, outcome

• Literatur

• 1 Alberda C, Gramlich L, Jones N. et al. The relationship between nutritional intake and clinical outcomes in critically ill patients: results of an international multicenter observational study. Intensive Care Med 2009; 35: 1728-1737
• 2 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
• 3 Arabi YM, Aldawood AS, Haddad SH. et al. Permissive underfeeding or standard enteral feeding in critically ill adults. N Engl J Med 2015; 372: 2398-2408
• 4 Artinian V, Krayem H, DiGiovine B. Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients. Chest 2006; 129: 960-967
• 5 Baker JP, Detsky AS, Wesson DE. et al. Nutritional assessment: a comparison of clinical judgement and objective measurements. N Engl J Med 1982; 306: 969-972
• 6 Berger MM, Berger-Gryllaki M, Wiesel PH. et al. Intestinal absorption in patients after cardiac surgery. Crit Care Med 2000; 28: 2217-2223
• 7 Berger MM, Chiolero RL. Enteral nutrition and cardiovascular failure: from myths to clinical practice. JPEN J Parenter Enteral Nutr 2009; 33: 702-709
• 8 Berger MM, Delodder F, Liaudet L. et al. Three short perioperative infusions of n-3 PUFAs reduce systemic inflammation induced by cardiopulmonary bypass surgery: a randomized controlled trial. Am J Clin Nutr 2013; 97: 246-254
• 9 Berger MM, Revelly JP, Cayeux MC. et al. Enteral nutrition in critically ill patients with severe hemodynamic failure after cardiopulmonary bypass. Clin Nutr 2005; 24: 124-132
• 10 Braga M, Ljungqvist O, Soeters P. et al. ESPEN guidelines on parenteral nutrition: surgery. Clin Nutr 2009; 28: 378-386
• 11 Brandstrup B, Tønnesen H, Beier-Holgersen R. et al. Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial. Ann Surg 2003; 238: 641-648
• 12 Breuer JP, von Dossow V, von Heymann C. et al. Preoperative oral carbohydrate administration to ASA III-IV patients undergoing elective cardiac surgery. Anesth Analg 2006; 103: 1099-1108
• 13 Bronicki RA, Hall M. Cardiopulmonary bypass-induced inflammatory response: Pathophysiology and treatment. Pediatr Crit Care Med 2016; 17: S272-S278
• 14 Cahill NE, Dhaliwal R, Day AG. et al. Nutrition therapy in the critical care setting: what is “best achievable” practice? An international multicenter observational study. Crit Care Med 2010; 38: 395-401
• 15 Casaer MP, Langouche L, Coudyzer W. et al. Impact of early parenteral nutrition on muscle and adipose tissue compartments during critical illness. Crit Care Med 2013; 41: 2298-2309
• 16 Casaer MP, Mesotten D, Hermans G. et al. Early versus late parenteral nutrition in critically ill adults. N Engl J Med 2011; 365: 506-517
• 17 Cederholm T, Bosaeus I, Barazzoni R. et al. Diagnostic criteria for malnutrition – An ESPEN Consensus Statement. Clin Nutr 2015; 34: 335-340
• 18 Chermesh I, Hajos J, Mashiach T. et al. Malnutrition in cardiac surgery: food for thought. Eur J Prev Cardiol 2014; 21: 475-483
• 19 Coltman A, Peterson S, Roehl K. et al. Use of 3 tools to assess nutrition risk in the intensive care unit. JPEN J Parenter Enteral Nutr 2015; 39: 28-33
• 20 Cresci G, Hummell AC, Raheem SA. et al. Nutrition intervention in the critically ill cardiothoracic patient. Nutr Clin Pract 2012; 27: 323-334
• 21 Detsky AS, McLaughlin JR, Baker JP. et al. What is subjective global assessment of nutritional status?. JPEN J Parenter Enteral Nutr 1987; 11: 8-13
• 22 Detsky AS, Smalley PS, Chang J. The rational clinical examination. Is this patient malnourished?. JAMA 1994; 271: 54-58
• 23 Doig GS, Heighes PT, Simpson F. et al. Early enteral nutrition, provided within 24 h of injury or intensive care unit admission, significantly reduces mortality in critically ill patients: a meta-analysis of randomised controlled trials. Intensive Care Med 2009; 35: 2018-2027
• 24 Doig GS, Simpson F, Finfer S. et al. Effect of evidence-based feeding guidelines on mortality of critically ill adults: a cluster randomized controlled trial. JAMA 2008; 300: 2731-2741
• 25 Drover JW, Cahill NE, Kutsogiannis J. et al. Nutrition therapy for the critically ill surgical patient: we need to do better!. JPEN J Parenter Enteral Nutr 2010; 34: 644-652
• 26 Engelman DT, Adams DH, Byrne JG. et al. Impact of body mass index and albumin on morbidity and mortality after cardiac surgery. J Thorac Cardiovasc Surg 1999; 118: 866-873
• 27 Evora PR, Bottura C, Arcêncio L. et al. Key points for curbing cardiopulmonary bypass inflammation. Acta Cir Bras 2016; 31 (Suppl. 01) 45-52
• 28 Ferguson M, Capra S, Bauer J. et al. Development of a valid and reliable malnutrition screening tool for adult acute hospital patients. Nutrition 1999; 15: 458-464
• 29 Ferrie S, Allman-Farinelli M. Commonly used “nutrition” indicators do not predict outcome in the critically ill: a systematic review. Nutrition Clin Practice 2013; 28: 463-484
• 30 Gavin NC, Button E, Keogh S. et al. Does parenteral nutrition increase the risk of catheter-related bloodstream infection? A systematic literature review. JPEN J Parenter Enteral Nutr 2017; 41: 918-928
• 31 Gillis C, Carli F. Promoting perioperative metabolic and nutritional care. Anesthesiology 2015; 123: 1455-1472
• 32 Goldhill DR, Whelpton R, Winyard JA. et al. Gastric emptying in patients the day after cardiac surgery. Anaesthesia 1995; 50: 122-125
• 33 Malnutrition Advisory Group. A consistent and reliable tool for malnutrition screening. Nurs Times 2003; 99: 26-27
• 34 Hall R. Identification of inflammatory mediators and their modulation by strategies for the management of the systemic inflammatory response during cardiac surgery. Cardiothorac Vasc Anesth 2013; 27: 983-1033
• 35 Harvey SE, Parrott F, Harrison DA. et al. Trial of the route of early nutritional support in critically ill adults. N Engl J Med 2014; 371: 1673-1684
• 36 Herdy AH, Marcchi PL, Vila A. et al. Pre- and postoperative cardiopulmonary rehabilitation in hospitalized patients undergoing coronary artery bypass surgery: a randomized controlled trial. Am J Phys Med Rehabil 2008; 87: 714-719
• 37 Heyland DK, Cahill N, Day AG. Optimal amount of calories for critically ill patients: depends on how you slice the cake!. Crit Care Med 2011; 39: 2619-2626
• 38 Heyland DK, Dhaliwal R, Jiang X. et al. Identifying critically ill patients who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011; 15: R268
• 39 Hoffer LJ, Dickerson RN, Martindale RG. et al. Will we ever agree on protein requirements in the intensive care unit?. Nutr Clin Pract 2017; 32 (Suppl. 01) 94S-100S
• 40 Järvelä K, Maaranen P, Sisto T. Pre-operative oral carbohydrate treatment before coronary artery bypass surgery. Acta Anaesthesiol Scand 2008; 52: 793-797
• 41 Kaiser MJ, Bauer JM, Ramsch C. et al. Validation of the Mini Nutritional Assessment short-form (MNA-SF): a practical tool for identification of nutritional status. J Nutr Health Aging 2009; 13: 782-788
• 42 Kalaiselvan MS, Renuka MK, Arunkumar AS. Use of nutrition risk in critically ill (NUTRIC) score to assess nutritional risk in mechanically ventilated patients: A prospective observational study. Indian J Crit Care Med 2017; 21: 253-256
• 43 Khalid I, Doshi P, DiGiovine B. Early enteral nutrition and outcomes of critically ill patients treated with vasopressors and mechanical ventilation. Am J Crit Care 2010; 19: 261-268
• 44 Kondrup J, Allison SP, Elia M. et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003; 22: 415-421
• 45 Kondrup J, Rasmussen HH, Hamberg O. et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr 2003; 22: 321-336
• 46 Kruizenga HM, Seidell JC, de Vet HC. et al. Development and validation of a hospital screening tool for malnutrition: the short nutritional assessment questionnaire (SNAQ). Clin Nutr 2005; 24: 75-82
• 47 Landis RC, Brown JR, Fitzgerald D. et al. Attenuating the systemic inflammatory response to adult cardiopulmonary bypass: A critical review of the evidence base. J Extra Corpor Technol 2014; 46: 197-211
• 48 Lebreton G, Tamion F, Coeffier M. et al. Modulation of mesenteric vasoreactivity and inflammatory response by protein undernutrition in cardiopulmonary bypass. Nutrition 2013; 29: 318-324
• 49 Leong JY, van der Merwe J, Pepe S. et al. Perioperative metabolic therapy improves redox status and outcomes in cardiac surgery patients: a randomised trial. Heart Lung Circ 2010; 19: 584-591
• 50 Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg 2003; 90: 400-406
• 51 Lobo DN, Bostock KA, Neal KR. et al. Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet 2002; 359: 1812-1818
• 52 Lomivorotov VV, Efremov SM, Boboshko VA. et al. Prognostic value of nutritional screening tools for patients scheduled for cardiac surgery. Interact Cardiovasc Thorac Surg 2013; 16: 612-618
• 53 Lomivorotov VV, Efremov SM, Boboshko VA. et al. Evaluation of nutritional screening tools for patients scheduled for cardiac surgery. Nutrition 2013; 29: 436-442
• 54 Love R, Choe E, Lippton H. et al. Positive end-expiratory pressure decreases mesenteric blood flow despite normalization of cardiac output. J Trauma 1995; 39: 195-199
• 55 Lu C, Sharma S, McIntyre L. et al. Omega-3 supplementation in patients with sepsis: a systematic review and meta-analysis of randomized trials. Ann Intensive Care 2017; 7: 58
• 56 Malone A, Hamilton C. The Academy of Nutrition and Dietetics/the American Society for Parenteral and Enteral Nutrition consensus malnutrition characteristics: application in practice. Nutr Clin Pract 2013; 28: 639-650
• 57 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
• 58 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
• 59 Mendes R, Policarpo S, Fortuna P. et al. Nutritional risk assessment and cultural validation of the modified NUTRIC score in critically ill patients-A multicenter prospective cohort study. J Crit Care 2017; 37: 45-49
• 60 National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Rice TW, Wheeler AP, Thompson BT. et al. Initial trophic vs. full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 2012; 307: 795-803
• 61 Ohri SK, Velissaris T. Gastrointestinal dysfunction following cardiac surgery. Perfusion 2006; 21: 215-223
• 62 Paparella D, Yau TM, Young E. Cardiopulmonary bypass induced inflammation: pathophysiology and treatment. An update. Eur J Cardiothorac Surg 2002; 21: 232-244
• 63 Paris MT, Mourtzakis M, Day A. et al. Validation of bedside ultrasound of muscle layer thickness of the quadriceps in the critically ill patient (VALIDUM study). JPEN J Parenter Enteral Nutr 2017; 41: 171-180
• 64 Pope NH, Ailawadi G. Minimally invasive valve surgery. J Cardiovasc Transl Res 2014; 7: 387-394
• 65 Prondzinsky R, Knüpfer A, Loppnow H. et al. Surgical trauma affects the proinflammatory status after cardiac surgery to a higher degree than cardiopulmonary bypass. J Thorac Cardiovasc Surg 2005; 129: 760-766
• 66 Rahman A, Agarwala R, Martin C. et al. Nutrition therapy in critically ill patients following cardiac surgery: Defining and improving practice. JPEN J Parenter Enteral Nutr 2017; 41: 1188-1194
• 67 Rahman A, Hasan RM, Agarwala R. et al. Identifying critically-ill patients who will benefit most from nutritional therapy: Further validation of the “modified NUTRIC” nutritional risk assessment tool. Clin Nutr 2016; 35: 158-162
• 68 Rahman A, Wu T, Bricknell R. et al. Malnutrition matters in Canadian hospitalized patients: Malnutrition risk in hospitalized patients in a tertiary care center using the Malnutrition Universal Screening Tool. Nutr Clin Pract 2015; 30: 709-713
• 69 Raja SG, Berg GA. Impact of off-pump coronary artery bypass surgery on systemic inflammation: current best available evidence. J Cardiac Surg 2007; 22: 445-455
• 70 Rapp-Kesek D, Stridsberg M, Andersson LG. et al. Insulin resistance after cardiopulmonary bypass in the elderly patient. Scand Cardiovasc J 2007; 41: 102-108
• 71 Revelly JP, Tappy L, Berger MM. et al. Early metabolic and splanchnic responses to enteral nutrition in postoperative cardiac surgery patients with circulatory compromise. Intensive Care Med 2001; 27: 540-547
• 72 Rice TW, Mogan S, Hays MA. et al. Randomized trial of initial trophic versus full-energy enteral nutrition in mechanically ventilated patients with acute respiratory failure. Crit Care Med 2011; 39: 967-974
• 73 Rossaint J, Berger C, Van Aken H. et al. Cardiopulmonary bypass during cardiac surgery modulates systemic inflammation by affecting different steps of the leukocyte recruitment cascade. PloS One 2012; 7: e45738
• 74 Rubenstein LZ, Harker JO, Salvà A. et al. Screening for undernutrition in geriatric practice: developing the short-form mini-nutritional assessment (MNA-SF). J Gerontol A Biol Sci Med Sci 2001; 56: M366-M372
• 75 Sanchez JA, Sanchez LL, Dudrick SJ. Nutritional considerations in adult cardiothoracic surgical patients. Surg Clin North Am 2011; 91: 857-875
• 76 Santa Mina D. et al. Effect of total-body prehabilitation on postoperative outcomes: a systematic review and meta-analysis. Physiotherapy 2014; 100: 196-207
• 77 Schmidt T, Pargger H, Seeberger E. et al. Effect of high-dose sodium selenite in cardiac surgery patients: A randomized controlled bi-center trial. Clin Nutr 2017; DOI: 10.1016/j.clnu.2017.04.019.
• 78 Schmitto JD, Mokashi SA, Cohn LH. Minimally-invasive valve surgery. J Am Coll Cardiol 2010; 56: 455-462
• 79 Sheean PM, Peterson SJ, Gurka DP. et al. Nutrition assessment: the reproducibility of subjective global assessment in patients requiring mechanical ventilation. Eur J Clin Nutr 2010; 64: 1358-1364
• 80 Simpson F, Doig GS. Parenteral vs. enteral nutrition in the critically ill patient: a meta-analysis of trials using the intention to treat principle. Intensive Care Med 2005; 31: 12-23
• 81 Stoppe C, Goetzenich A, Whitman G. et al. Role of nutrition support in adult cardiac surgery: a consensus statement from an international multidisciplinary expert group on nutrition in cardiac surgery. Crit Care 2017; 21: 131
• 82 Stoppe C, McDonald B, Benstoem C. et al. Evaluation of persistent organ dysfunction plus death as a novel composite outcome in cardiac surgical patients. J Cardiothorac Vasc Anesth 2016; 30: 30-38
• 83 Stoppe C, McDonald B, Rex S. et al. SodiUm SeleniTe Adminstration IN Cardiac Surgery (SUSTAIN CSX-trial): study design of an international multicenter randomized double-blinded controlled trial of high dose sodium-selenite administration in high-risk cardiac surgical patients. Trials 2014; 15: 339
• 84 Stoppe C, Spillner J, Rossaint R. et al. Selenium blood concentrations in patients undergoing elective cardiac surgery and receiving perioperative sodium selenite. Nutrition 2013; 29: 158-165
• 85 Strack van Schijndel RJ, Weijs PJ, Koopmans RH. et al. Optimal nutrition during the period of mechanical ventilation decreases mortality in critically ill, long-term acute female patients: a prospective observational cohort study. Crit Care 2009; 13: R132
• 86 Valkenet K, van de Port IG, Dronkers JJ. et al. The effects of preoperative exercise therapy on postoperative outcome: a systematic review. Clin Rehabil 2011; 25: 99-111
• 87 van Straten AH, Bramer S, Soliman Hamad MA. et al. Effect of body mass index on early and late mortality after coronary artery bypass grafting. Ann Thorac Surg 2010; 89: 30-37
• 88 Visser M, van Venrooij LM, Vulperhorst L. et al. Sarcopenic obesity is associated with adverse clinical outcome after cardiac surgery. Nutr Metab Cardiovasc Dis 2013; 23: 511-518 doi:10.1016/j.numecd.2011.12.001
• 89 Weijs PJ, Cynober L, DeLegge M. et al. Proteins and amino acids are fundamental to optimal nutrition support in critically ill patients. Crit Care 2014; 18: 591
• 90 Weijs PJ, Stapel SN, de Groot SD. et al. Optimal protein and energy nutrition decreases mortality in mechanically ventilated, critically ill patients: a prospective observational cohort study. JPEN J Parenter Enteral Nutr 2012; 36: 60-68
• 91 Weimann A, Braga M, Carli F. et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36: 623-650
• 92 White JV, Guenter P, Jensen G. et al. Consensus statement: Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition: characteristics recommended for the identification and documentation of adult malnutrition (undernutrition). JPEN J Parenter Enteral Nutr 2012; 36: 275-283
• 93 Wischmeyer PE, Hasselmann M, Kummerlen C. et al. A randomized trial of supplemental parenteral nutrition in underweight and overweight critically ill patients: the TOP-UP pilot trial. Crit Care 2017; 21: 142
• 94 Wischmeyer PE, Puthucheary Z, San Millán I. et al. Muscle mass and physical recovery in ICU: Innovations for targeting of nutrition and exercise. Curr Opin Crit Care 2017; 23: 269-278
• 95 Yeh DD, Fuentes E, Quraishi SA. et al. Adequate nutrition may get you home: Effect of caloric/protein deficits on the discharge destination of critically ill surgical patients. JPEN J Parenter Enteral Nutr 2016; 40: 37-44