Enterale Immunonutrition: wann, für wen, welche Zukunftsperspektiven gibt es?

Zusammenfassung

Eine zunehmende Anzahl aktueller klinischer Studien zur Evaluierung immunmodulierender enteraler Nährlösungen weisen auf eine günstige Beeinflussung definierter klinischer Endpunkte hin. Diese enteralen Nährlösungen werden mit einer Verringerung des Infektionsrisikos, einer Verkürzung der Beatmungszeit am Respirator sowie mit einer Reduktion des Aufenthalts auf der Intensivstation oder in der Klinik in Zusammenhang gebracht. Methodische Schwächen mancher dieser Untersuchungen sowie die Befunde aktueller Studien mahnen jedoch zur Vorsicht, was verallgemeinernde Empfehlungen zur klinischen Anwendung der enteralen Immunonutrition angeht. Zwar wurden an einem vorwiegend operativen Krankengut positive Resultate aufgezeigt, wobei jedoch nur bei denjenigen Patienten günstige Verläufe zu beobachten waren, bei denen eine kritische Mindestmenge der angebotenen enteralen Nährlösungen toleriert wurde. Zudem sind diese positiven Befunde nicht uneingeschränkt auf alle Patientenpopulationen übertragbar. Einige der Studien weisen darauf hin, dass kritisch Kranke mit schwersten Verlaufsformen von systemischer Inflammation (SIRS), Sepsis und konsekutivem Organversagen nicht von den derzeit verfügbaren enteralen Diäten zur Immunmodulation profitieren und unter Umständen sogar Schaden von deren Anwendung nehmen können. Mögliche Unzulänglichkeiten gegenwärtig verfügbarer Konzepte zur Immunonutrition bei kritisch kranken Patienten können wie folgt zusammengefasst werden: 1. inadäquate Bilanzierung von „Schlüsselsubstraten” bei eingeschränkter Toleranz der enteralen Ernährung; 2. mangelnde Prävention und Therapie gastrointestinaler Motilitätsstörungen; 3. mangelnde Prävention mukosaler Schädigungen durch den Einfluss freier Radikale; 4. Zufuhr immunmodulierender Substrate mit proinflammatorischen und radikalgenerierenden Wirkungen während schwerster hyperinflammatorischer Zustandsbilder. Während der Einsatz derzeit verfügbarer immunmodulierender Nährlösungen zur perioperativen Gabe bei mangelernährten Patienten sowie nach schweren Traumen empfohlen werden kann, sollte zukünftig die gezielte experimentelle und klinische Evaluierung neuer Konzepte zur enteralen Immunonutrition während schwerer Verlaufsformen von SIRS, Sepsis und Organversagen unter Berücksichtigung der genannten Kritikpunkte erfolgen.

Abstract

Numerous trials evaluating immune-enhancing diets suggest several beneficial clinical effects. These diets were shown to be associated with a reduction in infectious complications, ventilator days, ICU and hospital stay. However, methodological weaknesses of some of these studies as well as the results of recent publications give rise for concerns and may limit the inferences we can derive from these data. In particular, improvements in outcome were largely seen in surgical patients and in patients who tolerated critical amounts of formula. We posit that the beneficial findings cannot easily be extrapolated to other patient populations since there is suggestion from clinical trials that the sickest patients, especially those with severest appearances of sepsis, shock and organ failure, may not benefit or may even be harmed. We therefore hypothesise that currently available immune enhancing diets may not be suitable for this particular patient population. Potential limitations of currently available concepts for enteral immunonutrition in critically ill patients are to be summarized as follows: 1) inadequate provision of „key nutrients” via the enteral route while enteral feeding tolerance becomes significantly impaired; 2) inadequate prevention of intestinal motility disorders; 3) insufficient measures to fight free radical induced damage of the intestinal mucosal barrier; 4) administration of pro-inflammatory and radical generating substrates in patients presenting with severe appearances of a systemic inflammatory response syndrome (SIRS). In conclusion, the use of immune enhancing diets can be recommended in the perioperative period, in particular if patients are subjected to both malnutrition and operative stress as well as in the post trauma period not complicated by severe SIRS or sepsis. In patients with severe appearances of SIRS or sepsis, however, new concepts in enteral immunonutrition should be evaluated in the experimental and clinical setting whereas the potential limitations of currently available diets should be considered adequately.

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