Zusammenfassung
Fragestellung Trotz der Komplexizität des Krankheitsbildes beim kritisch Kranken haben sich evidenzbasiert
in den letzten 10 Jahren weitere Fortschritte auf dem Weg einer gezielt günstigen
Immunmodulation durch besonders angereicherte enterale und parenterale Ernährung ergeben.
Dies findet sich auch in aktuellen Leitlinienempfehlungen und soll hier noch einmal
dargestellt und diskutiert werden. Material und Methodik Übersicht der aktuellen klinischen Studien zur Immunmodulation im Konzept einer Pharmakonutrition
durch supplementierte Ernährung bei chirurgischen und kritisch kranken Patienten.
Ergebnisse Die Wirksamkeit von Substanzen wie Glutamin, Arginin, Omega-3-Fettsäuren, Antioxidanzien
und Synbiotika bei der Immunmodulation ist belegt. Aus den berechtigterweise hohen
Anforderungen an die Qualität von klinischen Studien resultiert ein erheblicher logistischer
und finanzieller Aufwand, sodass der Zuwachs an Evidenz nur langsam voranschreiten
wird. Dies wirkt sich nicht zuletzt aufgrund erhöhter Kosten limitierend auf die Einführung
in die Klinik aus. Vor dem Hintergrund von ökonomisch gebotener Rationalisierung und
Rationierung sollte aber gerade bei kritisch Kranken nicht außer Acht gelassen werden,
dass eine adäquate Ernährung per se auch eine günstige Beeinflussung des Immunsystems
als Voraussetzung für das Erreichen eines guten Therapieergebnisses darstellt. Schlussfolgerung Das Ziel einer Pharmakonutrition wird partiell durch den Nachweis zur Wirkung einzelner
Substrate erreicht, bleibt jedoch aufgrund noch ungenügender Daten zu den Dosis-Wirkungs-Beziehungen
und Toxizitätsgrenzen zunächst noch eine realistische Vision.
Abstract
Purpose With regard to the complexicity of critical illness the last decade has led to some
progress on the field of immune-enhancement by supplemented enteral and parenteral
nutrition. The improvement of knowledge has been incorporated in present clinical
guidelines and will be presented. Material and Methods Review of recent clinical trials about immune-enhancement in the concept of pharmaconutrition
in surgery and critical illness. Results New studies have confirmed the effectiveness of immune-enhancement by substrates
like glutamin, arginine, omega-3-fatty acids, antioxidants, and synbiotics. The need
for well designed and performed clinical studies of high quality is a considerable
logistic and financial burden, which will limit the growth of evidence. Related to
economic rationing in the intensive care unit one should be always aware about the
immune-enhancing impact of clinical nutrition per se on outcome. Conclusion Aiming on pharmaconutrition some progress about immune-enhancement in surgical and
critically ill patients has been obtained. There is still a lack of data about the
effects related to dosage and the limits by potential toxicity. So far, pharmaconutrition
will remain a realistic vision.
Schlüsselwörter
Immunmodulation - Immunonutrition - kritisch krank
Key words
immune-enhancement - immunonutrition - critically ill
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Prof. Dr. Arved Weimann
Klinik für Allgemein- und Viszeralchirurgie
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