Der mangelernährte Patient auf der Intensivstation

Bis zu 30% aller Krankenhauspatienten weisen einen Zustand der Mangelernährung auf, der Anteil der Intensivpatienten ist noch deutlich höher. Wenn man nun bedenkt, dass Unterernährung bei Krankenhauspatienten mit einem schlechteren Outcome verbunden ist als Normalgewichtigkeit, ist die Relevanz der Erfassung von eventuellen Mangelzuständen und deren möglichst umgehende Behebung offensichtlich.

Kernaussagen

• Mangelernährte Patienten finden sich auf der Intensivstation häufiger, als allgemein bekannt ist.

• Mangelernährte Intensivpatienten haben eine höhere Intensivletalität als normal- oder geringgradig übergewichtige Intensivpatienten.

• Ausgeprägte klinische Bilder einer Mangelernährung finden sich u. a. bei Patienten mit einer Tumorkachexie und bei Patienten mit einer Anorexia nervosa.

• Wenn möglich sollten mangelernährte Patienten vor elektiven großen operativen oder interventionellen Eingriffen schon eine spezielle Ernährungstherapie erhalten.

• Bei mangelernährten Patienten sollten die angestrebten täglichen Kalorien- und Proteinmengen innerhalb von 24 – 48 Stunden zu 80% und innerhalb von 7 Tagen zu 100% erreicht werden.

• Zu Beginn einer Ernährungstherapie von mangelernährten Patienten muss auf das Auftreten eines Refeeding-Syndroms geachtet werden.

Schlüsselwörter

Anorexia nervosa - Untergewicht - Malnutrition - Tumorkachexie - Refeeding-Syndrom

• Literatur

• 1 N.C.D. Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a pooled analysis of 1698 population-based measurement studies with 19.2 million participants. Lancet 2016; 387: 1377-1396 doi:10.1016/S0140-6736(16)30054-X
• 2 Bone HG, Freyhoff J, Utech M. Der adipöse Patient auf der Intensivstation – Was ist anders?. AINS 2014; 49: 288-296 doi:10.1055/s-0034-1376446
• 3 Mensink G, Schienkiewitz A, Haftenberger M. et al. Übergewicht und Adipositas in Deutschland – Ergebnisse der Studie zur Gesundheit Erwachsener in Deutschland (DEGS1). Bundesgesundheitsblatt 2013; 56: 786-794
• 4 Rojer AG, Kruizenga HM, Trappenburg MC. et al. The prevalence of malnutrition according to the new ESPEN definition in four diverse populations. Clin Nutr 2016; 35: 758-762 doi:10.1016/j.clnu.2015.06.005
• 5 Kirkland LL, Shaughnessy E. Recognition and prevention of nosocomial malnutrition: a review and a call to action!. Am J Med 2017; 130: 1345-1350 doi:10.1016/j.amjmed.2017.07.034
• 6 Lew CCH, Yandell R, Fraser RJL. et al. Association between malnutrition and clinical outcomes in the intensive care unit: a systematic review. J Parenter Enteral Nutr 2017; 41: 744-758 doi:10.1177/0148607115625638
• 7 Cederholm T, Barazzoni R, Austin P. et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr 2017; 36: 49-64 doi:10.1016/j.clnu.2016.09.004
• 8 Cederholm T, Bosaeus I, Barazzoni R. et al. Diagnostic criteria for malnutrition – An ESPEN Consensus Statement. Clin Nutr 2015; 34: 335-340 doi:10.1016/j.clnu.2015.03.001
• 9 Cederholm T, Jensen GL. To create a consensus on malnutrition diagnostic criteria. JPEN J Parenter Enteral Nutr 2017; 41: 311-314 doi:10.1177/0148607116686293
• 10 Taylor BE, McClave SA, 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.). Crit Care Med 2016; 44: 390-438 doi:10.1097/CCM.0000000000001525
• 11 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 (ASPEN). J Parenter Enteral Nutritit 2016; 40: 159-211 doi:10.1177/0148607115621863
• 12 Kondrup J, Allison SP, Elia M. et al. ESPEN guidelines for nutrition screening 2002. Clin Nutr 2003; 22: 415-421
• 13 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 doi:10.1186/cc10546
• 14 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
• 15 Kondrup J. Nutritional-risk scoring systems in the intensive care unit. Curr Opin Clin Nutrit Metab Care 2014; 17: 177-182 doi:10.1097/MCO.0000000000000041
• 16 Reintam Blaser A, Starkopf J, Alhazzani W. et al. Early enteral nutrition in critically ill patients: ESICM clinical practice guidelines. Intensive Care Med 2017; 43: 380-398 doi:10.1007/s00134-016-4665-0
• 17 Heyland DK, Stephens KE, Day AG. et al. The success of enteral nutrition and ICU-acquired infections: a multicenter observational study. Clin Nutr 2011; 30: 148-155 doi:10.1016/j.clnu.2010.09.011
• 18 Lemos T, Gallagher D. Current body composition measurement techniques. Curr Opin Endocrinol Diabetes Obes 2017; 24: 310-314 doi:10.1097/MED.0000000000000360
• 19 Mourtzakis M, Parry S, Connolly B. et al. Skeletal muscle ultrasound in critical care: a tool in need of translation. Ann Am Thorac Soc 2017; 14: 1495-1503 doi:10.1513/AnnalsATS.201612-967PS
• 20 Lukaski HC, Kyle UG, Kondrup J. Assessment of adult malnutrition and prognosis with bioelectrical impedance analysis: phase angle and impedance ratio. Curr Opin Clin Nutrit Metab Care 2017; 20: 330-339 doi:10.1097/MCO.0000000000000387
• 21 Zhang H, Zhang X, Dong L. Nutritional status plays a crucial role in the mortality of critically ill patients with acute renal failure. J Investig Med 2017; DOI: 10.1136/jim-2017-000518.
• 22 Mogensen KM, Robinson MK, Casey JD. et al. Nutritional status and mortality in the critically ill. Crit Care Med 2015; 43: 2605-2615 doi:10.1097/CCM.0000000000001306
• 23 Robinson MK, Mogensen KM, Casey JD. et al. The relationship among obesity, nutritional status, and mortality in the critically ill. Crit Care Med 2015; 43: 87-100 doi:10.1097/CCM.0000000000000602
• 24 Mogensen KM, Horkan CM, Purtle SW. et al. Malnutrition, critical illness survivors, and postdischarge outcomes: a cohort study. J Parenter Enteral Nutrit 2017; DOI: 10.1177/0148607117709766.
• 25 Havens JM, Columbus AB, Seshadri AJ. et al. Malnutrition at intensive care unit admission predicts mortality in emergency general surgery patients. J Parenter Enteral Nutrit 2016; DOI: 10.1177/0148607116676592.
• 26 Thibault R, Makhlouf AM, Mulliez A. et al. Fat-free mass at admission predicts 28-day mortality in intensive care unit patients: the international prospective observational study Phase Angle Project. Intensive Care Med 2016; 42: 1445-1453 doi:10.1007/s00134-016-4468-3
• 27 Shapiro ML, Komisarow J. The obesity paradox and effects of early nutrition: is there a paradox, or is there not?. Crit Care Med 2017; 45: 918-919 doi:10.1097/CCM.0000000000002392
• 28 Harris K, Zhou J, Liu X. et al. The obesity paradox is not observed in critically ill patients on early enteral nutrition. Crit Care Med 2017; 45: 828-834 doi:10.1097/CCM.0000000000002326
• 29 Laviano A, Meguid MM, Inui A. et al. Therapy insight: Cancer anorexia-cachexia syndrome – when all you can eat is yourself. Nat Clin Pract Oncol 2005; 2: 158-165 doi:10.1038/ncponc0112
• 30 Bai Y, Hu Y, Zhao Y. et al. Anamorelin for cancer anorexia-cachexia syndrome: a systematic review and meta-analysis. Support Care Cancer 2017; 25: 1651-1659 doi:10.1007/s00520-016-3560-0
• 31 Orthner M. Behandlung vital gefährdeter Anorexia nervosa Patienten unter Berücksichtigung der Möglichkeiten des Betreuungsrechts. München: Ludwig Maximilian Universität München; 2008
• 32 Hoang U, Goldacre M, James A. Mortality following hospital discharge with a diagnosis of eating disorder: national record linkage study, England, 2001–2009. Int J Eat Disord 2014; 47: 507-515 doi:10.1002/eat.22249
• 33 Stheneur C, Ali A, Tric L. et al. Impact of somatic severity on long-term mortality in anorexia nervosa. Eat Weight Disord 2017; 22: 285-289 doi:10.1007/s40519-016-0346-9
• 34 Mehler PS, Brown C. Anorexia nervosa – medical complications. J Eat Disord 2015; 3: 11 doi:10.1186/s40337-015-0040-8
• 35 Brown C, Mehler PS. Medical complications of anorexia nervosa and their treatments: an update on some critical aspects. Eat Weight Disord 2015; 20: 419-425 doi:10.1007/s40519-015-0202-3
• 36 Corcoran TB, ONeill MA, Webb SA. et al. Prevalence of vitamin deficiencies on admission: relationship to hospital mortality in critically ill patients. Anaesth Intensive Care 2009; 37: 254-260
• 37 Higgins DM, Wischmeyer PE, Queensland KM. et al. Relationship of vitamin D deficiency to clinical outcomes in critically ill patients. J Parenter Enteral Nutrit 2012; 36: 713-720 doi:10.1177/0148607112444449
• 38 Langlois PL, Szwec C, DʼAragon F. et al. Vitamin D supplementation in the critically ill: A systematic review and meta-analysis. Clin Nutrit 2017; DOI: 10.1016/j.clnu.2017.05.006.
• 39 Byrnes MC, Stangenes J. Refeeding in the ICU: an adult and pediatric problem. Curr Opin Clin Nutrit Metab Care 2011; 14: 186-192 doi:10.1097/MCO.0b013e328341ed93
• 40 Boateng AA, Sriram K, Meguid MM. et al. Refeeding syndrome: treatment considerations based on collective analysis of literature case reports. Nutrition 2010; 26: 156-167 doi:10.1016/j.nut.2009.11.017
• 41 Gentile MG, Pastorelli P, Ciceri R. et al. Specialized refeeding treatment for anorexia nervosa patients suffering from extreme undernutrition. Clin Nutr 2010; 29: 627-632 doi:10.1016/j.clnu.2010.03.008
• 42 Doig GS, Simpson F, Heighes PT. et al. Restricted versus continued standard caloric intake during the management of refeeding syndrome in critically ill adults: a randomised, parallel-group, multicentre, single-blind controlled trial. Lancet Respir Med 2015; 3: 943-952 doi:10.1016/S2213-2600(15)00418-X
• 43 Friedli N, Stanga Z, Culkin A. et al. Management and prevention of refeeding syndrome in medical inpatients: An evidence-based and consensus-supported algorithm. Nutrition 2018; 47: 13-20
• 44 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.). J Parenter Enteral Nutrit 2016; 40: 159-211 doi:10.1177/0148607115621863
• 45 Frankenfield DC, Ashcraft CM, Galvan DA. Prediction of resting metabolic rate in critically ill patients at the extremes of body mass index. J Parenter Enteral Nutrit 2013; 37: 361-367 doi:10.1177/0148607112457423
• 46 Jie B, Jiang ZM, Nolan MT. et al. Impact of preoperative nutritional support on clinical outcome in abdominal surgical patients at nutritional risk. Nutrition 2012; 28: 1022-1027 doi:10.1016/j.nut.2012.01.017
• 47 Weimann A, Braga M, Carli F. et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr 2017; 36: 623-650 doi:10.1016/j.clnu.2017.02.013
• 48 Gillis C, Carli F. Promoting perioperative metabolic and nutritional care. Anesthesiology 2015; 123: 1455-1472 doi:10.1097/ALN.0000000000000795
• 49 Santa Mina D, Scheede-Bergdahl C, Gillis C. et al. Optimization of surgical outcomes with prehabilitation. Appl Physiol Nutrit Metab 2015; 40: 966-969 doi:10.1139/apnm-2015-0084
• 50 Gunst J, Van den Berghe G. Parenteral nutrition in the critically ill. Curr Opin Crit Care 2017; 23: 149-158 doi:10.1097/MCC.0000000000000385
• 51 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 doi:10.1007/s00134-004-2511-2
• 52 Schütz T, Valentini L, Plaut M. Screening auf Mangelernährung nach den ESPEN-Leitlinien 2002. Aktuelle Ernaehr Med 2005; 30: 90-103