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Ernährung schwerverletzter Patienten

Therapie zwischen Leitlinien und Realität

Nutritional management of severely injured patients

Treatment between guidelines and reality

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Zusammenfassung

Hyperglykämie, Insulinresistenz und Eiweißkatabolie stellen die wesentlichen Besonderheiten des posttraumatischen Metabolismus dar. Sie werden durch Stresshormone und Entzündungsmediatoren ausgelöst und können zunächst nicht pharmakologisch oder durch Substratangebot allein durchbrochen werden. Ein ausreichendes Angebot an Energie und Protein kann aber zumindest helfen, eine überschießende Katabolie zu reduzieren.

Eine frühzeitige enterale Ernährung mit einem Energieangebot von etwa 25 kcal/kgKG/Tag und einem zusätzliches Proteinangebot um 1,5 g/kgKG/Tag wird in den verfügbaren Leitlinien empfohlen. Allerdings ist gerade bei polytraumatisierten Patienten dieses Ziel durch enterale Ernährung oft erst verzögert erreichbar. Hier sollte zur Überbrückung ebenfalls frühzeitig eine parenterale Ernährung eingesetzt werden. Gleichzeitig müssen Oberbauchatonie und paralytischer Ileus als Hinderungsfaktoren einer enterale Ernährung durch Propulsiva und -kinetika, Opiateinsparung und, in ausgewählten Indikationen, durch die Anlage von Dünndarmsonden behandelt werden.

Die euphorischen Erwartungen, die sich in den vergangenen Jahren an eine intensivierte Insulintherapie (IIT) bei Intensivpatienten mit Zielblutzuckerwerten <110 mg/dl geknüpft hatten, mussten stark relativiert werden: Nach heutigem Kenntnisstand werden Blutzuckerobergrenzen um 180 mg/dl angestrebt, die eine optimale Kombination aus Effizienz und Sicherheit in der Ernährungstherapie versprechen.

Abstract

Severe trauma triggers endocrine and inflammatory responses, leading to hyperglycaemia, insulin resistance and protein catabolism. Pharmacological and nutritional interventions cannot counteract these metabolic disturbances. However, adequate supply of energy and proteins may reduce excessive catabolism.

Available guidelines recommend early use of enteral nutrition with energetic supply of about 25 kcal/kg and additional protein supply of 1.5 g/kg/day. These aims will be missed frequently by solely providing enteral nutrition in severely injured patients. Early supplemental parenteral nutrition should be used in these cases. Concomitantly, gastric paresis and paralytic ileus hampering enteral nutrition should be treated by propulsive and prokinetic drugs and by use of duodenal or jejunal site of application in selected cases.

Euphoric hopes linked with intensified insulin therapy (IIT), targeting blood glucose levels <110 mg/dl in intensive care patients, had to be widely abandoned in recent years. The goal for blood glucose levels should be set at 180 mg/dl as the upper limit according to current knowledge, which promises to optimize the balance between efficacy and safety.

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  1. Chirurgische Klinik Innenstadt, Klinikum der Universität München, München, Deutschland

    L. Ney

  2. Klinik für Anaesthesiologie, Campus Innenstadt, Klinikum der Universität München, Nußbaumstraße 20, 80336, München, Deutschland

    L. Ney & T. Annecke

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  1. L. Ney
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  2. T. Annecke
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Correspondence to L. Ney.

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Ney, L., Annecke, T. Ernährung schwerverletzter Patienten. Unfallchirurg 114, 973–980 (2011). https://doi.org/10.1007/s00113-011-2032-8

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