Der Anaesthesist

, Volume 61, Issue 8, pp 696–702 | Cite as

Ernährungstherapie bei Schädel-Hirn-Trauma

Update 2012
  • H.E. Marcus
  • F.A. Spöhr
  • B.W. Böttiger
  • S. Grau
  • S.A. Padosch
Intensivmedizin

Zusammenfassung

Das schwere Schädel-Hirn-Trauma (SHT) gehört zu den häufigsten Todesursachen bei jungen Erwachsenen. Beim schweren SHT folgt der primären Verletzung in der Regel eine ausgeprägte pathophysiologische Kaskade, die Sekundärschäden anrichtet und für eine Vielzahl der Todesfälle verantwortlich ist. Ziel der intensivmedizinischen Therapie nach SHT ist es u. a., die Ausprägung und die damit einhergehenden Komplikationen zu kontrollieren. Von besonderer Bedeutung sind dabei das strikte Vermeiden von Hypoxämie, arterieller Hypotension, intrakranieller Hypertension, Hyperthermie, Hyperglykämie, Hypoglykämie und thrombembolischen Ereignissen. Eine weitere Möglichkeit, den Verlauf bzw. das Ausmaß eines SHT günstig zu beeinflussen, ergibt sich aus dem bis dato vergleichsweise wenig beachteten intensivmedizinischen Aspekt der Ernährung von Intensivpatienten nach SHT. Innerhalb von 24 h sollte bei diesen Patienten mit der Ernährung begonnen werden. Generell sollte, wenn möglich, einer enteralen Ernährung der Vorzug gegeben werden. Die volle enterale Verabreichung des errechneten Energiebedarfs vom ersten Tag nach Trauma, wenn möglich, kann dazu beitragen, die Infektions- und allgemeine Komplikationsrate signifikant zu senken. In der vorliegenden Arbeit soll der Stellenwert der Ernährung bei der Therapie des SHT betrachtet werden.

Schlüsselwörter

Intensivmedizinische Behandlung Enterale Ernährung Parenterale Ernährung Behandlungsergebnis Mortalität 

Nutritional therapy in traumatic brain injury

Update 2012

Abstract

Severe traumatic brain injury ranks among the most common causes of death in young adults in western countries. Severe traumatic brain injury is typically followed by a pronounced pathophysiological cascade that accounts for many deaths. The aim of intensive care medicine after traumatic brain injury is to minimize and to control the consequences of this potentially fatal cascade. The avoidance of hypoxemia, arterial hypotension, intracranial hypertension, hyperthermia, hyperglycemia, hypoglycemia and thromboembolic complications is essential in preventing this cascade. The effect of nutrition has been rather underestimated as a means of improving the outcome after traumatic brain injury. Nutrition should be started within the first 24 h after trauma. Enteral, wherever applicable, should be the route of administration of nutrition. Enteral administration of the whole calculated calorie requirement on day 1 after trauma, if possible, lowers the infection and overall complication rates. The present review gives an update of a practical approach to nutrition in traumatic brain injury.

Keywords

Intensive care Enteral nutrition Parenteral nutrition Treatment outcome Mortality 

Notes

Interessenkonflikt

Der korrespondierende Autor gibt für sich und seine Koautoren an, dass kein Interessenkonflikt besteht.

Literatur

  1. 1.
    Andrews BT (1994) Fluid and electrolyte disorders in neurosurgical intensive care. Neurosurg Clin N Am 5:707–723PubMedGoogle Scholar
  2. 2.
    Assadi F (2012) Hyponatremia: a problem-solving approach to clinical cases. J Nephrol 25:473–480PubMedCrossRefGoogle Scholar
  3. 3.
    Bratton SL, Chestnut RM, Ghajar J et al.; Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS (2007) Guidelines for the management of severe traumatic brain injury. XII. Nutrition. J Neurotrauma 24(Suppl 1):77–82Google Scholar
  4. 4.
    Casaer MP, Mesotten D, Hermans G et al (2011) Early versus late parenteral nutrition in critically ill adults. N Engl J Med 365:506–517PubMedCrossRefGoogle Scholar
  5. 5.
    Charrueau C, Belabed L, Besson V et al (2009) Metabolic response and nutritional support in traumatic brain injury: evidence for resistance to renutrition. J Neurotrauma 26:1911–1120PubMedCrossRefGoogle Scholar
  6. 6.
    Chesnut RM, Marshall LF, Klauber MR et al (1993) The role of secondary brain injury in determining outcome from severe head injury. J Trauma 34:216–222PubMedCrossRefGoogle Scholar
  7. 7.
    Clifton GL, Miller ER, Choi SC, Levin HS (2002) Fluid thresholds and outcome from severe brain injury. Crit Care Med 30:739–745PubMedCrossRefGoogle Scholar
  8. 8.
    Clifton GL, Robertson CS, Choi SC (1986) Assessment of nutritional requirements of head-injured patients. J Neurosurg 64:895–901PubMedCrossRefGoogle Scholar
  9. 9.
    Cole CD, Gottfried ON, Liu JK, Couldwell WT (2004) Hyponatremia in the neurosurgical patient: diagnosis and management. Neurosurg Focus 16:1–10CrossRefGoogle Scholar
  10. 10.
    Cook AM, Peppard A, Magnuson B (2009) Nutrition considerations in traumatic brain injury. Nutr Clin Pract 23:608–620CrossRefGoogle Scholar
  11. 11.
    Dickerson RN, Mitchell JN, Morgan LM et al (2009) Disparate response to metoclopramide therapy for gastric feeding intolerance in trauma patients with and without traumatic brain injury. JPEN J Parenter Enteral Nutr 33:646–655PubMedCrossRefGoogle Scholar
  12. 12.
    Drakulovic MB, Torres A, Bauer TT et al (1999) Supine body position as a risk factor for nosocomial pneumonia in mechanically ventilated patients: a randomised trial. Lancet 27;354(9193):1851–1858Google Scholar
  13. 13.
    Feng D, Xu W, Chen G et al (2007) Influence of glutamine on intestinal inflammatory response, mucosa structure alterations and apoptosis following traumatic brain injury in rats. J Int Med Res 35:644–656PubMedGoogle Scholar
  14. 14.
    Fresenius M, Heck M (2008) Repetitorium Intensivmedizin. Vorbereitung auf die Prüfung „Intensivmedizin“, 3., vollst. überarb. und akt. Aufl. Springer, Berlin Heidelberg New York TokioGoogle Scholar
  15. 15.
    Garg R, Chaudhuri A, Munschauer F, Dandona P (2006) Hyperglycemia, insulin, and acute ischemic stroke: a mechanistic justification for a trial of insulin infusion therapy. Stroke 37:267–273PubMedCrossRefGoogle Scholar
  16. 16.
    Hariri RJ, Firlick AD, Shepard SR et al (1993) Traumatic brain injury, hemorrhagic shock, and fluid resuscitation: effects on intracranial pressure and brain compliance. J Neurosurg 79:421–427PubMedCrossRefGoogle Scholar
  17. 17.
    Härtl R, Gerber LM, Ni Q, Ghajar J (2008) Effect of early nutrition on deaths due to severe traumatic brain injury. J Neurosurg 109:50–56PubMedCrossRefGoogle Scholar
  18. 18.
    Hatton J, Ziegler TR (1998) Nutritional support of the neurosurgical patient. In: Tindall G, Cooper PR, Barrow DL (Hrsg) The practice of neurosurgery. Williams & Wilkins, Baltimore, S 381–396Google Scholar
  19. 19.
    Kattelmann KK, Hise M, Russell M et al (2006) Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients. J Am Diet Assoc 106:1226–1241PubMedCrossRefGoogle Scholar
  20. 20.
    Kirby DF, Clifton GL, Turner H et al (1991) Early enteral nutrition after brain injury by percutaneous endoscopic gastrojejunostomy. JPEN J Parenter Enteral Nutr 15:298–302PubMedCrossRefGoogle Scholar
  21. 21.
    Krakau K, Omne-Pontén M, Karlsson T, Borg J (2006) Metabolism and nutrition in patients with moderate and severe traumatic brain injury: a systematic review. Brain Inj 20:345–367PubMedCrossRefGoogle Scholar
  22. 22.
    Kreymann KG, Berger MM, Deutz NE et al; DGEM (German Society for Nutritional Medicine), Ebner C, Hartl W, Heymann C, Spies C; ESPEN (European Society for Parenteral and Enteral Nutrition) (2006) ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 25:210–223PubMedCrossRefGoogle Scholar
  23. 23.
    Lepelletier D, Roquilly A, Demeure dit latte D et al (2010) Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical-ICU head-trauma patients. J Neurosurg Anesthesiol 22:32–37PubMedCrossRefGoogle Scholar
  24. 24.
    Liao KH, Chang CK, Chang HC et al; Brain Trauma Foundation (2009) Clinical practice guidelines in severe traumatic brain injury in Taiwan. Surg Neurol 72(Suppl 2):66–73CrossRefGoogle Scholar
  25. 25.
    Lindsey KA, Brown RO, Maish GO 3rd et al (2010) Influence of traumatic brain injury on potassium and phosphorus homeostasis in critically ill multiple trauma patients. Nutrition 26:784–790PubMedCrossRefGoogle Scholar
  26. 26.
    Liu-DeRyke X, Collingridge DS, Orme J et al (2009) Clinical impact of early hyperglycemia during acute phase of traumatic brain injury. Neurocrit Care 11:151–157PubMedCrossRefGoogle Scholar
  27. 27.
    Marik PE, Pinsky M (2003) Death by parenteral nutrition. Intensive Care Med 29:867–869PubMedGoogle Scholar
  28. 28.
    Marik PE, Zaloga GP (2001) Early enteral nutrition in acutely ill patients: a systematic review. Crit Care Med 29:2264–2270PubMedCrossRefGoogle Scholar
  29. 29.
    Masson F, Thicoipe M, Aye P; Aquitaine Group for Severe Brain Injuries Study (2001) Epidemiology of severe brain injuries: a prospective population-based study. J Trauma 51:481–489PubMedCrossRefGoogle Scholar
  30. 30.
    SAFE Study Investigators, Australian and New Zealand Intensive Care Society Clinical Trials Group, Australian Red Cross Blood Service et al (2007) Saline or albumin for fluid resuscitation in patients with traumatic brain injury. N Engl J Med 357:874–884CrossRefGoogle Scholar
  31. 31.
    NICE-SUGAR Study Investigators, Finfer S, Chittock DR et al (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297CrossRefGoogle Scholar
  32. 32.
    Norton JA, Ott LG, McClain C et al (1988) Intolerance to enteral feeding in the brain-injured patient. J Neurosurg 68:62–66PubMedCrossRefGoogle Scholar
  33. 33.
    Perel P, Yanagawa T, Bunn F et al (2006) Nutritional support for head-injured patients. Cochrane Database Syst Rev 18:CD001530Google Scholar
  34. 34.
    Pfab F, Winhard M, Nowak-Machen M et al (2011) Acupuncture in critically ill patients improves delayed gastric emptying: a randomized controlled trial. Anesth Analg 112:150–155PubMedCrossRefGoogle Scholar
  35. 35.
    Rhoney DH, Parker D Jr, Formea CM et al (2002) Tolerability of bolus versus continuous gastric feeding in brain-injured patients. Neurol Res 24:613–620PubMedCrossRefGoogle Scholar
  36. 36.
    Rhoney DH, Parker D Jr (2006) Considerations in fluids and electrolytes after traumatic brain injury. Nutr Clin Pract 21:462–478PubMedCrossRefGoogle Scholar
  37. 37.
    Rickels E, Wild K von, Wenzlaff P, Bock WJ (Hrsg) (2006) Schädel-Hirn-Verletzung. Epidemiologie und Versorgung. Ergebnisse einer prospektiven Studie. Zuckschwerdt, MünchenGoogle Scholar
  38. 38.
    Roberts I, Yates D, Sandercock P et al (2004) Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury (MRC CRASH trial): randomised placebo-controlled trial. Lancet 364:1321–1328PubMedCrossRefGoogle Scholar
  39. 39.
    Rovlias A, Kotsou S (2000) The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery 46:335–342PubMedCrossRefGoogle Scholar
  40. 40.
    Sampalis JS, Denis R, Lavoie A et al (1999) Trauma care regionalization: a process-outcome evaluation. J Trauma. 46:565–579 (discussion 579–581)Google Scholar
  41. 41.
    Schröder S, Hülst S van, Raabe W et al (2007) Nasojejunal enteral feeding tubes in critically ill patients. Successful placement without technical assistance. Anaesthesist 56:1217–1222PubMedCrossRefGoogle Scholar
  42. 42.
    Sen AP, Gulati A (2010) Use of magnesium in traumatic brain injury. Neurotherapeutics 7:91–99PubMedCrossRefGoogle Scholar
  43. 43.
    Singer P, Berger MM, Van den Berghe G et al; ESPEN (2009) ESPEN guidelines on parenteral nutrition: intensive care. Clin Nutr 28:387–400PubMedCrossRefGoogle Scholar
  44. 44.
    Taylor SJ, Fettes SB, Jewkes C, Nelson RJ (1999) Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 27:2525–2531PubMedCrossRefGoogle Scholar
  45. 45.
    Unterberg A, Sarrafzadeh A, Kiening K (2003) Management of traumatic brain injury. Akt Neurol 30:59–70CrossRefGoogle Scholar
  46. 46.
    Van den Berghe G, Schoonheydt K, Becx P et al (2005) Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology 64:1348–1353CrossRefGoogle Scholar
  47. 47.
    Van den Berghe G, Wouters P, Weekers F et al (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367CrossRefGoogle Scholar
  48. 48.
    Vink R, O’Connor CA, Nimmo AJ, Heath DL (2003) Magnesium attenuates persistent functional deficits following diffuse traumatic brain injury in rats. Neurosci Lett 336:41–44PubMedCrossRefGoogle Scholar
  49. 49.
    Wu A, Ying Z, Gomez-Pinilla F (2007) Omega-3 fatty acids supplementation restores mechanisms that maintain brain homeostasis in traumatic brain injury. J Neurotrauma 24:1587–1595PubMedCrossRefGoogle Scholar
  50. 50.
    Young B, Ott L, Kasarskis E et al (1996) Zinc supplementation is associated with improved neurologic recovery rate and visceral protein levels of patients with severe closed head injury. J Neurotrauma 13:25–34PubMedCrossRefGoogle Scholar
  51. 51.
    Young B, Ott L, Yingling B, McClain C (1992) Nutrition and brain injury. J Neurotrauma 9(Suppl 1):375–383Google Scholar

Copyright information

© Springer-Verlag 2012

Authors and Affiliations

  • H.E. Marcus
    • 1
  • F.A. Spöhr
    • 1
  • B.W. Böttiger
    • 1
  • S. Grau
    • 2
  • S.A. Padosch
    • 1
  1. 1.Klinik für Anästhesiologie und Operative IntensivmedizinUniklinik KölnKölnDeutschland
  2. 2.Klinik für Allgemeine NeurochirurgieUniklinik KölnKölnDeutschland

Personalised recommendations