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Elke G, Hartl WH, Adolph M, Angstwurm M, Brunkhorst FM, Edel A, Heer GD, Felbinger TW, Goeters C, Hill A, Kreymann KG, Mayer K, Ockenga J, Petros S, Rümelin A, Schaller SJ, Schneider A, Stoppe C, Weimann A. [Laboratory and calorimetric monitoring of medical nutrition therapy in intensive and intermediate care units : Second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI)]. Med Klin Intensivmed Notfmed 2023; 118:1-13. [PMID: 37067563 PMCID: PMC10106891 DOI: 10.1007/s00063-023-01001-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/23/2023] [Indexed: 04/18/2023]
Abstract
This second position paper of the Section Metabolism and Nutrition of the German Interdisciplinary Association for Intensive Care and Emergency Medicine (DIVI) provides recommendations on the laboratory monitoring of macro- and micronutrient intake as well as the use of indirect calorimetry in the context of medical nutrition therapy of critically ill adult patients. In addition, recommendations are given for disease-related or individual (level determination) substitution and (high-dose) pharmacotherapy of vitamins and trace elements.
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Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Arnold-Heller-Straße 3 Haus R3, 24105, Kiel, Deutschland.
| | - Wolfgang H Hartl
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Großhadern, München, Deutschland
| | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Matthias Angstwurm
- Medizinische Klinik und Poliklinik IV, Ludwig-Maximilians-Universität München - Klinikum der Universität, Campus Innenstadt, München, Deutschland
| | - Frank M Brunkhorst
- Zentrum für Klinische Studien, Klinik für Anästhesiologie und Intensivtherapie, Universitätsklinikum Jena, Jena, Deutschland
| | - Andreas Edel
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK, CCM), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Thomas W Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching und Neuperlach, Städtisches Klinikum München GmbH, München, Deutschland
| | - Christiane Goeters
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Münster, Deutschland
| | - Aileen Hill
- Kliniken für Anästhesiologie und Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen, Deutschland
| | | | - Konstantin Mayer
- Klinik für Pneumologie und Schlafmedizin, St. Vincentius-Kliniken, Karlsruhe, Deutschland
| | - Johann Ockenga
- Medizinische Klinik II, Klinikum Bremen Mitte, Bremen, Deutschland
| | - Sirak Petros
- Interdisziplinäre Internistische Intensivmedizin, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Andreas Rümelin
- Anästhesie, Intensivmedizin und Notfallmedizin, Helios St. Elisabeth-Krankenhaus Bad Kissingen, Kissingen, Deutschland
| | - Stefan J Schaller
- Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin (CVK, CCM), Charité - Universitätsmedizin Berlin, Berlin, Deutschland
- Medizinische Fakultät, Klinik für Anästhesiologie und Intensivmedizin, Technische Universität München, München, Deutschland
| | - Andrea Schneider
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Hannover, Deutschland
| | - Christian Stoppe
- Klinik und Poliklinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Arved Weimann
- Abteilung für Allgemein‑, Viszeral- und Onkologische Chirurgie, Klinikum St. Georg gGmbH, Leipzig, Deutschland
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Erratum: DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“. Aktuel Ernahrungsmed 2019. [DOI: 10.1055/a-1022-1588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel
| | - Wolfgang H. Hartl
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München – Klinikum der Universität, Campus Großhadern, München
| | | | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen
| | - Thomas W. Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching, Neuperlach und Schwabing, Städtisches Klinikum München GmbH, München
| | - Tobias Graf
- Universitäres Herzzentrum Lübeck – Medizinische Klinik II/Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Axel R. Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität Augsburg, Augsburg
| | - Ulrich Kampa
- Klinik für Anästhesiologie und Intensivmedizin, Ev. Krankenhaus Hattingen, Hattingen
| | - Konstantin Mayer
- Zentrum für Innere Medizin, Medizinische Klinik II, Universtitätsklinikum Gießen und Marburg, University of Giessen Lung Center, Standort Gießen, Gießen
| | - Elke Muhl
- Eichhörnchenweg 7, 23627 Gross Grönau
| | - Bernd Niemann
- Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen
| | - Andreas Rümelin
- Klinik für Anästhesie und operative Intensivmedizin, HELIOS St. Elisabeth-Krankenhaus Bad Kissingen, Bad Kissingen
| | - Stephan Steiner
- Abteilung für Kardiologie, Pneumologie und Internistische Intensivmedizin, St. Vincenz-Krankenhaus, Limburg
| | - Christian Stoppe
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie
, Klinikum St. Georg gGmbH, Leipzig
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. Clinical Nutrition in Critical Care Medicine - Guideline of the German Society for Nutritional Medicine (DGEM). Clin Nutr ESPEN 2019; 33:220-275. [PMID: 31451265 DOI: 10.1016/j.clnesp.2019.05.002] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 05/03/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Enteral and parenteral nutrition of adult critically ill patients varies in terms of the route of nutrient delivery, the amount and composition of macro- and micronutrients, and the choice of specific, immune-modulating substrates. Variations of clinical nutrition may affect clinical outcomes. The present guideline provides clinicians with updated consensus-based recommendations for clinical nutrition in adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. According to the S2k-guideline classification, no systematic review of the available evidence was required to make recommendations, which, therefore, do not state evidence- or recommendation grades. Nevertheless, we considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of other societies. The liability of each recommendation was described linguistically. Each recommendation was finally validated and consented through a Delphi process. RESULTS In the introduction the guideline describes a) the pathophysiological consequences of critical illness possibly affecting metabolism and nutrition of critically ill patients, b) potential definitions for different disease phases during the course of illness, and c) methodological shortcomings of clinical trials on nutrition. Then, we make 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in critically ill patients. Among others, recommendations include the assessment of nutrition status, the indication for clinical nutrition, the timing and route of nutrient delivery, and the amount and composition of substrates (macro- and micronutrients); furthermore, we discuss distinctive aspects of nutrition therapy in obese critically ill patients and those treated with extracorporeal support devices. CONCLUSION The current guideline provides clinicians with up-to-date recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g., mechanical ventilation) to maintain organ function. The period of validity of the guideline is approximately fixed at five years (2018-2023).
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Affiliation(s)
- Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
| | - Wolfgang H Hartl
- Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
| | | | - Michael Adolph
- University Department of Anesthesiology and Intensive Care Medicine, University Hospital Tübingen, Hoppe-Seyler-Straße 3, 72076, Tübingen, Germany.
| | - Thomas W Felbinger
- Department of Anesthesiology, Critical Care and Pain Medicine, Neuperlach and Harlaching Medical Center, The Munich Municipal Hospitals Ltd, Oskar-Maria-Graf-Ring 51, 81737, Munich, Germany.
| | - Tobias Graf
- Medical Clinic II, University Heart Center Lübeck, University Medical Center Schleswig-Holstein, Campus Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Geraldine de Heer
- Center for Anesthesiology and Intensive Care Medicine, Clinic for Intensive Care Medicine, University Hospital Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Axel R Heller
- Clinic for Anesthesiology and Surgical Intensive Care Medicine, University of Augsburg, Stenglinstrasse 2, 86156, Augsburg, Germany.
| | - Ulrich Kampa
- Clinic for Anesthesiology, Lutheran Hospital Hattingen, Bredenscheider Strasse 54, 45525, Hattingen, Germany.
| | - Konstantin Mayer
- Department of Internal Medicine, Justus-Liebig University Giessen, University of Giessen and Marburg Lung Center, Klinikstr. 36, 35392, Gießen, Germany.
| | - Elke Muhl
- Eichhörnchenweg 7, 23627, Gross Grönau, Germany.
| | - Bernd Niemann
- Department of Adult and Pediatric Cardiovascular Surgery, Giessen University Hospital, Rudolf-Buchheim-Str. 7, 35392, Gießen, Germany.
| | - Andreas Rümelin
- Clinic for Anesthesia and Surgical Intensive Care Medicine, HELIOS St. Elisabeth Hospital Bad Kissingen, Kissinger Straße 150, 97688, Bad Kissingen, Germany.
| | - Stephan Steiner
- Department of Cardiology, Pneumology and Intensive Care Medicine, St Vincenz Hospital Limburg, Auf dem Schafsberg, 65549, Limburg, Germany.
| | - Christian Stoppe
- Department of Intensive Care Medicine and Intermediate Care, RWTH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
| | - Arved Weimann
- Department of General, Visceral and Oncological Surgery, Klinikum St. Georg, Delitzscher Straße 141, 04129, Leipzig, Germany.
| | - Stephan C Bischoff
- Department for Nutritional Medicine, University of Hohenheim, Fruwirthstr. 12, 70599, Stuttgart, Germany.
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. [DGEM Guideline "Clinical Nutrition in Critical Care Medicine" - short version]. Anasthesiol Intensivmed Notfallmed Schmerzther 2019; 54:63-73. [PMID: 30620956 DOI: 10.1055/a-0805-4118] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
PURPOSE Variations of clinical nutrition may affect outcome of critically ill patients. Here we present the short version of the updated consenus-based guideline (S2k classification) "Clinical nutrition in critical care medicine" of the German Society for Nutritional Medicine (DGEM) in cooperation with 7 other national societies. The target population of the guideline was defined as critically ill adult patients who suffer from at least one acute organ dysfunction requiring specific drug therapy and/or a mechanical support device (e.g. mechanical ventilation) to maintain organ function. METHODS The former guidelines of the German Society for Nutritional Medicine (DGEM) were updated according to the current instructions of the Association of the Scientific Medical Societies in Germany (AWMF) valid for a S2k-guideline. We considered and commented the evidence from randomized-controlled trials, meta-analyses and observational studies with adequate sample size and high methodological quality (until May 2018) as well as from currently valid guidelines of international societies. The liability of each recommendation was indicated using linguistic terms. Each recommendation was finally validated and consented by a Delphi process. RESULTS The short version presents a summary of all 69 consented recommendations for essential, practice-relevant elements of clinical nutrition in the target population. A specific focus is the adjustment of nutrition according to the phases of critical illness, and to the individual tolerance to exogenous substrates. Among others, recommendations include the assessment of nutritional status, the indication for clinical nutrition, the timing, route, magnitude and composition of nutrition (macro- and micronutrients) as well as distinctive aspects of nutrition therapy in obese critically ill patients and those with extracorporeal support devices. CONCLUSION The current short version of the guideline provides a concise summary of the updated recommendations for enteral and parenteral nutrition of adult critically ill patients who suffer from at least one acute organ dysfunction requiring pharmacological and/or mechanical support. The validity of the guideline is approximately fixed at five years (2018 - 2023).
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Elke G, Hartl WH, Kreymann KG, Adolph M, Felbinger TW, Graf T, de Heer G, Heller AR, Kampa U, Mayer K, Muhl E, Niemann B, Rümelin A, Steiner S, Stoppe C, Weimann A, Bischoff SC. DGEM-Leitlinie: „Klinische Ernährung in der Intensivmedizin“. Aktuel Ernahrungsmed 2018. [DOI: 10.1055/a-0713-8179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Zusammenfassung
Fragestellung Die enterale und parenterale Ernährungstherapie kritisch kranker Patienten kann u. a. durch den Zeitpunkt des Beginns, die Wahl des Applikationswegs, die Menge und Zusammensetzung der Makro- und Mikronährstoffzufuhr sowie der Wahl spezieller, immunmodulierender Nährsubstrate variieren. Die Durchführung der Ernährungstherapie nimmt Einfluss auf den klinischen Ausgang dieser Patienten. Ziel der vorliegenden Leitlinie ist es, aktualisierte konsensbasierte Empfehlungen zur klinischen Ernährung kritisch kranker, erwachsener Patienten, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden, zu geben.
Methodik Die früheren Leitlinien der Deutschen Gesellschaft für Ernährungsmedizin (DGEM) wurden in Einklang mit den aktuellen Richtlinien der Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF) als S2k-Leitlinie aktualisiert. Entsprechend der S2k-Klassifikation dieser Leitlinie enthalten die dargestellten Empfehlungen keine Angabe von Evidenz- und Empfehlungsgraden, da keine systematische Aufbereitung der Evidenz zugrunde gelegt wurde. Als Grundlage für die Empfehlungen wurden insbesondere die seit Erscheinen der letzten DGEM-Leitlinien Intensivmedizin publizierten randomisiert-kontrollierten Studien und Metaanalysen, Beobachtungsstudien mit angemessener Fallzahl und hoher methodologischer Qualität (bis Mai 2018) sowie aktuell gültige Leitlinien anderer Fachgesellschaften herangezogen und kommentiert. Die Empfehlungsstärke ist rein sprachlich beschrieben. Jede Empfehlung wurde mittels Delphi-Verfahren abschließend bewertet und konsentiert.
Ergebnisse Die Leitlinie beschreibt einführend die pathophysiologischen Konsequenzen einer kritischen Erkrankung, welche den Metabolismus und die Ernährbarkeit der Patienten beeinflussen können, ferner die Definitionen unterschiedlicher Erkrankungsphasen im Krankheitsverlauf und sie diskutiert methodologische Aspekte zu ernährungsmedizinischen Studien. In der Folge werden 69 konsentierte Empfehlungen zu wesentlichen, praxisrelevanten Elementen der klinischen Ernährung kritisch kranker Patienten gegeben, darunter die Beurteilung des Ernährungszustands, die Indikation für die klinische Ernährungstherapie, der Beginn und Applikationsweg der Nahrungszufuhr, die Menge und Art der zugeführten Substrate (Makro- und Mikronährstoffe) sowie ernährungstherapeutische Besonderheiten bei adipösen kritisch kranken Patienten und Patienten mit mechanischen Unterstützungssystemen.
Schlussfolgerung Mit der Leitlinie werden aktuelle Handlungsempfehlungen zur enteralen und parenteralen Ernährung erwachsener Patienten geben, die an mindestens einer akuten, medikamentös und/oder mechanisch unterstützungspflichtigen Organdysfunktion leiden. Die Gültigkeit der Leitlinie beträgt voraussichtlich 5 Jahre (2018 – 2023).
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Affiliation(s)
- Gunnar Elke
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Kiel, Kiel
| | - Wolfgang H. Hartl
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Ludwig-Maximilians-Universität München – Klinikum der Universität, Campus Großhadern, München
| | | | - Michael Adolph
- Universitätsklinik für Anästhesiologie und Intensivmedizin und Stabsstelle Ernährungsmanagement, Universitätsklinikum Tübingen, Tübingen
| | - Thomas W. Felbinger
- Klinik für Anästhesiologie, Operative Intensivmedizin und Schmerztherapie, Kliniken Harlaching, Neuperlach und Schwabing, Städtisches Klinikum München GmbH, München
| | - Tobias Graf
- Universitäres Herzzentrum Lübeck – Medizinische Klinik II/Kardiologie, Angiologie, Intensivmedizin, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck
| | - Geraldine de Heer
- Zentrum für Anästhesiologie und Intensivmedizin, Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Axel R. Heller
- Klinik für Anästhesiologie und Operative Intensivmedizin, Universität Augsburg, Augsburg
| | - Ulrich Kampa
- Klinik für Anästhesiologie und Intensivmedizin, Ev. Krankenhaus Hattingen, Hattingen
| | - Konstantin Mayer
- Zentrum für Innere Medizin, Medizinische Klinik II, Universtitätsklinikum Gießen und Marburg, University of Giessen Lung Center, Standort Gießen, Gießen
| | - Elke Muhl
- Eichhörnchenweg 7, 23627 Gross Grönau
| | - Bernd Niemann
- Klinik für Herz-, Kinderherz- und Gefäßchirurgie, Universitätsklinikum Gießen und Marburg, Standort Gießen, Gießen
| | - Andreas Rümelin
- Klinik für Anästhesie und operative Intensivmedizin, HELIOS St. Elisabeth-Krankenhaus Bad Kissingen, Bad Kissingen
| | - Stephan Steiner
- Abteilung für Kardiologie, Pneumologie und Internistische Intensivmedizin, St. Vincenz-Krankenhaus, Limburg
| | - Christian Stoppe
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Arved Weimann
- Klinik für Allgemein-, Viszeral- und Onkologische Chirurgie
, Klinikum St. Georg gGmbH, Leipzig
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Kreymann KG, Heyland DK, de Heer G, Elke G. Intravenous fish oil in critically ill and surgical patients - Historical remarks and critical appraisal. Clin Nutr 2017; 37:1075-1081. [PMID: 28747247 DOI: 10.1016/j.clnu.2017.07.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 05/15/2017] [Accepted: 07/07/2017] [Indexed: 12/11/2022]
Abstract
The purpose of this review is to explain the historical and clinical background for intravenous fish oil administration, to evaluate its results by using a product specific metaanalysis, and to stimulate further research in the immune-modulatory potential of fish oil. Concerning the immune-modulatory effects of fatty acids, a study revealed that ω-3 as well as ω-6 fatty acids would prolong transplant survival, and only a mixture with an ω-6:ω-3 ratio of 2.1:1 would give immune-neutral results. In 1998, the label of a newly registered fish oil emulsion also acknowledged this immune-neutral ratio in conjunction with ω-6 lipids. Also, two fish oil-supplemented fat emulsions, registered in 2004, used a similar ω-6:ω-3 ratio. Such an immune-neutral ω-6:ω-3 ratio denoted progress for most patients compared to pure ω-6 lipid emulsions. However, this immune-neutrality might on the other hand be responsible for the limited positive clinical results gained so far in critically ill and surgical patients where in most cases significance could only be shown for the pooled effect of numerous trials. Our product specific metaanalysis also did not reveal any differences, neither in infections rates nor in ICU or hospital length of stay. To evaluate the immune-modulatory effect of fish oil administered alone, new dose finding studies, reporting relevant clinical outcome parameters, are required. Precise mechanistic or physiological biomarkers for the indication of such a therapy should also be developed and validated.
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Affiliation(s)
- K Georg Kreymann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany.
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada.
| | - Geraldine de Heer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Germany.
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Germany.
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Kreymann KG, DeLegge MH, Luft G, de Heer G. A nutrition strategy for obese ICU patients with special consideration for the reference of protein. Clin Nutr ESPEN 2015; 10:e160-e166. [DOI: 10.1016/j.clnesp.2015.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 05/26/2015] [Accepted: 07/05/2015] [Indexed: 01/10/2023]
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Adolph M, Heller AR, Koch T, Koletzko B, Kreymann KG, Krohn K, Pscheidl E, Senkal M. Lipid emulsions - Guidelines on Parenteral Nutrition, Chapter 6. Ger Med Sci 2009; 7:Doc22. [PMID: 20049078 PMCID: PMC2795378 DOI: 10.3205/000081] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/14/2009] [Indexed: 01/07/2023]
Abstract
The infusion of lipid emulsions allows a high energy supply, facilitates the prevention of high glucose infusion rates and is indispensable for the supply with essential fatty acids. The administration of lipid emulsions is recommended within ≤7 days after starting PN (parenteral nutrition) to avoid deficiency of essential fatty acids. Low-fat PN with a high glucose intake increases the risk of hyperglycaemia. In parenterally fed patients with a tendency to hyperglycaemia, an increase in the lipid-glucose ratio should be considered. In critically ill patients the glucose infusion should not exceed 50% of energy intake. The use of lipid emulsions with a low phospholipid/triglyceride ratio is recommended and should be provided with the usual PN to prevent depletion of essential fatty acids, lower the risk of hyperglycaemia, and prevent hepatic steatosis. Biologically active vitamin E (α-tocopherol) should continuously be administered along with lipid emulsions to reduce lipid peroxidation. Parenteral lipids should provide about 25–40% of the parenteral non-protein energy supply. In certain situations (i.e. critically ill, respiratory insufficiency) a lipid intake of up to 50 or 60% of non-protein energy may be reasonable. The recommended daily dose for parenteral lipids in adults is 0.7–1.3 g triglycerides/kg body weight. Serum triglyceride concentrations should be monitored regularly with dosage reduction at levels >400 mg/dl (>4.6 mmol/l) and interruption of lipid infusion at levels >1000 mg/dl (>11.4 mmol/l). There is little evidence at this time that the choice of different available lipid emulsions affects clinical endpoints.
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Affiliation(s)
- M Adolph
- Dept. of Anaesthesiology and Intensive Medicine, Eberhard-Karl University, Tuebingen, Germany
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Abstract
PURPOSE OF REVIEW Today, early nutrition support is considered standard care in most ICUs. The recommended method is the enteral route, although there is only minor evidence for this. Often inadequate delivery of energy and a cumulative energy deficit are implied. The purpose of this paper is to evaluate the indication for early enteral nutrition or immunonutrition and to discuss the application of additional parenteral nutrition. RECENT FINDINGS The indication for early enteral nutrition is also supported by guidelines for enteral nutrition recently published by the European Society for Clinical Nutrition and Metabolism. Some more recent results strengthen the indication for a special formula in acute respiratory distress syndrome and septic patients. A recent metaanalysis has shown that parenteral nutrition is superior to delayed enteral nutrition. Additional parenteral nutrition thus seems to be the way to avoid cumulative energy deficit associated with insufficient or no enteral nutrition. SUMMARY Early enteral nutrition is recommended for critically ill patients, with special formulas indicated in specific subgroups of patients. If enteral nutrition is insufficient or fails, parenteral nutrition should be instituted, respecting the often reduced demand for exogenous substrates in critically ill patients.
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Affiliation(s)
- K Georg Kreymann
- Department of Intensive Care, University Medical Centre, Hamburg-Eppendorf, Germany.
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Abstract
A concept for combined enteral and parenteral nutrition for critically ill patients is described in which endogenous substrate production during the acute phase of illness is taken into consideration and hyperalimentation is avoided. The nutritional goal is defined by multiplication of the base rate, i.e. body weight (BW) in kg as delivery rate in ml/h (wedge 24 kcal/kg BW/24 h), with a target factor, which varies between 0.2 and 1.8. An equivalent composition of enteral and parenteral nutrition allows a transition between both forms without problems. Simultaneously, immunologic aspects of nutrition are considered as well and both forms of nutrition are complemented by immune-modulating substrates such as glutamine and antioxidants.
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Affiliation(s)
- K G Kreymann
- Klinik für Intensivmedizin, Universitätskrankenhaus Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
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Kreymann KG, de Heer G, Nierhaus A, Kluge S. Use of polyclonal immunoglobulins as adjunctive therapy for sepsis or septic shock. Crit Care Med 2007; 35:2677-2685. [PMID: 18074464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVE There is ongoing debate about the efficacy of polyvalent immunoglobulins as adjunctive therapy for sepsis or septic shock. Two meta-analyses by the Cochrane collaboration calculated a significant reduction in mortality. However, data of the largest study were missing in one, and a subset of four high-quality studies failed to show an effect in the other. To broaden the database, we performed a meta-analysis of all randomized controlled studies published so far. DATA SOURCE MEDLINE, EMBASE, Cochrane Library of randomized trials, and personal files. STUDY SELECTION Meta-analysis of all published randomized controlled studies published on polyvalent immunoglobulins (Ig) for treatment of sepsis or septic shock in adults, children, or neonates. DATA EXTRACTION Twenty-seven trials with a total of 2,202 patients fulfilled the inclusion criteria. DATA SYNTHESIS As the immunologic state of neonates is different than that of adults or older children, data were evaluated separately for each group. Fifteen trials on 1,492 adults could be included. The pooled effect on mortality was a relative risk of death (RR) of 0.79 (95% confidence interval [CI] 0.69-0.90, p <or= .0003). There was a strong trend in favor of an immunoglobulin preparation enriched with IgA and IgM (IgGAM) (RR = 0.66, 95% CI 0.51-0.84, p <or= .0009) compared with preparations containing only IgG (RR = 0.85, 95% CI 0.73-0.99, p <or= .04). In 12 trials on 710 neonates, the pooled effect on mortality was 0.56 (95% CI 0.42-0.74, p <or= .0001). There was also a positive although less pronounced trend favoring the effect of IgGAM (RR = 0.50, 95% CI 0.34-0.73, p <or= .0003) compared with IgG (RR = 0.63, 95% CI 0.42-0.96, p <or= .03). A sensitivity analysis selecting eight trials in adults and ten in neonates of highest methodological quality confirmed these results. CONCLUSIONS Polyvalent immunoglobulins exert a significant effect on mortality in sepsis and septic shock, with a trend in favor of IgGAM.
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Affiliation(s)
- K Georg Kreymann
- Department of Intensive Care, University Medical Centre, Hamburg-Eppendorf, Germany.
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Kreymann KG, de Heer G, Felbinger T, Kluge S, Nierhaus A, Suchner U, Meier RF. [Nutritional concepts for patients under intensive care]. Pneumologie 2007; 61:574-80. [PMID: 17661267 DOI: 10.1055/s-2007-980086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
The clinical outcome of critical ill patients can be improved by standardised nutrition. However, trials meeting the standard of evidence-based medicine are rare. For this reason, standards still have to be based on pathophysiological considerations. We describe a concept of combined nutrition for critically ill patients which avoids hyperalimentation and considers also immunological aspects. An equivalent composition of enteral and parenteral nutrition allows a transition between both forms without problems. The nutritional goal is defined by multiplication of the base rate, i. e., body weight in kg as delivery rate in mL/h, - corresponding to 24 kcal/kg BW/24 h - with a target factor which varies between 0.2 and 1.8. Both forms of nutrition are complemented by immune-modulating substrates as glutamine and antioxidants.
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Affiliation(s)
- K G Kreymann
- Klinik für Intensivmedizin, Universitätskrankenhaus Hamburg-Eppendorf.
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Schmiedel S, Panning M, Lohse A, Kreymann KG, Gerloff C, Burchard G, Drosten C. Case report on fatal human rabies infection in Hamburg, Germany, March 2007. ACTA ACUST UNITED AC 2007; 12:E070531.5. [PMID: 17868587 DOI: 10.2807/esw.12.22.03210-en] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In this article we describe the clinical presentation of a fatal case of rabies in a German tourist returning from Morocco.
Rabies is an acute viral encephalomyelitis that is almost invariably fatal.
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Affiliation(s)
- S Schmiedel
- University Medical Centre, Hamburg, Germany.
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Kücken D, Kampe K, Thayssen G, Wenzel U, Kreymann KG, Gerloff C. Rituximab: eine neue Option in der Behandlung des Moschcowitz-Syndroms. Akt Neurol 2007. [DOI: 10.1055/s-2007-987856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Kreymann KG, Berger MM, Deutz NEP, Hiesmayr M, Jolliet P, Kazandjiev G, Nitenberg G, van den Berghe G, Wernerman J, Ebner C, Hartl W, Heymann C, Spies C. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006; 25:210-23. [PMID: 16697087 DOI: 10.1016/j.clnu.2006.01.021] [Citation(s) in RCA: 801] [Impact Index Per Article: 44.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Accepted: 01/20/2006] [Indexed: 02/07/2023]
Abstract
Enteral nutrition (EN) via tube feeding is, today, the preferred way of feeding the critically ill patient and an important means of counteracting for the catabolic state induced by severe diseases. These guidelines are intended to give evidence-based recommendations for the use of EN in patients who have a complicated course during their ICU stay, focusing particularly on those who develop a severe inflammatory response, i.e. patients who have failure of at least one organ during their ICU stay. These guidelines were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. EN should be given to all ICU patients who are not expected to be taking a full oral diet within three days. It should have begun during the first 24h using a standard high-protein formula. During the acute and initial phases of critical illness an exogenous energy supply in excess of 20-25 kcal/kg BW/day should be avoided, whereas, during recovery, the aim should be to provide values of 25-30 total kcal/kg BW/day. Supplementary parenteral nutrition remains a reserve tool and should be given only to those patients who do not reach their target nutrient intake on EN alone. There is no general indication for immune-modulating formulae in patients with severe illness or sepsis and an APACHE II Score >15. Glutamine should be supplemented in patients suffering from burns or trauma.
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Affiliation(s)
- K G Kreymann
- Department of Intensive Care Medicine, University Hospital Eppendorf, Hamburg, Germany.
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Affiliation(s)
- K G Kreymann
- Medizinische Kernklinik und Poliklinik, Universitäts-Krankenhaus Eppendorf, Hamburg.
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