Elke Gunnar, Hartl Wolfgang H, Kreymann K Georg, Adolph Michael, Felbinger Thomas W, Graf Tobias, de Heer Geraldine, Heller Axel R, Kampa Ulrich, Mayer Konstantin, Muhl Elke, Niemann Bernd, Rümelin Andreas, Steiner Stephan, Stoppe Christian, Weimann Arved, Bischoff Stephan C
Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 12, 24105, Kiel, Germany.
Department of Surgery, University School of Medicine, Grosshadern Campus, Ludwig-Maximilian University, Marchioninistr. 15, 81377 Munich, Germany.
Clin Nutr ESPEN. 2019 Oct;33:220-275. doi: 10.1016/j.clnesp.2019.05.002. Epub 2019 Jul 9.
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.
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.
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.
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).
成年危重症患者的肠内和肠外营养在营养输送途径、宏量和微量营养素的数量及组成，以及特定免疫调节底物的选择方面存在差异。临床营养的差异可能会影响临床结局。本指南为患有至少一种急性器官功能障碍、需要特定药物治疗和/或机械支持设备（如机械通气）以维持器官功能的成年危重症患者的临床营养提供了基于共识的最新建议。
德国营养医学学会（DGEM）的前版指南根据德国科学医学协会联合会（AWMF）对S2k指南有效的现行指令进行了更新。根据S2k指南分类，提出建议无需对现有证据进行系统评价，因此，本指南未注明证据等级或推荐等级。尽管如此，我们考虑并评论了来自随机对照试验、荟萃分析和样本量充足且方法学质量高的观察性研究（截至2018年5月）以及其他学会现行有效指南的证据。每条建议的可靠性都用语言进行了描述。每条建议最终通过德尔菲法进行了验证和认可。
在引言部分，本指南描述了：a）危重症可能影响危重症患者代谢和营养的病理生理后果；b）病程中不同疾病阶段的潜在定义；c）营养临床试验的方法学缺陷。然后，我们针对危重症患者临床营养的基本、与实践相关的要素提出了69条一致认可的建议。其中包括营养状况评估、临床营养指征、营养输送的时机和途径，以及底物（宏量和微量营养素）的数量和组成；此外，我们还讨论了肥胖危重症患者和接受体外支持设备治疗患者营养治疗的独特方面。
本现行指南为患有至少一种急性器官功能障碍、需要特定药物治疗和/或机械支持设备（如机械通气）以维持器官功能的成年危重症患者的肠内和肠外营养提供了最新建议。本指南的有效期约为五年（2018 - 2023年）。
