Fett in der klinischen Ernährung - AKE

ake.nutrition.at

Fett in der klinischen Ernährung - AKE

AKE-Dialog

Parenterales Fett: Mehr als Energie

Braucht ein Intensivpatient Fett?

wilfred.druml@meduniwien.ac.at


Fett in der klinischen Ernährung

• ENERGIE - Substrate

Energie Substrate

Energie Speicher

Funktionen

9 kcal/g

140.000 kcal

• STRUKTURELLE - Substrate

BEACHTE Komponenten : Fett aller ist Zellmembranen mehr als Energie !

(Membran-Funktionen, Signal-Transduktion)

• FUNKTIONELLE - Substrate

Essentielle Fettsäuren

Prekursoren von Lipid-Mediatorem (Eicosanoiden)

Prekursoren von Resolvinen /Protektinen

Vorstufen von Hormonen / Vitamin D

Träger von fett-löslichen Vitaminen

Endotoxin-Elimination

Immunmodulation


Influence of parenteral nutrition on

rates of net substrate oxydation in

severe trauma patients

Jeevanandam M et al. Crit Care Med 1990; 18: 467


Short-Term Energy Balance in Patients

with Infections: Carbohydrate-Based vs

Fat-Based Diets

Schneeweiß B et al. Metabolism 1992; 41: 125 - 130

Intake, expenditure, and storage of major fuels for the

carbohydrate based diet. Storage significantly different from zero

p < 0.05


Short-Term Energy Balance in Patients

with Infections: Carbohydrate-Based vs

Fat-Based Diets

Schneeweiß B et al. Metabolism 1992; 41: 125 - 130

Intake, expenditure, and storage of major fuels for the fat

based diet. Storage significantly different from zero p < 0.05


Effects of isoenergetic glucose-based or

lipid-based parenteral nutrition on

glucose metabolism, de novo lipogenesis,

and respiratory gas exchanges in critically

ill patients

Tappy L et al. Crit Care Med 1998; 26: 860-67

Fractional de novo

lipogenesis during

glucose-based total

parenteral nutrition

(TPN-glucose) or lipidbased

total parenteral

nutrition (TPN-lipid).

*p < .002 vs. TPNlipid.


Effects of enteral carbohydrates on

de novo lipogenesis in critically ill

patients

Schwarz MT et al. Am J Clin Nutr 2000; 72: 940-45

Fractional hepatic de

novo lipogenesis

(DNL) in patients

receiving continuous

enteral nutrition

containing

28% (EN-28%),

53% (EN-53%), or

75% (EN-75%) of

energy (100 BEE) as

carbohydrate.

* vs. fasted group, P <

0.05.

# vs. EN-28% and EN-

45%, P < 0.05.

= Leberverfettung unter Kohlenhydrat-reicher Ernährung!


Effects of isoenergetic glucose-based or

lipid-based parenteral nutrition on

glucose metabolism, de novo lipogenesis,

and respiratory gas exchanges in critically

ill patients

Tappy L et al. Crit Care Med 1998; 26: 860-67

Respiratory oxygen (VO 2 ) and CO 2 (VCO 2 ) exchanges in the unfed

state and after glucose-based total parenteral nutrition (TPN-G) or

lipid-based total parenteral nutrition (TPN-L). *p < .02 vs. basal.


Effects of Different Regimes of Parenteral

Nutrition on Respiratory Paramters in

Patients Requiring Artificial Ventilation

Buchmiller CE et al JPEN 1993; 17: 301-306

B1, B2, B3 = basal periods, G 1 = 100 % glucose (1.5 x BEE),

GL = 50% glucose, 50% lipid (1.5 x BEE)


Nutritionally associated increased carbon

dioxide production. Excess total calories vs

high proportion of carbohydrate calories

Talpers SS et al Chest 1992; 102: 551-68

CO 2 production (Vco2) in mechanically ventilated patients

receiving isocaloric nutrition regimen with varying percentage of

carbohydrates (A) and in patients receiving no nutrition

(fasting), 1.0 x REE, 1.5 x REE, and 2.0 x REE.


Effect of low-calorie parenteral

nutrition on the incidence and

severity of hyperglycemia in surgical

patients: A RCT

Ahrends Christine et al. Crit Care Med 2005; 33: 2507

Average blood

glucose during TPN.

Glucose curves begin

4 hrs after

administration of lowcalorie

(20 non-prot

kcal/kg/d = 26.6

kcal/kg/d) vs.

standard-calorie TPN

(30 non-prot

kcal/kg/d= 37

kcal/kg/d)


Stoner HB et al. Brit J Surg 1983; 70: 332-35


The effect of sepsis on the oxidation

of carbohydrate and fat

Stoner HB et al. Brit J Surg 1983; 70: 332-35

The relationship between fat oxidation and sepsis score in 55

measurements on 27 patients receiving parenteral nutrition


Stoffwechsel bei Akut-Phasen-

Reaktion/ SIRS /

Postaggressionssyndrom

grundsätzliche Störungen

• Proteinstoffwechsel

Aktivierung der peripheren (muskulären)

Proteolyse

Stimulation der hepatische Proteinsynthese

• Kohlenhydratstoffwechsel

Hemmung der peripheren (muskul.)

Glukoseaufnahme

Aktivierung der hepatischen Glukoneogenese

Fettstoffwechsel

Aktivierung der Lipolyse

Steigerung der Fett-Oxydation


Glukose-Infusion unterdrückt nicht

die erhöhte Lipolyse nach

Abdominalchirurgie

Schricker Th. et al. Nutrition 2001; 17: 85-90

Lipolysis rates (R a

glycerol) in volunteers

and patients in the

fasted state and

during glucose

infusion. +P < 0.05

vs volunteers, *P <

0.05 vs fasted

patients. R a , rate of

appearance

daher: persistierende Fett-Verwertung bei Akuterkrankungen!


Increased lipid utilization in weight

losing and weight stable cancer

patients

Körber J et al Europ J Clin Nutr 1999; 53: 740-45

Lipid clearance rates after bolus injections (0.1 g/kg/ bw

MCT/LCT vs LCT). * Significant vs controls (p < 0.05 or 0.01)


Fett in der klinischen Ernährung

Fett-Elimination bei versch. Krankheiten

• Elimination normal oder beschleunigt

Sepsis Robin 1983; Druml 98

Trauma Carpentier 1979

postoperativ Lindholm 1979

chron. Leberversagen Rössner 79, Druml 96

ICU Patient / MODS Lindholm 79, Druml 98

Tumor - Patient Körber 1999

• Elimination verzögert

chron. Nierenversagen Chan 1980

akutes Nierenversagen Druml 1983

hypodyname Sepsis Druml 1983


Increase in plasma triglycerides above basal concentrations during

long-chain tiglyceride (LCT) and medium-chain triglyceride (MCT)

infusions in control subjects and in patients with chronic hepatic

failure (CHF).

Fat elimination in chronic hepatic

failure: long-chain vs medium-chain

triglycerides

Druml W. et al Am J clin Nutr 1995; 61: 812-17


Use of Intravenous Lipids in

Critically Ill Patients with Sepsis

without and with Hepatic Failure

Druml W. et al Am J clin Nutr 1998; 22: 217-23

Increase in plasma triglycerides during infusion of a LCT lipid

emulsion in 8 healthy subjects (Ctrl), 8 patients with sepsis (S)

and 8 patients with sepsis and hepatic failure (S+L).

# p < 0.05, § p < 0.01 between Controls and patient groups


Fat Elimination in Acute Renal Failure :

long-chain vs medium-chain

triglycerides

Druml W et al. Am J Clin Nutr 1992; 55: 468 -472

Increase in plasma triglycerides above basal concentrations


Lipid Utilization in Acute Renal Failure

Plasma triglycerides during infusion of 1 g/kg.b.w./day of a

lipid emulsion in patients with acute renal failure


Effects of intravenous fat emulsions on

lung function in patients with acute

respiratory distress syndrome or sepsis

Suchner Ulrich et al.

Crit Care Med 2001;

29: 1569-74

6-keto-prostaglandin (PG)-

F 1 /thromboxane (Tx)-B 2 ratio in

arterial blood (A), pulmonary

shunt (B), oxygen exchange

ratio (C), and oxygenation index

(D) before, during, and after

rapid (left panel) or slow (right

panel) fat infusion.

dashed lines, severe sepsis;

solid lines, ARDS.

a

p .05 6 hrs fat infusion vs.

baseline; A’ p .05 ARDS vs sepsis


The Impact of Intravenous Fat

Emulsion Administration in

Acute Lung Injury

Lekka ME et al.

Am J Resp Crit Care Med

2004; 169: 638-44

BALF cells stained by Sudan

Black B from a

representative of ARDS-Lipid

group.

(A) Before and (B) after the

parenteral administration of

long-chain triglycerides/

medium-chain triglycerides

(LCT/MCT)

3.5 mg/kg/min = 5 g kg/d


Liver Dysfunction and Energy

Source : Results of a

Randomized Clinical Trial

Buchmiller CE et al JPEN 1993; 17: 301-306

TPN (LIP-CHO) 8.5% amino acids, 30% glucose, 40% of total

calories from lipids; TPN (CHO) 8.5 % amino acids, 50 %

dextrose, 7.5 % of total calories from lipids


Choline : A Conditionally

Essential Nutrient for Humans

Zeisel SH et al FASEB J 1991; 5: 2093-98

Serum alanine aminotransferase activity in humans

ingesting a control or choline-deficient diet


Choline : A Conditionally

Essential Nutrient for Humans

Zeisel SH et al FASEB J 1991; 5: 2093-98

Plasma choline concentration in humans ingesting a control or

choline-deficient diet


Impaired leukotriene C4 generation

in granulocytes from protein-energy

malnourished chronically ill elderly

Cederholm T et al. J Intern Med 2000; 247: 715

Leukotriene C4

(LTC4) generation in

granulocytes from

malnourished

chronically ill elderly

(grey columns) and

controls (white

columns) after

calcium ionophore

A23187 stimulation at

0.2 and 1.0 μmol L 1.

PEM, protein-energy

malnutrition.


Essential Fatty Acid Deficiency

During TPN

Barr LH et al.

Ann Surg 1981; 193:

304

Triene/ tetraene ratio

during a fat free

nutrition


Untersuchungen zum

Fettstoffwechsel bei

polytraumatisierten Patienten

V. Hundelhausen B et al.

Klin Ernähr 1982; 8: 206

Prozentualer

Linolsäureanteil C 18/2

Phospholipidfettsäuren

(oben) und

Prozentualer Arachidonsäureanteil

C 20/ 4

Phospholipidfettsäuren

unter parenteraler

Ernährung mit (---) und

ohne Fettemulsion (___)

= erhöhter Bedarf an

essentiellen

Fettsäuren bei

Akuterkrankungen


Chylomicrons alter the fate of

endotoxin, decreasing tumor necrosis

factor release and preventing death

Harris HW et al. J Clin Invest 1993; 91: 1028-34


Triglyceride-rich lipoproteins

prevent septic death in rats

Read TE et al. J Experimental Med 1995; 182: 267-72

Survival of rats after CLE

receiving i.v. either

mesenteric lymph

containing nascent

chylomicrons (1 g

triglyceride/kg), Intralipid

(1 g triglyceride/kg), or

normal saline every 4 h

for 28 h.

All deaths occurred

during the first 72 h after

CLP.

* P ~0.03 vs controls at

96 h


Triglyceride-rich lipoproteins

prevent septic death in rats

Read TE et al. J Experimental Med 1995; 182: 267-72

Serum endotoxin (LPS) levels and Serum TNF levels after CLP.


Enteral Administration of High-Fat

Nutrition Before and Directly After

Hemorrhagic Shock Reduces Endotoxemia

and Bacterial Translocation

Luyer M et al. Ann Surg 2004; 239: 257-64

Circulating endotoxin at 24 hours after shock is significantly

lower in the HS-HF group compared with both the HS-S group

(*P = 0.005) and the HS-LF group († P = 0.002).


Fett in der enteralen Ernährung

Was wird verwendet ?

Standard- NDD : PUFA-reiche LCT-Fette

Pflanzenöle

(Sonnenblumen-; Soyabohnen-Öl etc.)

Modifizierte - NDD : 50 % MCT (Kokosnuß-Öl)

(Resporptionsstörungen, Pankreatitis etc.)

Immunonutrition : Zusatz von Fischöl (ω-3-FA),

oder y-Linolensäure


Effect of enteral feeding with

eicosapentaenoic acid, gammalinolenic

acid, and antioxidants in

patients with ARDS

Gadek JE et al. Crit Care Med 1999; 27:1409-20

Mean number of 30-day ventilator-free days and ICU-free days.

*Patients with eicosapentaenoic acid + gamma-linolenic acid (EPA

+ GLA) had 4.9 more ventilator-free days (p = .02) and 4.0 more

ICU-free days (p = .01) compared with patients with control diet.


Effects of enteral feeding with

eicosapentaenoic acid, γ-linolenic acid, and

antioxidants in mechanically ventilated

patients with severe sepsis and septic shock

Pontes-Arruda A et al. Crit Care Med 2006; 34:2325

Survival curves

during the 28-day

period. Enteral

feeding with

eicosapentaenoic

acid (EPA) and γ-

linolenic acid

(GLA) („Opexa“)

was associated

with higher

survival

(p = .037).


KLINISCHE VORBEHALTE GEGEN DIE

VERWENDUNG VON FETT IN DER

PARENTERALEN ERNÄHRUNG

Blockade des RES ?

Phagozytose der Partikel in Granulozyten ?

Beeinträchtigung der Immunkompetenz ?

Klinische Bedeutung des Creaming ?

Inkompatibilität mit anderen Nährstoffen ?

Beeinträchtigung der Blutgerinnung ?

Verminderung der Thrombozytenzahl ?

Induktion einer Pankreatitis ?

Beeinträchtigung der Leberfunktion ?

Behinderung des Gasaustausches ?

WD 2003


Efficacy of a high-carbohydrate

diet in catabolic illness

Hart DW et al. Crit Care Med 2001; 29: 2318-24

Model calculations of protein synthesis, protein breakdown, and net

balance for children with burn injury. *p < .05; †p < .01.

High Carb = 82% Carb, 3% Fat, 14% potein; high fat = 44% (as enteral

Intralipid)Carb, 42% fat, 14 % protein, PHE phenylalanine (study using

enteral nutrition) hoch-kalorische Ernährung!!


A Prosprective, Randomized Trial of

Intravenous Fat Emulsion Administration

in Trauma Victims Requiring Total

Parenteral Nutrition

Battistella FD. et al. J Trauma 1997; 43: 52-59

Lipid No Lipid p Value

(N = 30) (N = 27)

Nonprot Cal. (kcal/kg/d) 28 + 2 21 + 2 0.0001

Calories as fat (%) 24 + 5 0 0.0001

Amino acids (g/kg/d) 1.6 + 0.2 1.6 + 0.1 0.41

Nitrogen balance (g/day) - 9 + 7 -9 + 5 0.78

Patient days with glucose

NUTRITIONAL PARAMETERS

> 200 mg/dl 32 38 0.72

Total insulin (U) for 10 d 245 227 0.52

Nicht isokalorisch – hyperkalorisch in der Lipid-Gruppe


A Prosprective, Randomized Trial of

Intravenous Fat Emulsion Administration

in Trauma Victims Requiring Total

Parenteral Nutrition

Battistella FD. et al. J Trauma 1997; 43: 52-59

Lipid No Lipid p Value

(N = 30) (N = 27)

CLINICAL OUTCOME

Hospital length of stay (d) 39 + 24 27 + 16 0.03

ICU length of stay (d) 29 + 22 18 + 12 0.02

Days on mech. Ventilation 27 + 21 15 + 12 0.01

INFECTIOUS COMPLICATIONS

Pneumonia (n) 22 13 0.05

Line sepsis (n) 13 5 0.04

Bacteriemia (n) 8 6 0.68

Abdominal abscess (n) 4 3 0.99

Mortality (n) 0 2 0.99

nicht isokalorisch – hyperkalorisch in der Fettgruppe !


Does Delaying Early Intravenous Fat

Emulsion during Parenteral Nutrition

Reduce Infections during Critical Illness?

Gerlach AT. et al. Surg Infect 2011; 12: 43-47

Retrospective review of two sequential periods


Bloodstream Infections in Patients

Receiving Manufactured Parenteral

Nutrition With vs Without Lipids:

Is the Use of Lipids Really Deleterious?

Pontes-Arruda A. et al.

JPEN 2012 – e-pub

Adjusted probability of infection adjusted for gender, geographic

region, hospital size, admission type, transfer status, additional

dextrose, additional mineral/ electrolyte, days of PN, malnutrition,

peritonitis, cirrhosis/ chronic liver failure, renal failure.


Hypocaloric total parenteral nutrition:

effectiveness in prevention of hyperglycemia and

infectious complications- a randomized trial

McCowen KC. et al. Crit Care Med 2000; 28: 3606-11

Nitrogen balance measured after 5 days of TPN*p < .03 for the difference

between the hypocaloric (= 14 kcal /kg/d, Fett-frei!) and control groups (= ca. 18

(Ziel 25) kcal/kg/d, 3-Kammer-Beutel).


KONTRAINDIKATIONEN GEGEN DIE

VERWENDUNG VON FETT IN DER

PARENTERALEN ERNÄHRUNG

• Hyperlipidämie

• Jede Art von Schock

• Störungen der Mikrozirkulation

• Diffuse intravaskuläre Gerinnug

• Schwere Acidose (ph


FETT in der klinischen Ernährung

Grenzen für die Fettzufuhr : Triglyceride

„Arbiträre“ Empfehlung von allen internat.

Gesellschaften:

350 – 450 (500) mg/dl

Gefahren einer Hypertriglyceridämie:

Fettspeicherung im Granulozyten

Sequestrierung im RES

Pankreatits

Pneumonitis

neurolog Komplikationen


The importance of clinical factors in

parenteral nutrition-associated

hypertriglyceridemia

Llop J et al.

Clin Nutr 2003;

22: 577-83

Clinical factors

associated with PN

hypertriglyceridemia


Effects of Fat Proportion to Glucose in

Peripheral Parenteral Nutrition on

Nutritional Status in Normal Rats

Nakayama M. et al Nutrition Res 2000; 20: 1771-82

Body weight changes and cumulative nitrogen balance during

PPN periods.


Praktische Hinweise für die

Infusion von FETT in der TPE

• beachte die Kontraindikationen

• beachte die Dosierungsrichtlinien

infundiere kontinuierlich (z.B. 18 - 24 h)

(Vermeidung von Konzentrationsspitzen)

• überwache die Infusion

(Plasma-Triglyceride, nicht Trübung !)

• reduziere bzw. beende Infusion bei

Triglyceriden > 350 mg/dl (4 mmol/l)

Merke : Eine verzögerte Elimination ist KEINE Kontraindikation

zur Fettgabe : aber Dosisanpassung !

WD 2003


Fett in der Ernährung von

Intensivpatienten

Statement

Fett bildet eine obligatorische

Komponente JEDER künstlichen Ernährung,

und damit auch Bestandteil jeder

parenteralen Nährlösung….

…wenn keine Kontraindikationen vorliegen…

In der enteralen Ernährung ist das akzeptiert, warum nicht

in der parenteralen?


Fett nicht vergessen !

Danke für die Aufmerksamkeit

wilfred.druml@meduniwien.ac.at

More magazines by this user
Similar magazines