Yoğun Bakımda Nutrisyona Yaklaşım
Özet
Yoğun bakım hastalarında gelişen stres cevabı, artan enerji ihtiyacı ve protein yıkımı malnütrisyon riskini önemli ölçüde artırdığından, kabul edilen her hastanın beslenme durumunun değerlendirilmesi kritik bir önem taşır. Malnütrisyon riskini belirlemek için NRS 2002 ve NUTRIC skorlama sistemleri yaygın olarak kullanılmakta olup, yüksek riskli hastalarda ilk 24-48 saat içinde beslenmeye başlanması önerilmektedir. Fizyolojik yapıyı koruması, bağırsak mukozal atrofisini önlemesi ve mukozal bağışıklığı desteklemesi nedeniyle enteral beslenme öncelikli olarak tercih edilmelidir. Beslenme planlamasında hedef kalori miktarı hastanın ideal kilosuna göre günlük 25-30 kcal/kg olarak belirlenmeli, ancak ciddi elektrolit şiftlerine yol açan "Re-feeding Sendromu" riskini önlemek amacıyla beslemeye düşük kalorili başlanıp kademeli bir artış sağlanmalıdır. Protein ihtiyacı ise hastanın maruz kaldığı stres düzeyine göre günlük 0.7-0.8 g/kg'dan 1.3-2.0 g/kg'a kadar değişkenlik göstermektedir. Enteral yolun kontrendike veya yetersiz olduğu durumlarda enfeksiyöz ve metabolik komplikasyon riskleri barındıran parenteral beslenme (TPN) devreye sokulabilir. Yoğun bakım sürecinde optimal hasta yönetimi için hekim, diyetisyen ve klinik eczacıdan oluşan multidisipliner bir ekibin hasta odaklı ve dinamik bir beslenme planı oluşturması esastır.
Since the stress response, increased energy expenditure, and protein breakdown developed in intensive care patients significantly raise the risk of malnutrition, evaluating the nutritional status of every admitted patient is of critical importance. The NRS 2002 and NUTRIC scoring systems are widely used to identify malnutrition risk, and it is recommended to initiate nutrition within the first 24-48 hours in high-risk patients. Enteral nutrition should be preferred primarily because it preserves physiological structure, prevents intestinal mucosal atrophy, and supports mucosal immunity. In nutritional planning, the target caloric intake should be set at 25-30 kcal/kg/day based on the patient's ideal body weight; however, to prevent the risk of "Re-feeding Syndrome" which causes severe electrolyte shifts, feeding should be started at a low calorie level and increased gradually. Protein requirements vary from 0.7-0.8 g/kg/day to 1.3-2.0 g/kg/day depending on the level of stress the patient is exposed to. In cases where the enteral route is contraindicated or insufficient, parenteral nutrition (TPN), which carries risks of infectious and metabolic complications, can be introduced. For optimal patient management during intensive care, it is essential for a multidisciplinary team consisting of a physician, dietitian, and clinical pharmacist to establish a patient-centered and dynamic nutritional plan.
Referanslar
Kreymann KG, Berger MM, Deutz DE, et al. ESPEN guidelines on enteral nutrition: intensive care. Clin Nutr 2006;25:210e23.
Cederholm T, Bosaeus I, Barazzoni R, et al. Diagnostic criteria for malnutrition- an ESPEN consensus statement. Clin Nutr 2015;34:335e40.
Puthucheary ZA, Rawal J, McPhail M, et al. Acute skeletal muscle wasting in critical illness. JAMA 2013;310:1591e600
Chandra RK. Nutrition and the immun system from birth to old age. Eur J Clin Nutr 2002; 56:73-76
Van den Berghe G, Wouters P, Weekers F, et al. Reactivation of pituitary hormone release and metabolic improvement by infusion of growth hormone-releasing peptide and thyrotropin-releasing hormone in patients with protracted critical illness. J Clin Endocrinol Metab. 1999;84:1311–1323.
Petit F, Bagby GJ, Lang CH. Tumor necrosis factor mediates zymosan-induced increase in glucose flux and insulin resistance. Am J Physiol. 1995;268:E219–E228.
Singer M , Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr 2019;38: 48-79
Kondrup J, Rasmussen HH, Hamberg O, et al. Nutritional risk screening (NRS 2002); a new method based on analysis of controlled clinical trials. Clin Nutr 2003;22:321e36.
Heyland DK, Dhaliwal R, Jiang X, et al. Identifying critically ill patient who benefit the most from nutrition therapy: the development and initial validation of a novel risk assessment tool. Crit Care 2011;15:R268
Tappenden KA.Mechanisms of enteral nutrient-enhanced intestinal adaptation. Gastroenterology 2006; 130:93-99
McClave SA, Taylor BE, Martindale RG. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN Parenter Enteral Nutr. 2016;2:159–211
Reignier K, Mercier E, Le Gouge A, et al. Effect of not monitoring residual gastric volüme on risk of ventilator-associated pneumonia in adults receiving mechanical ventilation and early enteral feding. JAMA 20113: 309:249-256
Booth CM, Heyland DK, Paterson WG. Gastrointestinal promotility drugs in the critical care setting: a systematic review of the evidence. Crit Care Med 2002; 30:1429-1435
Barton RG. Nutrition support. In J.E. Parillo & R.P. Dellinger, Critical Care Medicine Principles of Diagnosis and Management in the Adult. New Jersey, Elsevier, 5th edition 2019:1280-1281
Brinson RR, Kolts BE. Diarrhea associated with severe hypoalbuminemia: a comparison of a peptide-based chemically defined diet and standard enteral alimentation. Crit Care Med. 1988;16:130–136.
Simpson F, Doig GS. Parenteral vs. enteral nutrition in the critically ill patients: a meta-analysis of trials using the intention to treat principle. Intensive Care Med. 2005;31:12–23.
McClave SA, Martindale RG, Vanek VW, et al., the A.S.P.E.N: Board of Directors and the American College of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient. JPEN J Parenter Enteral Nutr. 2009;33:277–316.
