Aminosäuren – Leitlinie Parenterale Ernährung, Kapitel 4

Protein catabolism should be reduced and protein synthesis promoted with parenteral nutrion (PN). Amino acid (AA) solutions should always be infused with PN. Standard AA solutions are generally used, whereas specially adapted AA solutions may be required in certain conditions such as severe disorders of AA utilisation or in inborn errors of AA metabolism. An AA intake of 0.8 g/kg/day is generally recommended for adult patients with a normal metabolism, which may be increased to 1.2–1.5 g/kg/day, or to 2.0 or 2.5 g/kg/day in exceptional cases. Sufficient non-nitrogen energy sources should be added in order to assure adequate utilisation of AA. A nitrogen calorie ratio of 1:130 to 1:170 (g N/kcal) or 1:21 to 1:27 (g AA/kcal) is recommended under normal metabolic conditions. In critically ill patients glutamine should be administered parenterally if indicated in the form of peptides, for example 0.3–0.4 g glutamine dipeptide/kg body weight/day (=0.2–0.26 g glutamine/kg body weight/day). No recommendation can be made for glutamine supplementation in PN for patients with acute pancreatitis or after bone marrow transplantation (BMT), and in newborns. The application of arginine is currently not warranted as a supplement in PN in adults. N-acetyl AA are only of limited use as alternative AA sources. There is currently no indication for use of AA solutions with an increased content of glycine, branched-chain AAs (BCAA) and ornithine-α-ketoglutarate (OKG) in all patients receiving PN. AA solutions with an increased proportion of BCAA are recommended in the treatment of hepatic encephalopathy (III–IV).Ein Proteinkatabolismus soll bei parenteraler Ernährung (PE) vermindert und anabole Stoffwechselprozesse gefördert werden. Standard-Aminosäure (AS)-Lösungen werden empfohlen, falls nicht in Sondersituationen z. B. bei schweren AS-Verwertungsstörungen oder bei angeborenen Stoffwechselstörungen spezifisch adaptierte AS-Lösungen eingesetzt werden müssen. Für erwachsene Patienten in ausgeglichenem Stoffwechselzustand wird eine AS-Zufuhr von 0,8 g/kg/Tag empfohlen, die auf 1,2–1,5 g/kg/Tag oder in Ausnahmefällen auch auf 2,0–2,5 g/kg/Tag gesteigert werden kann. Zur Gewährleistung einer angemessenen Utilisation von AS sollten ausreichend Nicht-Stickstoff-Energieträger zugegeben werden. Das angestrebte Verhältnis zwischen Stickstoff- und Energiezufuhr (Stickstoff-Kalorien-Verhältnis) sollte unter Normalbedingungen 1:100–1:130 (g N:kcal) bzw. 1:16–1:21 (g AS:kcal) betragen. Glutamin sollte parenteral bei kritisch Kranken, sofern indiziert, in Form von Peptiden verabreicht werden, wie z.B. 0,3–0,4 g Glutamin-Dipepetid/kg KG/Tag (entsprechend 0,2–0,26 g Glutamin/kg KG/Tag). Für Patienten mit akuter Pankreatitis, nach Knochenmarkstransplantation sowie für Neugeborene kann derzeit keine Empfehlung für eine Glutaminsupplementierung mit der PE ausgesprochen werden. Der Einsatz von Arginin als Supplement in der PE beim Erwachsenen ist derzeit nicht gerechtfertigt. Den N-azetylierten AS kommen als alternative Aminosäurenquellen zur Zeit nur eine begrenzte Bedeutung zu. Für eine generelle Verwendung von AS-Lösungen mit einem erhöhten Gehalt von Glyzin und verzweigtkettigten AS (VKAS) wie auch für Ornithin-α-Ketoglutarat (OKG) besteht keine gesicherte Indikation. Die Wirksamkeit von AS-Lösungen mit erhöhtem Anteil an VKAS in der Behandlung der hepatischen Enzephalopathie (III–IV) wird empfohlen

Morbidity and mortality after anaesthesia in early life: results of the European prospective multicentre observational study, neonate and children audit of anaesthesia practice in Europe (NECTARINE)

Background: Neonates and infants requiring anaesthesia are at risk of physiological instability and complications, but triggers for peri-anaesthetic interventions and associations with subsequent outcome are unknown. Methods: This prospective, observational study recruited patients up to 60 weeks' postmenstrual age undergoing anaesthesia for surgical or diagnostic procedures from 165 centres in 31 European countries between March 2016 and January 2017. The primary aim was to identify thresholds of pre-determined physiological variables that triggered a medical intervention. The secondary aims were to evaluate morbidities, mortality at 30 and 90 days, or both, and associations with critical events. Results: Infants (n=5609) born at mean (standard deviation [sd]) 36.2 (4.4) weeks postmenstrual age (35.7% preterm) underwent 6542 procedures within 63 (48) days of birth. Critical event(s) requiring intervention occurred in 35.2% of cases, mainly hypotension (>30% decrease in blood pressure) or reduced oxygenation (SpO2 <85%). Postmenstrual age influenced the incidence and thresholds for intervention. Risk of critical events was increased by prior neonatal medical conditions, congenital anomalies, or both (relative risk [RR]=1.16; 95% confidence interval [CI], 1.04-1.28) and in those requiring preoperative intensive support (RR=1.27; 95% CI, 1.15-1.41). Additional complications occurred in 16.3% of patients by 30 days, and overall 90-day mortality was 3.2% (95% CI, 2.7-3.7%). Co-occurrence of intraoperative hypotension, hypoxaemia, and anaemia was associated with increased risk of morbidity (RR=3.56; 95% CI, 1.64-7.71) and mortality (RR=19.80; 95% CI, 5.87-66.7). Conclusions: Variability in physiological thresholds that triggered an intervention, and the impact of poor tissue oxygenation on patient's outcome, highlight the need for more standardised perioperative management guidelines for neonates and infants