[Nutritional management of severely injured patients : Treatment between guidelines and reality]

Severe trauma triggers endocrine and inflammatory responses, leading to hyperglycaemia, insulin resistance and protein catabolism. Pharmacological and nutritional interventions cannot counteract these metabolic disturbances. However, adequate supply of energy and proteins may reduce excessive catabolism.Available guidelines recommend early use of enteral nutrition with energetic supply of about 25 kcal/kg and additional protein supply of 1.5 g/kg/day. These aims will be missed frequently by solely providing enteral nutrition in severely injured patients. Early supplemental parenteral nutrition should be used in these cases. Concomitantly, gastric paresis and paralytic ileus hampering enteral nutrition should be treated by propulsive and prokinetic drugs and by use of duodenal or jejunal site of application in selected cases.Euphoric hopes linked with intensified insulin therapy (IIT), targeting blood glucose levels <110 mg/dl in intensive care patients, had to be widely abandoned in recent years. The goal for blood glucose levels should be set at 180 mg/dl as the upper limit according to current knowledge, which promises to optimize the balance between efficacy and safety.