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1、危重患儿的营养支持,2,营养支持在危重病人中的应用,营养支持为何重要,危重病+差的营养？,3,4,营养不良与危重症的关系,Impact of starvation,Negative nitrogen balance,further wt loss Morphological changes in the gut(Mucosal thickness,Cell proliferation and Villus height)Functional changes(Increased permeability&Decreased absorption of amino acids)Enzymatic/
2、Hormonal changes Decreased sucrase and lactase Impact on immunity Cellular:Decreased T cells,atrophied germinal centers,mitogenic proliferation,differentiation,Th cell function,altered homing Humoral:Complement,opsonins,Ig,secretory IgA(70-80%of all Ig produced is secretory IgA)Increased bacterial t
3、ranslocation,5,6,预后,体重下降35-40%，病死率接近100%,危重病+差的营养？,为何会发生急性蛋白质能量营养不良？,7,8,急性蛋白质能量营养不良,基础代谢率明显增加,应激高分解状态,营养素需求增加,丢失过多,摄入不足,基础疾病,9,代谢病理,糖元分解糖异生糖利用降低血糖增加,蛋白分解糖异生负氮平衡,优先动用 FFA TG,糖,蛋白,脂肪,When should nutrition support be started in the PICU?,10,营养评估,既往史体检饮食史实验室检验,11,Nutrition Focused Assessment,Past medic
4、al history as it impacts nutritional status and outcomes Anthropometric measures:weight,length,head circumference(for children 3 years of age)Dietary intake history:as available from parents or primary caretakers,history of feeding problems,loss of appetite,recent weight loss Laboratory values:CHEM-
5、10,total protein/albumin,as available Nutrition based exam to identify nutrition deficiency lesions History of and need for further nutrition education for specialized formula or diet.,12,children at increased nutritional risk,Hypermetabolic states:trauma:closed head injury,spinal cord injury Post-s
6、urgical patients Cardiorespiratory illness:congenital heart defects,bronchopulmonary dysplasia,cystic fibrosis Gastrointestinal disease and dysfunction:short gut syndrome,exacerbation of inflammatory bowel disease with history of PEM,hepatic failure,biliary atresia,pancreatitis Neurologic,muscular d
7、isease:genetic syndromes,Guillan-Barre,muscular dystrophy,history of CP/MR requiring G-tube feedings,13,Indications for Nutrition Support in the PICU:,All PICU patients will be screened by the PICU nutritionist within 72 hours of admission to determine if they are at nutrition risk or in need of nut
8、rition support via the enteral or parenteral route.,14,如何进行？经肠道还是全静脉？,15,16,TPN适应症,胃肠道功能障碍的重症患儿；手术或解剖问题胃肠道禁止使用的重症患儿；存在有尚未控制的腹部情况，如腹腔感染、肠梗阻、肠瘘等。,早期复苏阶段、血流动力学尚未稳定或存在严重水电介质与酸碱失衡；严重肝功能衰竭，肝性脑病；急性肾功能衰竭存在严重氮质血症；严重高血糖尚未控制。,相对禁忌,GI解剖、功能良好，具备肠道喂养通路 EN,17,危重病人营养支持时机选择,重症病人常合并代谢紊乱与营养不良，需要给予营养支持（C级）重症病人的营养支持应尽早开
9、始（B级）（预计57天内不能经口摄食者应及早开始营养支持）,如可进行？,热量及营养素的分配,18,Determining Calorie and Protein Needs,Estimate basal energy needs(BEE)-Refer to Table 1 Determine Stress Factor-Refer to Table 2 Total Calories=BEE X Stress Factor Estimate patients protein requirements-Refer to RDAs-Table 3 Total Protein=Protein RDAs
10、 X Stress Factor Continue to evaluate and adjust recommendations based on nutrition monitoring.,19,Calculation of Catch-Up Growth in the Term Infant and Child,Kcal/kg=RDA(kcal/kg)for weight age*x Ideal weight(kg)*/Actual weight*Age at which present weight is at the 50th%-ile*50th%-ile for age or ide
11、al body weight for height,20,Table 1.Basal Energy Needs for Infants and Children,21,BACK,Table 2.Determining Stress Factor,22,BACK,Table 3.Recommended Dietary Allowances for Infants and Children,23,BACK,24,能量供应,胃肠外营养支持期间热卡推荐量(kcal/d),体温每增高1C,热量需增加12%;心力衰竭时需增加5-25%;大手术时需增加20-30%;严重败血症时需增加40-60%;烧伤时需增
12、加100%。,25,Nutritional Support Targets for the PICU Patient,26,危重病人的营养供给原则,葡萄糖：一般占非蛋白质热卡的50-60，应根据糖代谢状态进行调整（C级）脂肪：一般为非蛋白质热卡的40-50；摄入量可达1-1.5g/kg.d，应根据血脂廓清能力进行调整，脂肪乳剂应匀速缓慢输注（B级）蛋白质：供给量一般为1.2-1.5g/kg.day，约相当于氮0.20-0.25g/kg.day；热氮比100150kcal:1gN（B级）,能量分配,Complications of overfeeding,Excess CO2 productio
13、n&increased minute ventilation Pulmonary edema&respiratory failure Hyperglycemia,which may increase infection rates Lipogenesis due to increased insulin production Immunosuppression Hepatic complications:fatty liver,intrahepatic cholestasis,27,28,对于不活动的重症患者能量消耗,29,水与电解质,碳水化合物 脂肪 蛋白质,维生素 微量元素,Macronu
14、trients,Micronutrients,营养底物Nutrients,碳水化合物（葡萄糖）,Dextrose-Begin PN at 10-15%dextrose.Advance by 2.5-5%in older infants and children and by 5-10%per day in adolescents until an endpoint of D12.5%dextrose for PPN or generally between 20-25%dextrose for CPN,as needed to meet nutritional needs.Provision
15、of excess carbohydrate calories may lead to the following adverse effects:hyperglycemia,hepatotoxicity,cholestasis,glycosuria,osmotic diuresis Insulin Use-A general guideline is addition of 1 unit of regular insulin per 10 grams of carbohydrate calories.,30,31,碳水化合物（葡萄糖）,葡萄糖输注速率 3-4mg/kg.min开始可逐渐增至6
16、-7mg/kg.min;使用小剂量外源性胰岛素时葡萄糖输注速率可达9mg/kg.min。,32,肠外营养：脂肪乳,脂肪乳是等渗的，单位体积含热卡量高脂肪乳和葡萄糖组成的双重能量系统比单一能量系统代谢更为有效，达到氮平衡所消耗的能量相对较少，与葡萄糖同时应用具有更好的节氮效应补充必需脂肪酸，防止EFA的缺乏CO2产生减少，RQ减轻,33,脂肪乳剂,脂肪推荐摄入量：占总摄入热量的30-40用量：从0.5-1.0 g/kg.d开始,每12天增加0.5g/kg,总量不超过3.5-4g/kg.d。输注速度20%脂肪乳剂的试验速率为0.05ml/kg.min。特别注意：危重疾病肾衰竭检查：脂肪廓清等血脂代
17、谢血浆TG（max：3-4 mmol/l）,34,蛋白质/氨基酸（氮）,首次：0.5-1.0g/kg.d，每日可增加0.5g/kg.d，MAX:2.5-3.5g/kg.d营养液中所含氨基酸的氮量(g)与非蛋白热卡(kcal)之比最好为1:150-200,稳定持续、优化的蛋白质补充是营养支持的重要策略,35,发挥特殊营养素的药理作用,Glutamine免疫增强-3 FA（FO）炎症反应调控,36,Recommended Parenteral Calcium&Phosphorus Intake,Parenteral Electrolyte&Vitamin/Mineral Guidelines in
18、 Pediatric Patients,37,MVI Pediatric Solution contains per 5 ml,38,Pediatric Trace Element Solution(PTES)per 0.2 ml,39,Nutrient Requirements in Pulmonary Failure,Calories:dont overfeed when weaning to prevent increased CO2 production(Provide 25-30 kcal/kg or resting energy expenditure)Protein:1.5-2
19、g/kg Amino acids may increase ventilation,increase O2 consumption.Fat:OMEGA 3 FA may be anti-inflammatory and alter immune status in sepsis/ARDS,40,Nutrient Requirements in liver Failure,Calories:caloric requirements affected by acuteness of disease,seriousness of injury,absorption,other organ failu
20、re,sepsis;25-35 kcals/kg or REE Protein:well nourished/low stress:.8 g/kg;malnourished/with metabolic stress:up to 1.5 g/kg CHO:70%non-protein calories;in acute failure,may need continuous glucose infusion Chronic:may have diabetes/hypoglycemia requiring controlled CHO and insulin;in septic pts hypo
21、glycemia occurs in 50%of cirrhotics FAT:30%non-protein calories;MCT may be helpful with LCT malabsorption,41,Nutrient Needs in MODS,Calories:35 kcal/kg or REE Protein:up to 1.5-2.0 g/kg Fat:30%nonprotein calories;MCT if bile salt deficient;N3 vs N6 Micronutrients:evaluate individually Fluid:based on
22、 fluid status,42,Nutrition Implications of ARF,ARF causes anorexia,nausea,vomiting,bleeding ARF causes rapid nitrogen loss and lean body mass loss(hypercatabolism)ARF causes gluconeogenesis with insulin resistance Dialysis causes loss of amino acids and protein Uremia toxins cause impaired glucose u
23、tilization and protein synthesis Impaired Conversion and resultant deficiencies of Gly,Ala(Tubular protectant)&Arg(Preserves renal perfusion).AA Supplementation helps renal perfusion and GFR and diuresis.,43,44,完全胃肠外营养的途径,操作方便且全身继发感染的危险性小。输注葡萄糖的最高浓度为12.5%完全胃肠外营养的患儿单靠外周静脉途径很难在单位时间内提供足够的液体及热量维持静脉输液时间短
24、。可使用静脉套管针延长了穿刺静脉使用的时间。,经外周静脉途径的胃肠外营养只适用于:1、短期需营养支持2、轻度急性蛋白质能量营养不良患儿的围手术期3、不能接受中心静脉插管4、暂时不能确定禁食时间5、使用中心静脉导管前后6、糖利用障碍的患儿,外周静脉,45,中心静脉:,操作复杂所需导管价高易出现机械合并症存在全身感染和血栓的危险,可输入高浓度葡萄糖(12.5%)；单位时间内可提供较高的热卡和较大量的液体；中心静脉开放维持时间长；液体外渗发生率低；一般选用颈内静脉、锁骨下静脉、大隐静脉及贵要静脉放置单腔或多腔中心静脉导管。,Complications:,Infection Hepatic dysfu
25、nction Metabolic complications:hyperglycemia,hypoglycemia,acidosis,hypomagnesemia,hyperlipidemia,hypocalcemia Trace metal deficiencies Mechanical complications:dysrrhythmias,venous thrombosis,air embolism&skin sloughs Bilirubin displacement by intralipid,46,Monitoring:,Daily weight Routine nursing o
26、bservations Laboratory investigations:-CBC-Urine(sugar,acetone)-Electrolytes-Transaminases,alkaline phosphatase and bilirubin levels-Urea&creatinine-Lipid levels Fat infusion should be stopped 2-4 hours before taking blood samples(8 hours for lipid tests),47,48,营养支持中的血糖控制,SSC推荐：感染与感染性休克患者应控制血糖150mg/
27、dl任何形式的营养支持，应配合强化胰岛素治疗，严格控制血糖水平150mg/dl并应避免低血糖发生中华医学会重症医学会2005,5,49,胃肠外营养的终止,原发病好转,考虑恢复经胃肠喂养时,应给予胃肠道充分的“复苏”时间及条件。可先经口、经胃管或经肠管给予等渗葡萄糖液,由1-2ml/kg/次开始,每日三次；逐渐增至8次/日;当患儿在24小时内耐受量达20-30ml/kg时,可把喂养液改为2:1稀释奶,若仍能耐受,继用1:1稀释奶,逐渐过度到全奶。增加胃肠内喂养量及喂养液性质时,逐渐减少胃肠外营养液量;当经肠喂养量50ml/kg/d时,即可停用胃肠外营养。此交替过程至少也需一周的时间。,50,肠内
28、营养,选择原则：如肠道具有功能，应首选经肠喂养 BUT:“All the routes are abnormal.Doing it badly or poorly adds risks.”Griffths GR 对仍需要液体复苏、内脏低灌注仍然存在的危重症患者暂不宜使用,Benefits of enteral nutrition in pediatric patients include:,Physiological presentation of nutrients Trophic effects on the GI tract Stimulation and maintenance of
29、the gut mucosa Reduced metabolic and infectious complications Improved hepatic function versus parenteral nutrition Simplified fluid and electrolyte management More complete nutrition May reduce the incidence of pathogen entry or bacterial translocation into the peritoneal cavity or circulation Less
30、 expensive,51,52,53,肠内营养时机,血流动力学稳定、具有功能性肠道患者应及早开始适量的肠内营养（C）中华医学会危重症分会2006ESPEN guidelines on EN in ICU 2006 Canada Guideline2448 hrs内开始喂养,54,肠内营养不耐受,EN不耐受的特点胃残余量过多恶心，呕吐腹胀，绞痛腹泻大约30%60%ICU病人由于EN不耐受中断肠内营养,De Jonghe B et al.CCM.2001 29:204Montejo JC et al.CCM.1999;27:1447Mentec H et al.CCM.2001;29:1955,
31、55,EN禁忌或不宜应用,不能进食没有EN通路未解决的腹部问题GI功能肠梗阻严重GI出血梗阻性内脏血管疾病，EN可引起或加重肠道缺血严重腹胀：IAH 等严重腹胀、腹泻，处理无改善暂停用,56,Intermittent Tube Feeding Progression,57,58,59,病例,患儿，女，10岁。以发烧4天，抽搐，昏迷3天为主诉入院。入院前4天发烧，体温38-39.2oC，伴流清涕。咽痛、次日下午突然抽搐，昏迷不醒，抽搐每天5-6次，每次持续3-5分钟.于抽搐当日到当地医院就诊，诊断“病毒性脑炎”，给予安定止惊，20%甘露醇150ml，每日二次静脉推注降颅压，10%葡萄糖500 m
32、l+能量合剂，每日一次静点，penicilin 320万u每日2次静脉。抽搐无缓解，且高烧至39-40oC,病后未进食，呕吐咖啡样物而转我院。,60,体格检查:,一般状差，深昏迷，体重26kg,皮肤弹性差，眼窝凹陷，双眼睑闭合不良，双瞳孔等大，直径2.5mm，光反应迟钝，双眼球结膜水肿，呼吸略深大，呼吸32次/分，双肺少许干鸣音。心音有力，节律规整，心率82次/分。腹部不胀，肝、脾未触及，肠鸣减弱。四肢肌张力正常，肢端稍凉，双膝反射减弱，脑膜刺激征阴性。,61,血常规:WBC 8.8 x 109/L,N 0.3 L0.68 HB108g/L 尿常规:蛋白阳性，酮体+，糖阴性。便常规:潜血(十十
33、)。肝功:谷草转氨酶45 u/L，血尿素氮6.8mmol/L。动脉血气:pH 7.36,PaCO22.1kPa PaO213kPa，HCO310mmol/L,电解质：钠140mmol/L，钾3.5 mmol/L，氯110mmol/L,辅助检查:,62,入院诊断:,病毒脑炎、代偿性代谢性酸中毒合并呼吸性碱中毒,63,胃肠外营养,因患儿入院当日处于深昏迷，频抽，且伴应激性消化道出血，不能经消化道摄入营养，故于入院头3天给予全胃肠道外营养。患儿有颅内水肿且伴有脱水，又因高烧不感蒸发多，采取边脱边补原则，在发病急性期保持患儿处于轻度脱水状态，,64,入院第一天补液，患儿体重26kg，入液量为1000+
34、500+1201620ml高热增加30，脑水肿时减30。纠酸：5%碳酸氢钠（ml)=ABE x体重(kg)x0.5=14X26x0.5=182ml，首次给予1/3量(60ml)，用10%葡萄糖稀释成1.4%碳酸氢钠210ml,留200ml备用。热卡：26*25650kal,糖60：650*0.55357kal相当于糖：357/490g脂肪：650*0.3195kal相当于脂肪：195/921g20FAT100ml氨基酸：650*0.1597.5kal相当于：97.5/423g6.25aa:=360ml,65,66,静脉营养,剩余液1210(1620一200一210)ml:6.25%复合氨基酸3
35、60 ml(0.9g/kd.d);20%脂肪乳100ml(0.78g/kd.d);水乐维他10ml，维他利匹特10 ml,安达美10ml;因电解质无明显紊乱，氯化钠按0.3%配制，氯化钾按0.3%配制，所需 10%氯化钠(ml)=1200 x 3/100=36m1,10%氯化钾(ml)=1200 x 3/100=36ml;50%葡萄糖(ml)二(360+100+10 x3+36+36)/4=140m1余量1210-562-140500 ml，由10%葡萄糖补充。,热卡480+90+180=750kal糖4*（500*10+140*50）480kal蛋白=4*6.25%*360=90kal脂肪=
36、9*20%*100=180kal750/26=28kal/kg液：热1620/7502.1氮：热22.5/6.25/6601：183,67,糖浓度120/1210*10010.糖速120*1000/24/26/60120000/374403.2mg/kg.min,68,例2,10kg NEC患儿入院第二天，胃肠减压出黄绿色液体100ml，血钠120mmol/L，血糖：2.1mmol/L，血气：PH：7.53，HCO3:34mmol/L，BE:10mmol/L，如何进行TPN。,69,1，纠正低血糖：50GS 1ml/kg.稀释1倍后缓慢静脉注射。2.用生理盐水补充胃肠引流量：NS：100ml3
37、.补酸：25%盐酸精氨酸（ml)=ABE x体重(kg)x0.8 x0.3=10X10 x0.24=24ml，先给半量10ml。4.补钠:10氯化钠：（135-120）*1.2*10/3.3/227ml.稀释成3.3（加注射用水63ml）后微泵注入。,70,71,入院第二天补液，患儿体重10kg，总入液量为1000ml，留150ml备用。暂定热卡：10*30kal300kal,糖60：300*0.55165kal相当于糖：165/441g脂肪：300*0.390kal相当于脂肪：90/910g20FAT50ml氨基酸：300*0.1545kal相当于AA：45/411g6.25aa:=200m
38、l,72,73,静脉营养,剩余液750(1000一150-100)ml:6.25%复合氨基酸200 ml(1.2g/kd.d);20%脂肪乳50ml(1g/kd.d);水乐维他10ml，维他利匹特10 ml,安达美5ml;氯化钠按0.3%配制，氯化钾按0.3%配制，需 10%氯化钠(ml)=750 x 3/100=22.5m1,10%氯化钾(ml)=750 x 3/100=22.5ml;50%葡萄糖(ml)二(200+50+25+22.5+22.5)/4=80m1余量750-400350 ml，由10%葡萄糖补充。,热卡300+50+90=440kal糖4*（350*10+80*50）300k
39、al蛋白=4*6.25%*200=50kal脂肪=9*20%*50=90kal440/10=44kal/kg液：热1000/4402.2氮：热12.5/6.25/3901：180,74,糖浓度75/1000*1007.5糖速75*1000/24/10/6075000/144005.2mg/kg.min,75,CONCLUSIONS,Start nutrition early Enteral route is preferred when available Set goals for the individual patient Appropriate monitoring is essential Avoid overfeeding Critically ill patients with organ failure present special challenges to the nutrition care professional and medical team,76,
