【医学课件精品】危重患儿的营养支持

危重患儿的营养支持 昆明市儿童医院PICU 李斌 2 营养支持在危重病人中的应用 营养不良与危重症关系1 危重症营养支持原则2 不良影响与监测3 营养支持的实施4 营养支持为何重要营养支持为何重要 n n 危重病危重病+ +差的营养？差的营养？ 3 4 营养不良与危重症的关系 危重患儿发生营养不良是常见 的临床现象. 16-20%患儿入院48小时内存 在主要营养物质不良.60%有低 蛋白血症 人体测量结果：72，主观判 断46 Impact of starvation Impact of starvation n n Negative nitrogen balance, further wt loss Negative nitrogen balance, further wt loss n n Morphological changes in the gut (Mucosal thickness, Cell Morphological changes in the gut (Mucosal thickness, Cell proliferation and Villus height) proliferation and Villus height) n n Functional changes (Increased permeability 心力衰竭时需增加5-25%; n大手术时需增加20-30%; 严重败血症时需增加40-60%; n烧伤时需增加100%。 25 StageClinical GoalsHospital DayNutritional Targets I Fluid Resuscitation Hypermetabolic phase which may continue with infection Day #2 to 9 Achieve BEE for energy with significant protein source; Next step progress to BEE X stress factor (Table 1 n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 n脂肪乳是等渗的，单位体积含热卡量高 n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 n补充必需脂肪酸，防止EFA的缺乏 nCO2产生减少，RQ减轻 33 脂肪乳剂 n脂肪推荐摄入量：占总摄入热量的30-40 n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。 n输注速度20%脂肪乳剂的试验速率为 0.05ml/kg.min。 n特别注意： n危重疾病 n肾衰竭 n检查：脂肪廓清等血脂代谢 n血浆TG（max：3-4 mmol/l） 34 蛋白质/氨基酸（氮） n首次：0.5-1.0g/kg.d， 每日可增加 0.5g/kg.d，MAX:2.5-3.5g/kg.d n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 nGlutamine免疫增强 n-3 FA（FO）炎症反应调控 Recommended Intake Calcium (mEq/kg) Phosphorus (mEq/kg) Preterm, Term Infants3.0 - 4.0 3.0 - 4.0 Older Children (10-40 kg)1.0 - 31.0 - 3 Adolescents (40 kg) 1.0 - 1.5 1.0 - 1.5 36 Recommended Parenteral Calcium 25-35 kcals/kg or REE failure, sepsis; 25-35 kcals/kg or REE n n Protein: well nourished/low stress: .8 g/kg; Protein: well nourished/low stress: .8 g/kg; malnourished/with metabolic stress: up to 1.5 g/kg malnourished/with metabolic stress: up to 1.5 g/kg n n CHO: 70% non-protein calories; in acute failure, may CHO: 70% non-protein calories; in acute failure, may need continuous glucose infusion need continuous glucose infusion n n Chronic: may have diabetes/hypoglycemia requiring Chronic: may have diabetes/hypoglycemia requiring controlled CHO and insulin; in septic pts controlled CHO and insulin; in septic pts hypoglycemia occurs in 50% of cirrhotics hypoglycemia occurs in 50% of cirrhotics n n FAT: 30% non-protein calories; MCT may be helpful with FAT: 30% non-protein calories; MCT may be helpful with LCT malabsorption LCT malabsorption 41 Nutrient Needs in MODS Nutrient Needs in MODS n n Calories: 35 kcal/kg or REE Calories: 35 kcal/kg or REE n n Protein: up to 1.5-2.0 g/kg Protein: up to 1.5-2.0 g/kg n n Fat: 30% nonprotein calories; Fat: 30% nonprotein calories; MCT if MCT if bile salt deficient; N3 vs N6 bile salt deficient; N3 vs N6 n n Micronutrients: evaluate individually Micronutrients: evaluate individually n n Fluid: based on fluid status Fluid: based on fluid status 42 Nutrition Implications of ARF Nutrition Implications of ARF n n ARF causes anorexia, nausea, vomiting, bleeding ARF causes anorexia, nausea, vomiting, bleeding n n ARF causes rapid nitrogen loss and lean body mass loss ARF causes rapid nitrogen loss and lean body mass loss (hypercatabolism) (hypercatabolism) n n ARF causes ARF causes gluconeogenesis with insulin resistance gluconeogenesis with insulin resistance n n Dialysis causes loss of amino acids and protein Dialysis causes loss of amino acids and protein n n Uremia toxins cause impaired glucose utilization and Uremia toxins cause impaired glucose utilization and protein synthesis protein synthesis n n Impaired Conversion and resultant deficiencies of Gly, Ala Impaired Conversion and resultant deficiencies of Gly, Ala (Tubular protectant) 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。 n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; n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 肠内营养 n选择原则：如肠道具有功能，应首选经肠喂 养 n BUT: “All the routes are abnormal. Doing it badly or poorly adds risks.”Griffths GR n 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 Benefits of enteral nutrition in pediatric patients include:pediatric patients include: n n Physiological presentation of nutrients Physiological presentation of nutrients n n Trophic effects on the GI tract Trophic effects on the GI tract n n Stimulation and maintenance of the gut mucosa Stimulation and maintenance of the gut mucosa n n Reduced metabolic and infectious complications Reduced metabolic and infectious complications n n Improved hepatic function versus parenteral nutrition Improved hepatic function versus parenteral nutrition n n Simplified fluid and electrolyte management Simplified fluid and electrolyte management n n More “complete“ nutrition May reduce the incidence of More “complete“ nutrition May reduce the incidence of pathogen entry or bacterial translocation into the peritoneal pathogen entry or bacterial translocation into the peritoneal cavity or circulation cavity or circulation n n Less expensiveLess expensive 51 Patient FactorsFormula Factors Age Diagnosis Associated nutritional problems Nutritional requirements Gastrointestinal function Osmolality Renal solute load Caloric density and viscosity Nutrient composition: type 27:1447 nMentec H et al. CCM. 2001;29:1955 55 EN禁忌或不宜应用 n不能进食 n没有EN通路 n未解决的腹部问题 nGI功能 n肠梗阻 n严重GI出血 n梗阻性内脏血管疾病，EN可引起或加重肠道缺血 n严重腹胀：IAH 等 n严重腹胀、腹泻，处理无改善暂停用 56 Age/Weight Initial Infusion Rate Daily Increases Goal Rate 2.0 - 15 kg 2 - 15 cc/hr (1 cc/kg/hr) 2 - 15 cc/hr q 4 - 8 hr (1 cc/kg) 15 - 55 cc/hr 16 - 30 kg 8 - 25 cc/hr (0.5 - 1 cc/kg/hr) 8 - 16 cc/hr q 4 - 8 hr (0.5 cc/kg) 45 - 90 cc/hr 30 - 50 kg 15 - 25 cc/hr (0.5 cc/kg/hr) 15 - 25 cc/hr q 4 - 8 hr (0.5 cc/kg) 70 - 130 cc/hr 50 kg25 cc/hr 25 cc/hr q 4 - 8 hr 90 - 150 cc/hr Intermittent Tube Feeding Progression 57 Age/WeightInitial Volumes Daily Increases Goal Volume 2.0 - 15 kg5 - 30 cc q 3 - 4 hr 5 - 30 cc q 6 - 8 hr50 - 200 q 4 hr 12 - 30 kg20 - 60 cc q 4 hr20 - 60 cc q 6 - 8 hr150 - 350 cc q 4 hr 30 kg30 - 60 cc q 4 h30 - 60 cc q 6 - 8 hr 240 - 400 cc q 4 hr 58 Formulas Kcal/cc PRO (gm/cc) FAT (gm/cc) CHO (gm/cc) Comments Human Milk .67.011.040 .068Vitamin D supplement required Standard Enfamil 20.67.015.038.069whey:casein ratio 60:40 Enfamil 24.80.018.045.084whey:casein ratio 60:40 Similac 20.67.015.036.072whey:casein ratio 48:52 Similac 24.80.022.043.085whey:casein ratio 48:52 Lactofree .67.015.037 .069milk-based, for lactose intolerance Soy Prosobee.67.020.036.068for milk protein allergy; lactose intolerance Isomil .67 .018 .037 .068for milk protein allergy; lactose intolerance Specialized Pregestimil.67.019.028.091for generalized malabsorption Portagen.67.022.030.074for long chain fatty acid malabsorption Nutramigen.67.019.026.090for allergy to intact milk Ca:Phos ratio similar to human milk Preterm Enfamil Premature.80.024.041.089for preterm infants below 2000 grams EnfaCare.73 .020.039 .078 discharge preterm formula for 1st year Pediatric Enteral Kindercal1.06.034.044.135for children 1-10 years: contains fiber PediaSure1.0 .030.050 .110 for children 1-10 years of age 59 病例 n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 ml +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: n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 n血常规:WBC 8.8 x 109/L, N 0.3 L0.68 HB108g/L n 尿常规:蛋白阳性，酮体+，糖阴性。 n便常规:潜血(十十)。 n肝功:谷草转氨酶45 u/L，血尿素氮6.8mmol/L。 n动脉血气:pH 7.36, PaCO22.1kPa PaO213kPa， HCO310mmol/L, n电解质：钠140mmol/L，钾3.5 mmol/L，氯 110mmol/L 辅助检查: 62 入院诊断: n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 n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。 n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 n入院第一天补液，患儿体重26kg，入 液量为1000+500+1201620ml n高热增加30，脑水肿时减30。 n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, n留200ml备用。热卡：26*25650kal n n 糖糖6060：650*0.55650*0.55357kal357kal n n 相当于糖：相当于糖：357/4357/490g90g n n 脂肪：脂肪：650*0.3650*0.3195kal195kal n n 相当于脂肪：相当于脂肪：195/9195/921g21g n n 2020FATFAT100ml100ml n n 氨基酸：氨基酸：650*0.15650*0.1597.5kal97.5kal n n 相当于：相当于：97.5/497.5/423g23g n n 6.256.25aa:=360mlaa:=360ml 65 66 静脉营养 n剩余液1210(1620一200一210) ml: n6.25%复合氨基酸360 ml (0.9g/kd.d); n20%脂肪乳100ml(0.78g/kd.d); n水乐维他10ml，维他利匹特10 ml,安达美 10ml; n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; n 50%葡萄糖( ml)二 (360+100+10x3+36+36 )/4=140m1 n余量1210-562-140500 ml，由10%葡萄糖 补充。 n n 热卡热卡480+90+180=750kal480+90+180=750kal n n 糖糖4*4*（500*10500*10+140*50+140*50） 480kal480kal n n 蛋白蛋白=4*6.25%*360=90kal=4*6.25%*360=90kal n n 脂肪脂肪=9*20%*100=180kal=9*20%*100=180kal n n 750/26=28kal/kg750/26=28kal/kg n n 液：热液：热1620/7501620/7502.12.1 n n 氮：热氮：热22.5/6.25/66022.5/6.25/6601 1：183183 67 n n 糖浓度糖浓度120/1210*100120/1210*10010.10. n n 糖速糖速120*1000/24/26/60120*1000/24/26/60 120000/37440120000/374403.2mg/kg.min3.2mg/kg.min 68 例例2 2 n n 10kg NEC10kg NEC患儿入院第二天，胃肠减压患儿入院第二天，胃肠减压 出黄绿色液体出黄绿色液体100ml100ml，血钠，血钠120mmol/L120mmol/L ，血糖：，血糖：2.1mmol/L2.1mmol/L，血气：，血气：PHPH：7.537.53 ，HCO3:34mmol/LHCO3:34mmol/L，BE:10mmol/LBE:10mmol/L， 如何进行如何进行TPNTPN。 69 n n 1 1，纠正低血糖：，纠正低血糖：5050GS 1ml/kg.GS 1ml/kg.稀释稀释1 1倍后缓慢倍后缓慢 静脉注射。静脉注射。 n n 2.2.用生理盐水补充胃肠引流量：用生理盐水补充胃肠引流量： NS NS：100ml100ml n n 3.3.补酸：补酸： 25%盐酸精氨酸（ml ) = ABE x体重 (kg)x0.8 x0.3=10X10x0.24 = 24ml，先给半量 10ml。 n4.补钠:10氯化钠： n（135-120）*1.2*10/3.3/227ml. n稀释成3.3（加注射用水63ml）后微泵注入。 70 71 n入院第二天补液，患儿体重10kg，总 入液量为1000ml， n留150ml备用。 n暂定热卡：10*30kal300kal n n 糖糖6060：300*0.55300*0.55165kal165kal n n 相当于糖：相当于糖：165/4165/441g41g n n 脂肪：脂肪：300*0.3300*0.390kal90kal n n 相当于脂肪：相当于脂肪：90/990/910g10g n n 2020FATFAT50ml50ml n n 氨基酸：氨基酸：300*0.15300*0.1545kal45kal n n 相当于相当于AAAA：45/445/411g11g n n 6.256.25aa:=200mlaa:=200ml 72 73 静脉营养 n剩余液750(1000一150-100) ml: n6.25%复合氨基酸200 ml (1.2g/kd.d); n20%脂肪乳50ml(1g/kd.d); n水乐维他10ml，维他利匹特10 ml,安达美 5ml; n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)=75