医学课件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12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营养支持为何重要危重病+差的营养＝？34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％ImpactofstarvationNegativenitrogenbalance,furtherwtlossMorphologicalchangesinthegut(Mucosalthickness,CellproliferationandVillusheight)Functionalchanges(Increasedpermeability&Decreasedabsorptionofaminoacids)Enzymatic/HormonalchangesDecreasedsucraseandlactaseImpactonimmunityCellular:DecreasedTcells,atrophiedgerminalcenters,mitogenicproliferation,differentiation,Thcellfunction,alteredhomingHumoral:Complement,opsonins,Ig,secretoryIgA(70-80%ofallIgproducedissecretoryIgA)Increasedbacterialtranslocation56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？78急性蛋白质能量营养不良APEM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WhenshouldnutritionsupportbestartedinthePICU?10营养评估既往史体检饮食史实验室检验11NutritionFocusedAssessmentPastmedicalhistoryasitimpactsnutritionalstatusandoutcomesAnthropometricmeasures:weight,length,headcircumference(forchildren<3yearsofage)Dietaryintakehistory:asavailablefromparentsorprimarycaretakers,historyoffeedingproblems,lossofappetite,recentweightlossLaboratoryvalues:CHEM-10,totalprotein/albumin,asavailableNutritionbasedexamtoidentifynutritiondeficiencylesionsHistoryofandneedforfurthernutritioneducationforspecializedformulaordiet.12childrenatincreasednutritionalriskHypermetabolicstates:trauma:closedheadinjury,spinalcordinjuryPost-surgicalpatientsCardiorespiratoryillness:congenitalheartdefects,bronchopulmonarydysplasia,cysticfibrosisGastrointestinaldiseaseanddysfunction:shortgutsyndrome,exacerbationofinflammatoryboweldiseasewithhistoryofPEM,hepaticfailure,biliaryatresia,pancreatitisNeurologic,musculardisease:geneticsyndromes,Guillan-Barre',musculardystrophy,historyofCP/MRrequiringG-tubefeedings13IndicationsforNutritionSupportinthePICU:AllPICUpatientswillbescreenedbythePICUnutritionistwithin72hoursofadmissiontodetermineiftheyareatnutritionriskorinneedofnutritionsupportviatheenteralorparenteralroute.14如何进行？

经肠道还是全静脉？

1516TPN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→EN17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始（B级）（预计5－7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18DeterminingCalorieandProteinNeedsEstimatebasalenergyneeds(BEE)-RefertoTable1DetermineStressFactor-RefertoTable2

TotalCalories=BEEXStressFactor

Estimatepatient'sproteinrequirements-RefertoRDAs-Table3

TotalProtein=ProteinRDAsXStressFactor

Continuetoevaluateandadjustrecommendationsbasedonnutritionmonitoring.19CalculationofCatch-UpGrowthintheTermInfantandChildKcal/kg=RDA(kcal/kg)forweightage*xIdealweight(kg)**/Actualweight*Ageatwhichpresentweightisatthe50th%-ile

**50th%-ileforageoridealbodyweightforheight20Table1.BasalEnergyNeedsforInfantsandChildren

21Age1wkto10moAge11to36moAge3to16yrMetabolicRateMetabolicRateMetabolicRateWeight(kcal/day)Weight(kcal/day)Weight(kcal/day)(kg)MaleorFemaleMaleFemale(kg)MaleFemale3.52029.0528509158597994.02289.5547528209538984.525210.05665472510469965.027810.558656630113910925.530511.060558635123111906.033111.562460540132512896.535812.064362445141813877.038412.566264650151214867.541013.068266555160615848.043713.570168460169916808.546314.072070365179317769.049014.573972270188618749.551415.0758741751980197310.054015.577876010.556616.079778211.059316.5816802BACKTable2.DeterminingStressFactor22ClinicalConditionStressFactorMaintenancewithoutStress

Fever

Routine/electivesurgery,minorsepsis

Cardiacfailure

Majorsurgery

Sepsis

Catch-upGrowth

Traumaorheadinjury1.0-1.2

12%perdegree>37C

1.1-1.3

1.25-1.5

1.2-1.4

1.4-1.5

1.5-2.0

1.5-1.7BACKTable3.RecommendedDietaryAllowancesforInfantsandChildren

23

AgeWeightHeightCaloriesProteinFluid

(years)(kg)(lbs)(cm)(in)(kcal/kg)(gm/kg)(ml/kg)Infants0.0-0.561360241082.2140-1600.5-1.09207128981.5125-145Children1-3132990351021.23115-1254-6204411244901.290-1107-10286213252701.070-85Males11-14459915762551.070-8515-186614517669450.850-60Females11-144610115762471.070-8515-185512016364400.850-60BACK24能量供应20kal×Wt50kal×Wt100kal×Wt>20Kg部分第二个10Kg第一个10Kg胃肠外营养支持期间热卡推荐量(kcal/d)体温每增高1°C,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%;烧伤时需增加100%。

25StageClinicalGoalsHospitalDayNutritionalTargetsIFluidResuscitation&restoretissueperfusion.Day#1to2Fluidandelectrolytemanagement.IIMetabolicResuscitation:limitproteincatabolism&elevatedglucoselevels;HypermetabolicphasewhichmaycontinuewithinfectionDay#2to9AchieveBEEforenergywithsignificantproteinsource;NextstepprogresstoBEEXstressfactor(Table1&Table2)astolerated.IINutritionalRecovery-recoveryrepletion,increasingactivityandgrowthDay#7to10andbeyondFulltargetsatBEEXinjuryfactororevenhigherusingRDAtable(Table3)orcatch-upgrowthoncestresssubsidesandgrowthresumes.

Forinfants&malnourishedInitiatenutritionbyDay#3AchieveBEEXStressfactorbyDay#5-6.

Forolderchildren&goodnutritionalstatuspriortoadmissionInitiatenutritionbyDay#3-5.AchieveBEEXStressfactorbyDay#5-8.NutritionalSupportTargetsforthePICUPatient26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，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，约相当于氮；热氮比100－150kcal:1gN（B级）Fat30-35%G.S50%Protein15-20%能量分配ComplicationsofoverfeedingExcessCO2production&increasedminuteventilationPulmonaryedema&respiratoryfailureHyperglycemia,whichmayincreaseinfectionratesLipogenesisduetoincreasedinsulinproductionImmunosuppressionHepaticcomplications:fattyliver,intrahepaticcholestasis2728对于不活动的重症患者能量消耗“允许性低热卡”29水与电解质碳水化合物脂肪蛋白质维生素微量元素MacronutrientsMicronutrients营养底物Nutrients碳水化合物（葡萄糖）Dextrose-BeginPNat10-15%dextrose.Advanceby2.5-5%inolderinfantsandchildrenandby5-10%perdayinadolescentsuntilanendpointofD12.5%dextroseforPPNorgenerallybetween20-25%dextroseforCPN,asneededtomeetnutritionalneeds.Provisionofexcesscarbohydratecaloriesmayleadtothefollowingadverseeffects:hyperglycemia,hepatotoxicity,cholestasis,glycosuria,osmoticdiuresisInsulinUse-Ageneralguidelineisadditionof1unitofregularinsulinper10gramsofcarbohydratecalories.3031碳水化合物（葡萄糖）葡萄糖输注速率开始可逐渐增至6-7mg/kg.min;使用小剂量外源性胰岛素时葡萄糖输注速率可达。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：从开始,每1～2天增加0.5g/kg,总量不超过。输注速度20%脂肪乳剂的试验速率为。特别注意：危重疾病肾衰竭检查：脂肪廓清等血脂代谢血浆TG（max：3-4mmol/l）34蛋白质/氨基酸（氮）首次：，每日可增加，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ω-3FA（FO）－炎症反应调控RecommendedIntakeCalcium

(mEq/kg)Phosphorus

(mEq/kg)Preterm,TermInfants3.0-4.03.0-4.0OlderChildren(10-40kg)1.0-31.0-3Adolescents(>40kg)1.0-1.51.0-1.536RecommendedParenteralCalcium&PhosphorusIntakeParenteralElectrolyte&Vitamin/MineralGuidelinesinPediatricPatients37ElectrolyteorNutrientPretermInfantsTermInfantsChildrenandAdolescentsSodium(mEq)2.0-6.0(average3.0)mEq/kg2-4mEq/100mlPotassium(mEq)2.0-6.0(average3.0)mEq/kg2-3mEq/100mlChloride(mEq)2.0-8.0(average4.0)mEq/kg2-3mEq/100mlCalcium(mEq)2-4mEq/kg0.5-2mEq/100mlPhosphate(mEq)1.5-3mEq/kg1.5-2.5mEq/100mlMagnesium(mEq)0.2502.0(average1.0)mEq/kg0.3-0.5mEq/100mlMVI-Pediatric

<2.5kg2cc/kg/day>2.5kg5cc/dayPTESSolution0.2cc/kg/day(upto1cc)>40kg,usATESSelenium(mcg)1-2mcg/kg/dayMVIPediatricSolutioncontainsper5ml38VitaminContentAscorbicAcid80mgVitaminA2300IUVitaminD400IUThiamine(B1)1.2mgRoboflavin(B2)1.4mgPyridoxine(B6)1mgNiacinamide17mgPantothenicacid5mgVitaminE7IUFolicAcid140mcgVitaminB121mcgBiotin20mcgVitaminK0.2mgPediatricTraceElementSolution(PTES)per0.2ml39Zinc300mcgCopper20mcgChromium0.17mcgManganese5mcgNutrientRequirementsinPulmonaryFailureCalories:don’toverfeedwhenweaningtopreventincreasedCO2production(Provide25-30kcal/kgorrestingenergyexpenditure)Protein:1.5-2g/kgAminoacidsmayincreaseventilation,increaseO2consumption.Fat:OMEGA3FAmaybeanti-inflammatoryandalterimmunestatusinsepsis/ARDS40NutrientRequirementsinliverFailureCalories:caloricrequirementsaffectedbyacutenessofdisease,seriousnessofinjury,absorption,otherorganfailure,sepsis;25-35kcals/kgorREEProtein:wellnourished/lowstress:.8g/kg;malnourished/withmetabolicstress:upto1.5g/kgCHO:~70%non-proteincalories;inacutefailure,mayneedcontinuousglucoseinfusionChronic:mayhavediabetes/hypoglycemiarequiringcontrolledCHOandinsulin;insepticptshypoglycemiaoccursin50%ofcirrhoticsFAT:30%non-proteincalories;MCTmaybehelpfulwithLCTmalabsorption41NutrientNeedsinMODSCalories:35kcal/kgorREEProtein:upto1.5-2.0g/kgFat:30%nonproteincalories;↑MCTifbilesaltdeficient;N3vsN6Micronutrients:evaluateindividuallyFluid:basedonfluidstatus42NutritionImplicationsofARFARFcausesanorexia,nausea,vomiting,bleedingARFcausesrapidnitrogenlossandleanbodymassloss(hypercatabolism)ARFcauses↑gluconeogenesiswithinsulinresistanceDialysiscauseslossofaminoacidsandproteinUremiatoxinscauseimpairedglucoseutilizationandproteinsynthesisImpairedConversionandresultantdeficienciesofGly,Ala(Tubularprotectant)&Arg(Preservesrenalperfusion)……..AASupplementationhelpsrenalperfusionandGFRanddiuresis.4344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。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:InfectionHepaticdysfunctionMetaboliccomplications:hyperglycemia,hypoglycemia,acidosis,hypomagnesemia,hyperlipidemia,hypocalcemiaTracemetaldeficienciesMechanicalcomplications:dysrrhythmias,venousthrombosis,airembolism&skinsloughsBilirubindisplacementbyintralipid46Monitoring:DailyweightRoutinenursingobservationsLaboratoryinvestigations:-CBC-Urine(sugar,acetone)-Electrolytes-Transaminases,alkalinephosphataseandbilirubinlevels-Urea&creatinine-LipidlevelsFatinfusionshouldbestopped2-4hoursbeforetakingbloodsamples(8hoursforlipidtests)4748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/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2005,549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肠内营养选择原则：如肠道具有功能，应首选经肠喂养BUT:“Alltheroutesareabnormal.Doingitbadlyorpoorlyaddsrisks.”－GriffthsGR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Benefitsofenteralnutritioninpediatricpatientsinclude:PhysiologicalpresentationofnutrientsTrophiceffectsontheGItractStimulationandmaintenanceofthegutmucosaReducedmetabolicandinfectiouscomplicationsImprovedhepaticfunctionversusparenteralnutritionSimplifiedfluidandelectrolytemanagementMore"complete"nutritionMayreducetheincidenceofpathogenentryorbacterialtranslocationintotheperitonealcavityorcirculationLessexpensive51PatientFactorsFormulaFactorsAge

Diagnosis

Associatednutritionalproblems

Nutritionalrequirements

GastrointestinalfunctionOsmolality

Renalsoluteload

Caloricdensityandviscosity

Nutrientcomposition:type&amountofCHO,Fatandprotein

Productavailabilityandcost5253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2006－ESPENguidelinesonENinICU2006－CanadaGuideline24～48hrs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DeJongheBetal.CCM.200129:204MontejoJCetal.CCM.1999;27:1447MentecHetal.CCM.2001;29:195555EN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56Age/WeightInitialInfusionRateDailyIncreasesGoalRate2.0-15kg2-15cc/hr

(1cc/kg/hr)2-15cc/hrq4-8hr

(1cc/kg)15-55cc/hr16-30kg8-25cc/hr

(0.5-1cc/kg/hr)8-16cc/hrq4-8hr

(0.5cc/kg)45-90cc/hr30-50kg15-25cc/hr

(0.5cc/kg/hr)15-25cc/hrq4-8hr

(0.5cc/kg)70-130cc/hr>50kg25cc/hr25cc/hrq4-8hr90-150cc/hrIntermittentTubeFeedingProgression57Age/WeightInitialVolumesDailyIncreasesGoalVolume2.0-15kg5-30ccq3-4hr5-30ccq6-8hr50-200q4hr12-30kg20-60ccq4hr20-60ccq6-8hr150-350ccq4hr30kg30-60ccq4h30-60ccq6-8hr240-400ccq4hr58

FormulasKcal/ccPRO

(gm/cc)FAT

(gm/cc)CHO

(gm/cc)CommentsHumanMilk.67.011.040.068VitaminDsupplementrequiredStandard

Enfamil20.67.015.038.069whey:caseinratio60:40Enfamil24.80.018.045.084whey:caseinratio60:40Similac20.67.015.036.072whey:caseinratio48:52Similac24.80.022.043.085whey:caseinratio48:52Lactofree.67.015.037.069milk-based,forlactoseintoleranceSoy

Prosobee.67.020.036.068formilkproteinallergy;lactoseintoleranceIsomil.67.018.037.068formilkproteinallergy;lactoseintoleranceSpecialized

Pregestimil.67.019.028.091forgeneralizedmalabsorptionPortagen.67.022.030.074forlongchainfattyacidmalabsorptionNutramigen.67.019.026.090forallergytointactmilk&soyproteinAlimentum.67.019.038.068forgeneralizedmalabsorptionSimilacPM60/40.67.016.038.069lowRSL;Ca:PhosratiosimilartohumanmilkPretermEnfamilPremature.80.024.041.089forpreterminfantsbelow2000gramsEnfaCare.73.020.039.078dischargepretermformulafor1styearPediatricEnteral

Kindercal1.06.034.044.135forchildren1-10years:containsfiberPediaSure1.0.030.050.110forchildren1-10yearsofage59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oC，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500ml+能量合剂，每日一次静点，penicilin320万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，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:WBC8.8x109/L,N0.3L0.68HB108g/L尿常规:蛋白阳性，酮体+，糖阴性。便常规:潜血(十十)。肝功:谷草转氨酶45u/L，血尿素氮。动脉血气:pH7.36,PaCO22.1kPaPaO213kPa，HCO310mmol/L,电解质：钠140mmol/L，钾3.5mmol/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+500+120＝1620ml高热增加30％，脑水肿时减30％。纠酸：5%碳酸氢钠（ml)=ABEx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*25＝650kal糖60％：＝357kal相当于糖：357/4＝90g脂肪：＝195kal相当于脂肪：195/9＝21g20％FAT＝100ml氨基酸：＝相当于：＝23g％aa:=360ml6566静脉营养剩余液1210(1620一200一210)ml:①6.25%复合氨基酸