危重患兒的營(yíng)養(yǎng)支持課件

危重患兒的營(yíng)養(yǎng)支持昆明市兒童醫(yī)院PICU李斌危重患兒的營(yíng)養(yǎng)支持昆明市兒童醫(yī)院PICU李斌2營(yíng)養(yǎng)支持在危重病人中的應(yīng)用營(yíng)養(yǎng)不良與危重癥關(guān)系1危重癥營(yíng)養(yǎng)支持原則2不良影響與監(jiān)測(cè)3營(yíng)養(yǎng)支持的實(shí)施42營(yíng)養(yǎng)支持在危重病人中的應(yīng)用營(yíng)養(yǎng)不良與危重癥關(guān)系1危重癥營(yíng)養(yǎng)營(yíng)養(yǎng)支持為何重要危重病+差的營(yíng)養(yǎng)＝？3營(yíng)養(yǎng)支持為何重要危重病+差的營(yíng)養(yǎng)＝？34營(yíng)養(yǎng)不良與危重癥的關(guān)系危重患兒發(fā)生營(yíng)養(yǎng)不良是常見(jiàn)的臨床現(xiàn)象.16-20%患兒入院48小時(shí)內(nèi)存在主要營(yíng)養(yǎng)物質(zhì)不良.60%有低蛋白血癥人體測(cè)量結(jié)果：72％，主觀判斷46％4營(yíng)養(yǎng)不良與危重癥的關(guān)系危重患兒發(fā)生營(yíng)養(yǎng)不良是常見(jiàn)的臨床現(xiàn)象ImpactofstarvationNegativenitrogenbalance,furtherwtlossMorphologicalchangesinthegut(Mucosalthickness,CellproliferationandVillusheight)Functionalchanges(Increasedpermeability&Decreasedabsorptionofaminoacids)Enzymatic/HormonalchangesDecreasedsucraseandlactaseImpactonimmunityCellular:DecreasedTcells,atrophiedgerminalcenters,mitogenicproliferation,differentiation,Thcellfunction,alteredhomingHumoral:Complement,opsonins,Ig,secretoryIgA(70-80%ofallIgproducedissecretoryIgA)Increasedbacterialtranslocation5ImpactofstarvationNegative6預(yù)后體重下降35-40%，病死率接近100%危重病+差的營(yíng)養(yǎng)＝？6預(yù)后體重下降35-40%，病死率接近100%危重病+差的營(yíng)為何會(huì)發(fā)生急性蛋白質(zhì)能量營(yíng)養(yǎng)不良？7為何會(huì)發(fā)生急性蛋白質(zhì)能量營(yíng)養(yǎng)不良？78急性蛋白質(zhì)能量營(yíng)養(yǎng)不良APEM基礎(chǔ)代謝率明顯增加應(yīng)激高分解狀態(tài)營(yíng)養(yǎng)素需求增加丟失過(guò)多攝入不足基礎(chǔ)疾病8急性蛋白質(zhì)能量營(yíng)養(yǎng)不良APEM基礎(chǔ)代謝率明顯增加應(yīng)激高分解9代謝病理糖元分解糖異生糖利用降低血糖增加蛋白分解糖異生負(fù)氮平衡優(yōu)先動(dòng)用FFA↑TG↑糖蛋白脂肪9代謝病理糖元分解蛋白分解優(yōu)先動(dòng)用糖蛋白脂肪W(wǎng)henshouldnutritionsupportbestartedinthePICU?10Whenshouldnutritionsupport營(yíng)養(yǎng)評(píng)估既往史體檢飲食史實(shí)驗(yàn)室檢驗(yàn)11營(yíng)養(yǎng)評(píng)估既往史11NutritionFocusedAssessmentPastmedicalhistoryasitimpactsnutritionalstatusandoutcomesAnthropometricmeasures:weight,length,headcircumference(forchildren<3yearsofage)Dietaryintakehistory:asavailablefromparentsorprimarycaretakers,historyoffeedingproblems,lossofappetite,recentweightlossLaboratoryvalues:CHEM-10,totalprotein/albumin,asavailableNutritionbasedexamtoidentifynutritiondeficiencylesionsHistoryofandneedforfurthernutritioneducationforspecializedformulaordiet.12NutritionFocusedAssessmentPachildrenatincreasednutritionalriskHypermetabolicstates:trauma:closedheadinjury,spinalcordinjuryPost-surgicalpatientsCardiorespiratoryillness:congenitalheartdefects,bronchopulmonarydysplasia,cysticfibrosisGastrointestinaldiseaseanddysfunction:shortgutsyndrome,exacerbationofinflammatoryboweldiseasewithhistoryofPEM,hepaticfailure,biliaryatresia,pancreatitisNeurologic,musculardisease:geneticsyndromes,Guillan-Barre',musculardystrophy,historyofCP/MRrequiringG-tubefeedings13childrenatincreasednutritioIndicationsforNutritionSupportinthePICU:AllPICUpatientswillbescreenedbythePICUnutritionistwithin72hoursofadmissiontodetermineiftheyareatnutritionriskorinneedofnutritionsupportviatheenteralorparenteralroute.14IndicationsforNutritionSupp如何進(jìn)行？

經(jīng)腸道還是全靜脈？

15如何進(jìn)行？

經(jīng)腸道還是全靜脈？

1516TPN適應(yīng)癥胃腸道功能障礙的重癥患兒；手術(shù)或解剖問(wèn)題胃腸道禁止使用的重癥患兒；存在有尚未控制的腹部情況，如腹腔感染、腸梗阻、腸瘺等。早期復(fù)蘇階段、血流動(dòng)力學(xué)尚未穩(wěn)定或存在嚴(yán)重水電介質(zhì)與酸堿失衡；嚴(yán)重肝功能衰竭，肝性腦??；急性腎功能衰竭存在嚴(yán)重氮質(zhì)血癥；嚴(yán)重高血糖尚未控制。相對(duì)禁忌GI解剖、功能良好，具備腸道喂養(yǎng)通路→EN16TPN適應(yīng)癥胃腸道功能障礙的重癥患兒；早期復(fù)蘇階段、血流17危重病人營(yíng)養(yǎng)支持時(shí)機(jī)選擇重癥病人常合并代謝紊亂與營(yíng)養(yǎng)不良，需要給予營(yíng)養(yǎng)支持（C級(jí)）重癥病人的營(yíng)養(yǎng)支持應(yīng)盡早開(kāi)始（B級(jí)）（預(yù)計(jì)5－7天內(nèi)不能經(jīng)口攝食者應(yīng)及早開(kāi)始營(yíng)養(yǎng)支持）17危重病人營(yíng)養(yǎng)支持時(shí)機(jī)選擇重癥病人常合并代謝紊亂與營(yíng)養(yǎng)不良如可進(jìn)行？熱量及營(yíng)養(yǎng)素的分配18如可進(jìn)行？熱量及營(yíng)養(yǎng)素的分配18DeterminingCalorieandProteinNeedsEstimatebasalenergyneeds(BEE)-RefertoTable1DetermineStressFactor-RefertoTable2

TotalCalories=BEEXStressFactor

Estimatepatient'sproteinrequirements-RefertoRDAs-Table3

TotalProtein=ProteinRDAsXStressFactor

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

**50th%-ileforageoridealbodyweightforheight20CalculationofCatch-UpGrowthTable1.BasalEnergyNeedsforInfantsandChildren

21Age1wkto10moAge11to36moAge3to16yrMetabolicRateMetabolicRateMetabolicRateWeight(kcal/day)Weight(kcal/day)Weight(kcal/day)(kg)MaleorFemaleMaleFemale(kg)MaleFemale3.52029.0528509158597994.02289.5547528209538984.525210.05665472510469965.027810.558656630113910925.530511.060558635123111906.033111.562460540132512896.535812.064362445141813877.038412.566264650151214867.541013.068266555160615848.043713.570168460169916808.546314.072070365179317769.049014.573972270188618749.551415.0758741751980197310.054015.577876010.556616.079778211.059316.5816802BACKTable1.BasalEnergyNeedsfoTable2.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

1.5-1.7BACKTable2.DeterminingStressFaTable3.RecommendedDietaryAllowancesforInfantsandChildren

23

AgeWeightHeightCaloriesProteinFluid

(years)(kg)(lbs)(cm)(in)(kcal/kg)(gm/kg)(ml/kg)Infants0.0-0.561360241082.2140-1600.5-1.09207128981.5125-145Children1-3132990351021.23115-1254-6204411244901.290-1107-10286213252701.070-85Males11-14459915762551.070-8515-186614517669450.850-60Females11-144610115762471.070-8515-185512016364400.850-60BACKTable3.RecommendedDietaryA24能量供應(yīng)20kal×Wt50kal×Wt100kal×Wt>20Kg部分第二個(gè)10Kg第一個(gè)10Kg胃腸外營(yíng)養(yǎng)支持期間熱卡推薦量(kcal/d)體溫每增高1°C,熱量需增加12%;心力衰竭時(shí)需增加5-25%;大手術(shù)時(shí)需增加20-30%;嚴(yán)重?cái)⊙Y時(shí)需增加40-60%;燒傷時(shí)需增加100%。

24能量供應(yīng)20kal×Wt50kal×Wt100kal×W25StageClinicalGoalsHospitalDayNutritionalTargetsIFluidResuscitation&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.NutritionalSupportTargetsforthePICUPatient25StageClinicalGoalsHospital26危重病人的營(yíng)養(yǎng)供給原則葡萄糖：一般占非蛋白質(zhì)熱卡的50-60％，應(yīng)根據(jù)糖代謝狀態(tài)進(jìn)行調(diào)整（C級(jí)）脂肪：一般為非蛋白質(zhì)熱卡的40％-50％；攝入量可達(dá)1-1.5g/kg.d，應(yīng)根據(jù)血脂廓清能力進(jìn)行調(diào)整，脂肪乳劑應(yīng)勻速緩慢輸注（B級(jí)）蛋白質(zhì)：供給量一般為1.2-1.5g/kg.day，約相當(dāng)于氮0.20-0.25g/kg.day；熱氮比100－150kcal:1gN（B級(jí)）Fat30-35%G.S50%Protein15-20%能量分配26危重病人的營(yíng)養(yǎng)供給原則葡萄糖：一般占非蛋白質(zhì)熱卡的50-ComplicationsofoverfeedingExcessCO2production&increasedminuteventilationPulmonaryedema&respiratoryfailureHyperglycemia,whichmayincreaseinfectionratesLipogenesisduetoincreasedinsulinproductionImmunosuppressionHepaticcomplications:fattyliver,intrahepaticcholestasis27ComplicationsofoverfeedingEx28對(duì)于不活動(dòng)的重癥患者能量消耗“允許性低熱卡”28對(duì)于不活動(dòng)的重癥患者能量消耗“允許性低熱卡”29水與電解質(zhì)碳水化合物脂肪蛋白質(zhì)維生素微量元素MacronutrientsMicronutrients營(yíng)養(yǎng)底物Nutrients29水與電解質(zhì)碳水化合物脂肪蛋白質(zhì)維生素微碳水化合物（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.30碳水化合物（葡萄糖）Dextrose-BeginPN31碳水化合物（葡萄糖）葡萄糖輸注速率3-4mg/kg.min開(kāi)始可逐漸增至6-7mg/kg.min;使用小劑量外源性胰島素時(shí)葡萄糖輸注速率可達(dá)9mg/kg.min。31碳水化合物（葡萄糖）葡萄糖輸注速率3-4mg/kg.32腸外營(yíng)養(yǎng)：脂肪乳脂肪乳是等滲的，單位體積含熱卡量高脂肪乳和葡萄糖組成的雙重能量系統(tǒng)比單一能量系統(tǒng)代謝更為有效，達(dá)到氮平衡所消耗的能量相對(duì)較少，與葡萄糖同時(shí)應(yīng)用具有更好的節(jié)氮效應(yīng)補(bǔ)充必需脂肪酸，防止EFA的缺乏↑CO2產(chǎn)生減少，RQ減輕32腸外營(yíng)養(yǎng)：脂肪乳脂肪乳是等滲的，單位體積含熱卡量高33脂肪乳劑脂肪推薦攝入量：占總攝入熱量的30-40％用量：從0.5-1.0g/kg.d開(kāi)始,每1～2天增加0.5g/kg,總量不超過(guò)3.5-4g/kg.d。輸注速度20%脂肪乳劑的試驗(yàn)速率為0.05ml/kg.min。特別注意：危重疾病腎衰竭檢查：脂肪廓清等血脂代謝血漿TG（max：3-4mmol/l）33脂肪乳劑脂肪推薦攝入量：占總攝入熱量的30-40％34蛋白質(zhì)/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營(yíng)養(yǎng)液中所含氨基酸的氮量(g)與非蛋白熱卡(kcal)之比最好為1:150-200穩(wěn)定持續(xù)、優(yōu)化的蛋白質(zhì)補(bǔ)充是營(yíng)養(yǎng)支持的重要策略34蛋白質(zhì)/氨基酸（氮）首次：0.5-1.0g/kg.d，35發(fā)揮特殊營(yíng)養(yǎng)素的藥理作用Glutamine－免疫增強(qiáng)ω-3FA（FO）－炎癥反應(yīng)調(diào)控35發(fā)揮特殊營(yíng)養(yǎng)素的藥理作用Glutamine－免疫增強(qiáng)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&PhosphorusIntakeRecommendedIntakeCalcium

(mParenteralElectrolyte&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/dayParenteralElectrolyte&VitamMVIPediatricSolutioncontainsper5ml38VitaminContentAscorbicAcid80mgVitaminA2300IUVitaminD400IUThiamine(B1)1.2mgRoboflavin(B2)1.4mgPyridoxine(B6)1mgNiacinamide17mgPantothenicacid5mgVitaminE7IUFolicAcid140mcgVitaminB121mcgBiotin20mcgVitaminK0.2mgMVIPediatricSolutioncontainPediatricTraceElementSolution(PTES)per0.2ml39Zinc300mcgCopper20mcgChromium0.17mcgManganese5mcgPediatricTraceElementSolutiNutrientRequirementsinPulmonaryFailureCalories:don’toverfeedwhenweaningtopreventincreasedCO2production(Provide25-30kcal/kgorrestingenergyexpenditure)Protein:1.5-2g/kgAminoacidsmayincreaseventilation,increaseO2consumption.Fat:OMEGA3FAmaybeanti-inflammatoryandalterimmunestatusinsepsis/ARDS40NutrientRequirementsinPulmoNutrientRequirementsinliverFailureCalories: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;MCTmaybehelpfulwithLCTmalabsorption41NutrientRequirementsinliverNutrientNeedsinMODSCalories:35kcal/kgorREEProtein:upto1.5-2.0g/kgFat:30%nonproteincalories;↑MCTifbilesaltdeficient;N3vsN6Micronutrients:evaluateindividuallyFluid:basedonfluidstatus42NutrientNeedsinMODSCalorieNutritionImplicationsofARFARFcausesanorexia,nausea,vomiting,bleedingARFcausesrapidnitrogenlossandleanbodymassloss(hypercatabolism)ARFcauses↑gluconeogenesiswithinsulinresistanceDialysiscauseslossofaminoacidsandproteinUremiatoxinscauseimpairedglucoseutilizationandproteinsynthesisImpairedConversionandresultantdeficienciesofGly,Ala(Tubularprotectant)&Arg(Preservesrenalperfusion)……..AASupplementationhelpsrenalperfusionandGFRanddiuresis.43NutritionImplicationsofARF44完全胃腸外營(yíng)養(yǎng)的途徑操作方便且全身繼發(fā)感染的危險(xiǎn)性小。輸注葡萄糖的最高濃度為12.5%完全胃腸外營(yíng)養(yǎng)的患兒?jiǎn)慰客庵莒o脈途徑很難在單位時(shí)間內(nèi)提供足夠的液體及熱量維持靜脈輸液時(shí)間短?？墒褂渺o脈套管針延長(zhǎng)了穿刺靜脈使用的時(shí)間。經(jīng)外周靜脈途徑的胃腸外營(yíng)養(yǎng)只適用于:1、短期需營(yíng)養(yǎng)支持2、輕度急性蛋白質(zhì)能量營(yíng)養(yǎng)不良患兒的圍手術(shù)期3、不能接受中心靜脈插管4、暫時(shí)不能確定禁食時(shí)間5、使用中心靜脈導(dǎo)管前后6、糖利用障礙的患兒外周靜脈44完全胃腸外營(yíng)養(yǎng)的途徑操作方便經(jīng)外周靜脈途徑的胃腸外營(yíng)養(yǎng)只45中心靜脈:

操作復(fù)雜所需導(dǎo)管價(jià)高易出現(xiàn)機(jī)械合并癥存在全身感染和血栓的危險(xiǎn)可輸入高濃度葡萄糖(>12.5%)；單位時(shí)間內(nèi)可提供較高的熱卡和較大量的液體；中心靜脈開(kāi)放維持時(shí)間長(zhǎng)；液體外滲發(fā)生率低；一般選用頸內(nèi)靜脈、鎖骨下靜脈、大隱靜脈及貴要靜脈放置單腔或多腔中心靜脈導(dǎo)管。45中心靜脈:操作復(fù)雜可輸入高濃度葡萄糖Complications:InfectionHepaticdysfunctionMetaboliccomplications:hyperglycemia,hypoglycemia,acidosis,hypomagnesemia,hyperlipidemia,hypocalcemiaTracemetaldeficienciesMechanicalcomplications:dysrrhythmias,venousthrombosis,airembolism&skinsloughsBilirubindisplacementbyintralipid46Complications:Infection46Monitoring:DailyweightRoutinenursingobservationsLaboratoryinvestigations:-CBC-Urine(sugar,acetone)-Electrolytes-Transaminases,alkalinephosphataseandbilirubinlevels-Urea&creatinine-LipidlevelsFatinfusionshouldbestopped2-4hoursbeforetakingbloodsamples(8hoursforlipidtests)47Monitoring:Dailyweight4748營(yíng)養(yǎng)支持中的血糖控制SSC推薦：感染與感染性休克患者應(yīng)控制血糖≤150mg/dl任何形式的營(yíng)養(yǎng)支持，應(yīng)配合強(qiáng)化胰島素治療，嚴(yán)格控制血糖水平≤150mg/dl并應(yīng)避免低血糖發(fā)生－中華醫(yī)學(xué)會(huì)重癥醫(yī)學(xué)會(huì)2005,548營(yíng)養(yǎng)支持中的血糖控制SSC推薦：感染與感染性休克患者應(yīng)控49胃腸外營(yíng)養(yǎng)的終止原發(fā)病好轉(zhuǎn),考慮恢復(fù)經(jīng)胃腸喂養(yǎng)時(shí),應(yīng)給予胃腸道充分的“復(fù)蘇”時(shí)間及條件?？上冉?jīng)口、經(jīng)胃管或經(jīng)腸管給予等滲葡萄糖液,由1-2ml/kg/次開(kāi)始,每日三次；逐漸增至8次/日;當(dāng)患兒在24小時(shí)內(nèi)耐受量達(dá)20-30ml/kg時(shí),可把喂養(yǎng)液改為2:1稀釋奶,若仍能耐受,繼用1:1稀釋奶,逐漸過(guò)度到全奶。增加胃腸內(nèi)喂養(yǎng)量及喂養(yǎng)液性質(zhì)時(shí),逐漸減少胃腸外營(yíng)養(yǎng)液量;當(dāng)經(jīng)腸喂養(yǎng)量>50ml/kg/d時(shí),即可停用胃腸外營(yíng)養(yǎng)。此交替過(guò)程至少也需一周的時(shí)間。49胃腸外營(yíng)養(yǎng)的終止原發(fā)病好轉(zhuǎn),考慮恢復(fù)經(jīng)胃腸喂養(yǎng)時(shí),應(yīng)給予50腸內(nèi)營(yíng)養(yǎng)選擇原則：如腸道具有功能，應(yīng)首選經(jīng)腸喂養(yǎng)BUT:“Alltheroutesareabnormal.Doingitbadlyorpoorlyaddsrisks.”－GriffthsGR對(duì)仍需要液體復(fù)蘇、內(nèi)臟低灌注仍然存在的危重癥患者暫不宜使用50腸內(nèi)營(yíng)養(yǎng)選擇原則：如腸道具有功能，應(yīng)首選經(jīng)腸喂養(yǎng)Benefitsofenteralnutritioninpediatricpatientsinclude:PhysiologicalpresentationofnutrientsTrophiceffectsontheGItractStimulationandmaintenanceofthegutmucosaReducedmetabolicandinfectiouscomplicationsImprovedhepaticfunctionversusparenteralnutritionSimplifiedfluidandelectrolytemanagementMore"complete"nutritionMayreducetheincidenceofpathogenentryorbacterialtranslocationintotheperitonealcavityorcirculationLessexpensive51BenefitsofenteralnutritionPatientFactorsFormulaFactorsAge

Diagnosis

Associatednutritionalproblems

Nutritionalrequirements

GastrointestinalfunctionOsmolality

Renalsoluteload

Caloricdensityandviscosity

Nutrientcomposition:type&amountofCHO,Fatandprotein

Productavailabilityandcost52PatientFactorsFormulaFactors53腸內(nèi)營(yíng)養(yǎng)時(shí)機(jī)血流動(dòng)力學(xué)穩(wěn)定、具有功能性腸道患者應(yīng)及早開(kāi)始適量的腸內(nèi)營(yíng)養(yǎng)（C）－中華醫(yī)學(xué)會(huì)危重癥分會(huì)2006－ESPENguidelinesonENinICU2006－CanadaGuideline24～48hrs內(nèi)開(kāi)始喂養(yǎng)53腸內(nèi)營(yíng)養(yǎng)時(shí)機(jī)血流動(dòng)力學(xué)穩(wěn)定、具有功能性腸道患者應(yīng)及早開(kāi)始54腸內(nèi)營(yíng)養(yǎng)不耐受EN不耐受的特點(diǎn)胃殘余量過(guò)多惡心，嘔吐腹脹，絞痛腹瀉大約30%~60%ICU病人由于EN不耐受中斷腸內(nèi)營(yíng)養(yǎng)DeJongheBetal.CCM.200129:204MontejoJCetal.CCM.1999;27:1447MentecHetal.CCM.2001;29:195554腸內(nèi)營(yíng)養(yǎng)不耐受EN不耐受的特點(diǎn)DeJongheBe55EN禁忌或不宜應(yīng)用不能進(jìn)食沒(méi)有EN通路未解決的腹部問(wèn)題GI功能腸梗阻嚴(yán)重GI出血梗阻性內(nèi)臟血管疾病，EN可引起或加重腸道缺血嚴(yán)重腹脹：IAH等嚴(yán)重腹脹、腹瀉，處理無(wú)改善－暫停用55EN禁忌或不宜應(yīng)用不能進(jìn)食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/hr56Age/WeightInitialInfusionIntermittentTubeFeedingProgression57Age/WeightInitialVolumesDailyIncreasesGoalVolume2.0-15kg5-30ccq3-4hr5-30ccq6-8hr50-200q4hr12-30kg20-60ccq4hr20-60ccq6-8hr150-350ccq4hr30kg30-60ccq4h30-60ccq6-8hr240-400ccq4hrIntermittentTubeFeedingProg58

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:containsfiberPediaSure1.0.030.050.110forchildren1-10yearsofage58

FormulasKcal/ccPRO

(gm/cc59病例患兒，女，10歲。以發(fā)燒4天，抽搐，昏迷3天為主訴入院。入院前4天發(fā)燒，體溫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，每次持續(xù)3-5分鐘.于抽搐當(dāng)日到當(dāng)?shù)蒯t(yī)院就診，診斷“病毒性腦炎”，給予安定止驚，20%甘露醇150ml，每日二次靜脈推注降顱壓，10%葡萄糖500ml+能量合劑，每日一次靜點(diǎn)，penicilin320萬(wàn)u每日2次靜脈。抽搐無(wú)緩解，且高燒至39-40oC,病后未進(jìn)食，嘔吐咖啡樣物而轉(zhuǎn)我院。59病例患兒，女，10歲。以發(fā)燒4天，抽搐，昏迷3天為主訴入60體格檢查:一般狀差，深昏迷，體重26kg,皮膚彈性差，眼窩凹陷，雙眼瞼閉合不良，雙瞳孔等大，直徑2.5mm，光反應(yīng)遲鈍，雙眼球結(jié)膜水腫，呼吸略深大，呼吸32次/分，雙肺少許干鳴音。心音有力，節(jié)律規(guī)整，心率82次/分。腹部不脹，肝、脾未觸及，腸鳴減弱。四肢肌張力正常，肢端稍涼，雙膝反射減弱，腦膜刺激征陰性。60體格檢查:一般狀差，深昏迷，體重26kg,皮膚彈性差，眼61血常規(guī):WBC8.8x109/L,N0.3L0.68HB108g/L尿常規(guī):蛋白陽(yáng)性，酮體+，糖陰性。便常規(guī):潛血(十十)。肝功:谷草轉(zhuǎn)氨酶45u/L，血尿素氮6.8mmol/L。動(dòng)脈血?dú)?pH7.36,PaCO22.1kPaPaO213kPa，HCO310mmol/L,電解質(zhì)：鈉140mmol/L，鉀3.5mmol/L，氯110mmol/L輔助檢查:61血常規(guī):WBC8.8x109/L,N0.362入院診斷:病毒腦炎、代償性代謝性酸中毒合并呼吸性堿中毒62入院診斷:病毒腦炎、代償性代謝性酸中毒合并呼吸性堿中毒63胃腸外營(yíng)養(yǎng)因患兒入院當(dāng)日處于深昏迷，頻抽，且伴應(yīng)激性消化道出血，不能經(jīng)消化道攝入營(yíng)養(yǎng)，故于入院頭3天給予全胃腸道外營(yíng)養(yǎng)?；純河酗B內(nèi)水腫且伴有脫水，又因高燒不感蒸發(fā)多，采取邊脫邊補(bǔ)原則，在發(fā)病急性期保持患兒處于輕度脫水狀態(tài)，63胃腸外營(yíng)養(yǎng)因患兒入院當(dāng)日處于深昏迷，頻抽，且伴應(yīng)激性消化64入院第一天補(bǔ)液，患兒體重26kg，入液量為1000+500+120＝1620ml高熱增加30％，腦水腫時(shí)減30％。糾酸：5%碳酸氫鈉（ml)=ABEx體重(kg)x0.5=14X26x0.5=182ml，首次給予1/3量(60ml)，用10%葡萄糖稀釋成1.4%碳酸氫鈉210ml,留200ml備用。熱卡：26*25＝650kal64入院第一天補(bǔ)液，患兒體重26kg，入液量為1000+50糖60％：650*0.55＝357kal相當(dāng)于糖：357/4＝90g脂肪：650*0.3＝195kal相當(dāng)于脂肪：195/9＝21g20％FAT＝100ml氨基酸：650*0.15＝97.5kal相當(dāng)于：97.5/4＝23g6.25％aa:=360ml65糖60％：650*0.55＝357kal6566靜脈營(yíng)養(yǎng)剩余液1210(1620一200一210)ml:①6.25%復(fù)合氨基酸360ml(0.9g/kd.d);②20%脂肪乳100ml(0.78g/kd.d);③水樂(lè)維他10ml，維他利匹特10ml,安達(dá)美10ml;④因電解質(zhì)無(wú)明顯紊亂，氯化鈉按0.3%配制，氯化鉀按0.3%配制，所需10%氯化鈉(ml)=1200x3/100=36m1,10%氯化鉀(ml)=1200x3/100=36ml;⑤50%葡萄糖(ml)二(360+100+10x3+36+36)/4=140m1余量1210-562-140＝500ml，由10%葡萄糖補(bǔ)充。66靜脈營(yíng)養(yǎng)剩余液1210(1620一200一210)m熱卡＝480+90+180=750kal糖＝4*（500*10％+140*50％）＝480kal蛋白=4*6.25%*360=90kal脂肪=9*20%*100=180kal750/26=28kal/kg液：熱＝1620/750＝2.1氮：熱＝22.5/6.25/660＝1：18367熱卡＝480+90+180=750kal67糖濃度＝120/1210*100％＝10.％糖速＝120*1000/24/26/60＝120000/37440＝3.2mg/kg.min68糖濃度＝120/1210*100％＝10.％68例210kgNEC患兒入院第二天，胃腸減壓出黃綠色液體100ml，血鈉120mmol/L，血糖：2.1mmol/L，血?dú)猓篜H：7.53，HCO3:34mmol/L，BE:10mmol/L，如何進(jìn)行TPN。69例210kgNEC患兒入院第二天，胃腸減壓出黃綠色液體101，糾正低血糖：50％GS1ml/kg.稀釋1倍后緩慢靜脈注射。2.用生理鹽水補(bǔ)充胃腸引流量：NS：100ml3.補(bǔ)酸：25%鹽酸精氨酸（ml)=ABEx體重(kg)x0.8x0.3=10X10x0.24=24ml，先給半量10ml。4.補(bǔ)鈉:10％氯化鈉：（135-120）*1.2*10/3.3/2＝27ml.稀釋成3.3％（加注射用水63ml）后微泵注入。701，糾正低血糖：50％GS1ml/kg.稀釋1倍后緩慢靜脈71入院第二天補(bǔ)液，患兒體重10kg，總?cè)胍毫繛?000ml，留150ml備用。暫定熱卡：10*30kal＝300kal71入院第二天補(bǔ)液，患兒體重10kg，總?cè)胍毫繛?000ml糖60％：300*0.55＝165kal相當(dāng)于糖：165/4＝41g脂肪：300*0.3＝90kal相當(dāng)于脂肪：90/9＝10g20％FAT＝50ml氨基酸：300*0.15＝45kal相當(dāng)于AA：45/4＝11g6.25％aa:=200ml72糖60％：300*0.55＝165kal7273靜脈營(yíng)養(yǎng)剩余液750(1000一150-100)ml:①6.25%復(fù)合氨基酸200ml(1.2g/kd.d);②20%脂肪乳50ml(1g/kd.d);③水樂(lè)維他10ml，維他利匹特10ml,安達(dá)美5ml;④氯化鈉按0.3%配制，氯化鉀按0.3%配制，需10%氯化鈉(ml)=750x3/100=22.5m1,10%氯化鉀(ml)=750x3/100=22.5ml;⑤50%葡萄糖(ml)二(200+50+25+22.5+22.5)/4=80m1余量750-400＝350ml，由10%葡萄糖補(bǔ)充。73靜脈營(yíng)養(yǎng)剩余液750(1000一150-100)ml熱卡＝300+50+90=440kal糖＝4*（350*10％+80*50％）＝300kal蛋白=4*6.25%*200=50kal脂肪=9*20%*50=90kal440/10=44kal/kg液：熱＝1000/440＝2.2氮：熱＝12.5/6.25/390＝1：18074熱卡＝300+50+90=440kal74糖濃度＝75/1000*100％＝7.5％糖速＝75*1000/24/10/60＝75000/14400＝5.2mg/kg.min75糖濃度＝75/1000*100％＝7.5％75CONCLUSIONSStartnutritionearlyEnteralrouteispreferredwhenavailableSetgoalsfortheindividualpatientAppropriatemonitoringisessentialAvoidoverfeedingCriticallyillpatientswithorganfailurepresentspecialchallengestothenutritioncareprofessionalandmedicalteam76CONCLUSIONSStartnutritioneaThankyou!Thankyou!危重患兒的營(yíng)養(yǎng)支持昆明市兒童醫(yī)院PICU李斌危重患兒的營(yíng)養(yǎng)支持昆明市兒童醫(yī)院PICU李斌79營(yíng)養(yǎng)支持在危重病人中的應(yīng)用營(yíng)養(yǎng)不良與危重癥關(guān)系1危重癥營(yíng)養(yǎng)支持原則2不良影響與監(jiān)測(cè)3營(yíng)養(yǎng)支持的實(shí)施42營(yíng)養(yǎng)支持在危重病人中的應(yīng)用營(yíng)養(yǎng)不良與危重癥關(guān)系1危重癥營(yíng)養(yǎng)營(yíng)養(yǎng)支持為何重要危重病+差的營(yíng)養(yǎng)＝？80營(yíng)養(yǎng)支持為何重要危重病+差的營(yíng)養(yǎng)＝？381營(yíng)養(yǎng)不良與危重癥的關(guān)系危重患兒發(fā)生營(yíng)養(yǎng)不良是常見(jiàn)的臨床現(xiàn)象.16-20%患兒入院48小時(shí)內(nèi)存在主要營(yíng)養(yǎng)物質(zhì)不良.60%有低蛋白血癥人體測(cè)量結(jié)果：72％，主觀判斷46％4營(yíng)養(yǎng)不良與危重癥的關(guān)系危重患兒發(fā)生營(yíng)養(yǎng)不良是常見(jiàn)的臨床現(xiàn)象ImpactofstarvationNegativenitrogenbalance,furtherwtlossMorphologicalchangesinthegut(Mucosalthickness,CellproliferationandVillusheight)Functionalchanges(Increasedpermeability&Decreasedabsorptionofaminoacids)Enzymatic/HormonalchangesDecreasedsucraseandlactaseImpactonimmunityCellular:DecreasedTcells,atrophiedgerminalcenters,mitogenicproliferation,differentiation,Thcellfunction,alteredhomingHumoral:Complement,opsonins,Ig,secretoryIgA(70-80%ofallIgproducedissecretoryIgA)Increasedbacterialtranslocation82ImpactofstarvationNegative83預(yù)后體重下降35-40%，病死率接近100%危重病+差的營(yíng)養(yǎng)＝？6預(yù)后體重下降35-40%，病死率接近100%危重病+差的營(yíng)為何會(huì)發(fā)生急性蛋白質(zhì)能量營(yíng)養(yǎng)不良？84為何會(huì)發(fā)生急性蛋白質(zhì)能量營(yíng)養(yǎng)不良？785急性蛋白質(zhì)能量營(yíng)養(yǎng)不良APEM基礎(chǔ)代謝率明顯增加應(yīng)激高分解狀態(tài)營(yíng)養(yǎng)素需求增加丟失過(guò)多攝入不足基礎(chǔ)疾病8急性蛋白質(zhì)能量營(yíng)養(yǎng)不良APEM基礎(chǔ)代謝率明顯增加應(yīng)激高分解86代謝病理糖元分解糖異生糖利用降低血糖增加蛋白分解糖異生負(fù)氮平衡優(yōu)先動(dòng)用FFA↑TG↑糖蛋白脂肪9代謝病理糖元分解蛋白分解優(yōu)先動(dòng)用糖蛋白脂肪W(wǎng)henshouldnutritionsupportbestartedinthePICU?87Whenshouldnutritionsupport營(yíng)養(yǎng)評(píng)估既往史體檢飲食史實(shí)驗(yàn)室檢驗(yàn)88營(yíng)養(yǎng)評(píng)估既往史11NutritionFocusedAssessmentPastmedicalhistoryasitimpactsnutritionalstatusandoutcomesAnthropometricmeasures:weight,length,headcircumference(forchildren<3yearsofage)Dietaryintakehistory:asavailablefromparentsorprimarycaretakers,historyoffeedingproblems,lossofappetite,recentweightlossLaboratoryvalues:CHEM-10,totalprotein/albumin,asavailableNutritionbasedexamtoidentifynutritiondeficiencylesionsHistoryofandneedforfurthernutritioneducationforspecializedformulaordiet.89NutritionFocusedAssessmentPachildrenatincreasednutritionalriskHypermetabolicstates:trauma:closedheadinjury,spinalcordinjuryPost-surgicalpatientsCardiorespiratoryillness:congenitalheartdefects,bronchopulmonarydysplasia,cysticfibrosisGastrointestinaldiseaseanddysfunction:shortgutsyndrome,exacerbationofinflammatoryboweldiseasewithhistoryofPEM,hepaticfailure,biliaryatresia,pancreatitisNeurologic,musculardisease:geneticsyndromes,Guillan-Barre',musculardystrophy,historyofCP/MRrequiringG-tubefeedings90childrenatincreasednutritioIndicationsforNutritionSupportinthePICU:AllPICUpatientswillbescreenedbythePICUnutritionistwithin72hoursofadmissiontodetermineiftheyareatnutritionriskorinneedofnutritionsupportviatheenteralorparenteralroute.91IndicationsforNutritionSupp如何進(jìn)行？

經(jīng)腸道還是全靜脈？

92如何進(jìn)行？

經(jīng)腸道還是全靜脈？

1593TPN適應(yīng)癥胃腸道功能障礙的重癥患兒；手術(shù)或解剖問(wèn)題胃腸道禁止使用的重癥患兒；存在有尚未控制的腹部情況，如腹腔感染、腸梗阻、腸瘺等。早期復(fù)蘇階段、血流動(dòng)力學(xué)尚未穩(wěn)定或存在嚴(yán)重水電介質(zhì)與酸堿失衡；嚴(yán)重肝功能衰竭，肝性腦?。患毙阅I功能衰竭存在嚴(yán)重氮質(zhì)血癥；嚴(yán)重高血糖尚未控制。相對(duì)禁忌GI解剖、功能良好，具備腸道喂養(yǎng)通路→EN16TPN適應(yīng)癥胃腸道功能障礙的重癥患兒；早期復(fù)蘇階段、血流94危重病人營(yíng)養(yǎng)支持時(shí)機(jī)選擇重癥病人常合并代謝紊亂與營(yíng)養(yǎng)不良，需要給予營(yíng)養(yǎng)支持（C級(jí)）重癥病人的營(yíng)養(yǎng)支持應(yīng)盡早開(kāi)始（B級(jí)）（預(yù)計(jì)5－7天內(nèi)不能經(jīng)口攝食者應(yīng)及早開(kāi)始營(yíng)養(yǎng)支持）17危重病人營(yíng)養(yǎng)支持時(shí)機(jī)選擇重癥病人常合并代謝紊亂與營(yíng)養(yǎng)不良如可進(jìn)行？熱量及營(yíng)養(yǎng)素的分配95如可進(jìn)行？熱量及營(yíng)養(yǎng)素的分配18DeterminingCalorieandProteinNeedsEstimatebasalenergyneeds(BEE)-RefertoTable1DetermineStressFactor-RefertoTable2

TotalCalories=BEEXStressFactor

Estimatepatient'sproteinrequirements-RefertoRDAs-Table3

TotalProtein=ProteinRDAsXStressFactor

Continuetoevaluateandadjustrecommendationsbasedonnutritionmonitoring.96DeterminingCalorieandProteiCalculationofCatch-UpGrowthintheTermInfantandChildKcal/kg=RDA(kcal/kg)forweightage*xIdealweight(kg)**/Actualweight*Ageatwhichpresentweightisatthe50th%-ile

**50th%-ileforageoridealbodyweightforheight97CalculationofCatch-UpGrowthTable1.BasalEnergyNeedsforInfantsandChildren

98Age1wkto10moAge11to36moAge3to16yrMetabolicRateMetabolicRateMetabolicRateWeight(kcal/day)Weight(kcal/day)Weight(kcal/day)(kg)MaleorFemaleMaleFemale(kg)MaleFemale3.52029.0528509158597994.02289.5547528209538984.525210.05665472510469965.027810.558656630113910925.530511.060558635123111906.033111.562460540132512896.535812.064362445141813877.038412.566264650151214867.541013.068266555160615848.043713.570168460169916808.546314.072070365179317769.049014.573972270188618749.551415.0758741751980197310.054015.577876010.556616.079778211.059316.5816802BACKTable1.BasalEnergyNeedsfoTable2.DeterminingStressFactor99ClinicalConditionStressFactorMaintenancewithoutStress

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

1.5-1.7BACKTable2.DeterminingStressFaTable3.RecommendedDietaryAllowancesforInfantsandChildren

100

AgeWeightHeightCaloriesProteinFluid

(years)(kg)(lbs)(cm)(in)(kcal/kg)(gm/kg)(ml/kg)Infants0.0-0.561360241082.2140-1600.5-1.09207128981.5125-145Children1-3132990351021.23115-1254-6204411244901.290-1107-10286213252701.070-85Males11-14459915762551.070-8515-186614517669450.850-60Females11-144610115762471.070-8515-185512016364400.850-60BACKTable3.RecommendedDietaryA101能量供應(yīng)20kal×Wt50kal×Wt100kal×Wt>20Kg部分第二個(gè)10Kg第一個(gè)10Kg胃腸外營(yíng)養(yǎng)支持期間熱卡推薦量(kcal/d)體溫每增高1°C,熱量需增加12%;心力衰竭時(shí)需增加5-25%;大手術(shù)時(shí)需增加20-30%;嚴(yán)重?cái)⊙Y時(shí)需增加40-60%;燒傷時(shí)需增加100%。

24能量供應(yīng)20kal×Wt50kal×Wt100kal×