(精编)【医学课件精品】危重患儿的营养支持.pptVIP

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/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 translocation 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 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 nutrition 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 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 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 a