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1、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,Cellproliferat
2、ionandVillusheight)Functionalchanges(Increasedpermeability&Decreasedabsorptionofaminoacids)Enzymatic/HormonalchangesDecreasedsucraseandlactaseImpactonimmunityCellular:DecreasedTcells,atrophiedgerminalcenters,mitogenicproliferation,differentiation,Thcellfunction,alteredhomingHumoral:Compleme
3、nt,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?
4、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,recen
5、tweightlossLaboratoryvalues:CHEM-10,totalprotein/albumin,asavailableNutritionbasedexamtoidentifynutritiondeficiencylesionsHistoryofandneedforfurthernutritioneducationforspecializedformulaordiet.12childrenatincreasednutritionalriskHypermetabolicstates:trauma:closedheadinjury,spinalcordinjury
6、Post-surgicalpatientsCardiorespiratoryillness:congenitalheartdefects,bronchopulmonarydysplasia,cysticfibrosisGastrointestinaldiseaseanddysfunction:shortgutsyndrome,exacerbationofinflammatoryboweldiseasewithhistoryofPEM,hepaticfailure,biliaryatresia,pancreatitisNeurologic,musculardisease:gen
7、eticsyndromes,Guillan-Barre',musculardystrophy,historyofCP/MRrequiringG-tubefeedings13IndicationsforNutritionSupportinthePICU:AllPICUpatientswillbescreenedbythePICUnutritionistwithin72hoursofadmissiontodetermineiftheyareatnutritionriskorinneedofnutrition
