1208例全营养混合液临床应用的前瞻性调查

目的了解与分析住院患者全营养混合液（TNA）临床应用情况。方法前瞻性分析1208例患者的营养风险、科室分布、TNA使用时间、输液途径等。结果使用TNA的患者遍及临床各科室。欧洲营养风险筛查（NRS2002）≥3分的患者1090例,占90．2％,〈3分的患者118例,占9．8％。接受TNA治疗时间〈5d者495例,占41％。接受TNA治疗时间≤14d者908例,其中使用中心静脉插管占12％,使用外周静脉插管占88％;接受TNA治疗时间〉14d者300例,其中使用中心静脉插管占95％,使用外周静脉插管占5％。结论TNA应用广泛,但还需进一步规范与完善。应加强全面的临床营养培训,并进一步推广NRS2002的应用,推荐采用经外周置入中心静脉导管输液途径。     

1208例全营养混合液临床应用的前瞻性调查

目的 了解与分析住院患者全营养混合液(TNA)临床应用情况.方法 前瞻性分析1208例患者的营养风险、科室分布、TNA使用时间、输液途径等.结果使用TNA的患者遍及临床各科室.欧洲营养风险筛查(NRS 2002)≥3分的患者1090例,占90.2%,<3分的患者118例,占9.8%.接受TNA治疗时间<5 d者495例,占41%.接受TNA治疗时间≤14d者908例,其中使用中心静脉插管占12%,使用外周静脉插管占88%;接受TNA治疗时间>14d者300例,其中使用中心静脉插管占95%,使用外周静脉插管占5%.结论 TNA应用广泛,但还需进一步规范与完善.应加强全面的临床营养培训,并进一步推广NRS 2002的应用,推荐采用经外周置人中心静脉导管输液途径.     

胃肠道外营养用于危重症患儿救治的临床研究

目的了解采用胃肠道外营养支持治疗临床危重症患者的临床疗效。方法66例危重症患儿采用含葡萄糖、氨基酸、维生素及中长链脂肪乳的PN支持治疗，胃肠道外营养输液均采用周围静脉途径输注营养液。结果66例患儿中92．4％（61t66）体重显著增加，每天增重平均（0．028±0．009）kg，胃肠道外营养治疗前及治疗后1周各指标均有显著性改善，差异有统计学意义（P〈0．05）。结论PN支持疗法治疗危重患儿可改善危重患儿全身营养状况，提高患儿生存质量。     

不同置放途径中心静脉导管的临床效果研究

目的 对比两种经不同途径置放中心静脉导管的临床效果及并发症。方法 选择需长期输液治疗的患80例，分为A、B两组，每组各40例。A组应用双腔或单腔中心静脉导管(美国Arrow公司)经锁骨下静脉穿刺至上腔静脉置管，B组应用“经外周静脉置人中心静脉导管”(美国B—D公司Peripherally Insented Central Catheter，简称PICC)经外周静脉置人中心静脉，观察2组置管成功率、流速及导管相关并发症30天。结果 置管成功率相近(P=0．5562)：PICC导管置管成功97．5％(39例)；锁骨下静脉穿刺成功100％(40例)。导管堵塞率有明显差别(P=0．0231)：PICC9例(22．5％)，锁骨下静脉穿刺2例(5％)。锁骨下静脉置管流速明显快于PICC(P＝0．0001)。其他导管相关并发症两组无明显差异(P＝0．1521～0．5562)。气、血胸并发症：PICC末发生，锁骨下静脉穿刺1例(2．5％)。动脉损伤：PICC末发生，锁骨下静脉穿刺1例(2．5％)。导管易位：PICC2例(5％)，锁骨下静脉穿刺1例(2．5％)。静脉炎：PICC2例(5％)，锁骨下静脉穿刺末发生。导管感染：PICC末发生，锁骨下静脉穿刺2例(5％)。大多数PICC置管可由护士完成，而锁骨下静脉置管全部由医师操作。结论 经锁骨下静脉置入的中心静脉导管流速大，是抢救危重患的首选导管。PICC导管穿刺更安全、易推广；导管堵塞或感染后，能进行原地置换；是长期输液和大剂量长时间化疗的首选中心静脉导管。两种置管途径的导管相关感染率无统计学羌异。     

PICC置管术的临床应用与护理体会

<正>经外周插管的中心静脉导管(PICC)是由外周静脉(贵要静脉、肘正中静脉、头静脉)穿刺插管,其尖端定位于上腔静脉或锁骨下静脉的导管[1]。用于为患者提供中期到长期的静脉输液治疗(7 d~1年)。我院从2009年3月以来已开展了PICC置管     

锁骨下静脉穿刺置管术的临床应用

静脉输液是临床上治疗、抢救病人的必要措施之一,也是护理操作技术之一。经锁骨下静脉穿刺置管输注营养液,已逐渐被公认为是长期TPN(胃肠外静脉营养)支持治疗最为适宜的途径之一。近两年来,我科应用美国ARROW公司生产的中心静脉导管进行锁骨下静脉穿刺置管输液,通过临床观察,取得较好治疗效果。现将应用体会介绍如下。1 临床资料及方法1·1 对象 本组300例外科住院患者,男170例,女130例,年龄25～80岁,TPN天数5～35天,本组30例接受锁骨下静脉穿刺置管术314次,右侧锁骨下静脉穿刺201次,左侧锁骨下静脉穿刺113次,一次成功率95.6％,无空气栓塞、血胸、气胸、液胸,无导管感染、皮下血肿。     

微型营养评定法和微型营养评定简表在老年痴呆患者营养筛查中的应用

目的采用微型营养评定法（MNA）和微型营养评定简表（MNA—SF）对老年痴呆患者营养状况进行筛查，比较两者的适用性。方法对267例老年痴呆患者应用MNA和MNA—SF进行营养筛查，测量人体学指标和实验室指标，分析两者的相关性。结果根据MNA值评定营养不良者占59．7％，潜在营养不良者占20．9％，营养正常者占19．4％；营养不良评价敏感性73．4％，特异性60．1％。根据MNA-SF值评定营养不良者占70．4％，营养正常者占29．6％；营养不良评定敏感性50．6％，特异性92．4％。MNA法和MNA-SF法具有高度相关性（r=0．924，P〈0．01）。结论老年痴呆患者营养不良的发生率高，两种方法联合评定提高了老年痴呆患者营养不良患者的检出率，是筛查老年痴呆患者营养不良的有效方法。     

锁骨下静脉穿刺后插管困难原因分析及处理

锁骨下静脉插管是心导管术中常用来植人心脏起搏器、冠状静脉窦电极插入或临床上测量中心静脉压、胃肠外营养快速扩容等治疗的有效途径。此静脉直径约1-2cm．操作简单，成功率高。我院自1994-02心导管术时行锁骨下静脉穿刺术1400例，对其中6例插管困难的原因进行分析并总结其处理经验。     

深圳某区中心城小学生营养状况调查

目的：了解深圳市龙岗区中心城小学生营养状况，为科学地指导学生营养和保健工作提供依据。方法：对深圳市龙岗区中心城5所小学7～14岁在校学生进行身高、体重两项发育指标的测量，根据卫生部下发的身高标准体重值进行个体营养评价。结果：被调查的6339名学生中营养正常者占69．3％，营养不良者占17．0％，超重与肥胖者占13．6％。营养不良以轻、中度为主，占97．8％（1054／1078）。不同年级的营养不良率差异有统计学意义，随年级的升高而逐渐上升；不同年级的超重与肥胖率的差异则无统计学意义。女生营养不良率高于男生（P〈0．01）男生超重或肥胖率高于女生（P〈0．01）。结论：该区中心小学生营养不良情况仍较严重，学生的营养和健康工作应得到学校、家长和社会各方面的关注和支持。     

用球囊漂浮起搏电极床旁行心脏临时起搏58例临床观察

目的探讨经静脉途径应用球囊漂浮电极在床旁行心脏临时起搏的可行性、有效性、安全性。方法在无X线透视条件下，床边经右锁骨下静脉、左锁骨下静脉、右股静脉及右颈内静脉4种不同的途径穿刺插管，用气囊漂浮起搏电极行心脏临时起搏。观察其成功率、操作时间及并发症。结果58例患者中57例在无X线透视条件下起搏成功，成功率98．3％，无严重并发症发生。其中经左锁骨下静脉途径5例，右颈内静脉途径2例，右股静脉途径6例均盲插起搏成功，从穿刺到起搏成功用时左锁骨下静脉途径2—12min，平均4．5min，右颈内静脉途径3min及4min，右股静脉途径5—18min，平均9．2min。经右锁骨下静脉途径45例盲插成功42例，成功率93．3％，从穿刺到起搏成功平均5min，3例未成功者1例为起搏电极置入失败，2例为置管失败，其中2例改行左锁骨下静脉途径成功2例，另1例经左锁骨下静脉途径及右股静脉途径均未成功，后在x线透视条件下从左股静脉途径起搏成功。结论应用球囊漂浮电极导管行床旁临时起搏有创伤小、置入迅速、成功率高、并发症少、操作简单容易掌握、所需设备简单等优点，适合于急危重患者的抢救。     

石家庄市中小医院住院患者营养风险筛查及营养支持应用现状

目的 调查1所中等医院的普通外科、胸外科、消化内科、神经内科、肾内科、呼吸内科6个科室的住院患者和1所县级医院的内、外科住院患者营养风险发生率、实际应用营养支持率,为住院患者合理应用营养支持提供参考依据.方法 采用营养风险筛查2002评分方法对住院患者进行营养风险筛查评估以及营养支持应用现状调查.结果 中等医院6个科室住院患者的营养风险发生率为25%,其中呼吸内科营养风险发生率最高,为31%,其次为神经内科29%,以后依次为肾内科27%、胸外科23%、消化内科22%、普通外科18%,有营养风险的患者中24%进行了营养支持,无营养风险患者中9%进行了营养支持.小医院营养风险发生率为18%,其中内科29%、外科7%,有营养风险患者使用营养支持占24%,无营养风险患者中4%进行了营养支持.结论 石家庄市中小医院住院患者存在一定数量的营养风险和营养不良(不足),肠外和肠内营养存在不合理性,今后在中小医院进一步推广基于循证医学的肠外肠内营养指南和应用规范尤为重要.     

石家庄市中小医院住院患者营养风险筛查及营养支持应用现状

目的调查1所中等医院的普通外科、胸外科、消化内科、神经内科、肾内科、呼吸内科6个科室的住院患者和1所县级医院的内、外科住院患者营养风险发生率、实际应用营养支持率，为住院患者合理应用营养支持提供参考依据。方法采用营养风险筛查2002评分方法对住院患者进行营养风险筛查评估以及营养支持应用现状调查。结果中等医院6个科室住院患者的营养风险发生率为25％，其中呼吸内科营养风险发生率最高，为31％，其次为神经内科29％，以后依次为’肾内科27％、胸外科23％、消化内科22％、普通外科18％，有营养风险的患者中24％进行了营养支持，无营养风险患者中9％进行了营养支持。小医院营养风险发生率为18％，其中内科29％、外科7％，有营养风险患者使用营养支持占24％，无营养风险患者中4％进行了营养支持。结论石家庄市中小医院住院患者存在一定数量的营养风险和营养不良（不足），肠外和肠内营养存在不合理性，今后在中小医院进一步推广基于循证医学的肠外肠内营养指南和应用规范尤为重要。     

ESPEN Guidelines on Parenteral Nutrition: Pancreas

Assessment of the severity of acute pancreatitis (AP), together with the patient's nutritional status is crucial in the decision making process that determines the need for artificial nutrition. Both should be done on admission and at frequent intervals thereafter. The indication for nutritional support in AP is actual or anticipated inadequate oral intake for 5–7 days. This period may be shorter in those with pre-existing malnutrition. Substrate metabolism in severe AP is similar to that in severe sepsis or trauma. Parenteral amino acids, glucose and lipid infusion do not affect pancreatic secretion and function. If lipids are administered, serum triglycerides must be monitored regularly. The use of intravenous lipids as part of parenteral nutrition (PN) is safe and feasible when hypertriglyceridemia is avoided.PN is indicated only in those patients who are unable to tolerate targeted requirements by the enteral route. As rates of EN tolerance increase then volumes of PN should be decreased.When PN is administered, particular attention should be given to avoid overfeeding. When PN is indicated, a parenteral glutamine supplementation should be considered.In chronic pancreatitis PN may, on rare occasions, be indicated in patients with gastric outlet obstruction secondary to duodenal stenosis or those with complex fistulation, and in occasional malnourished patients prior to surgery.     

Total parenteral nutrition by peripheral vein--substitute or supplement to the central venous route? A prospective trial

51 consecutive gastroenterological patients who required total parenteral nutrition (TPN) were entered into this study. Two patients were withdrawn because of specific nutritional requirements, leaving 49 patients for randomisation. 23 patients were allocated to receive peripheral parenteral nutrition (PPN) and 26 to receive feeding through a central venous line (CPN). There was no significant difference between the groups with respect to the median duration of feeding (9.4 +/- 3.6 days; 12.0 +/- 7.8 days) but significant morbidity occurred more frequently in the CPN group (11%) compared to the PPN group (0%). TPN by the designated route was not possible in 4 patients in the PPN group and in 3 of the CPN group. Of the 19 patients commenced on PPN, 13 continued without complication until resumption of oral feeding (median 10.7 +/- 3.2 days); 6 of these patients had to be converted to central venous feeding for completion of their nutritional requirements. Of the 23 patients commenced on CPN, 21 completed their nutritional course (median 11.8 +/- 5.3 days), 2 patients in the CPN group required conversion to PPN to complete their nutritional course. This study shows that PPN is a feasible, safe alternative to CPN in many patients. It is not necessary to subject all patients who require TPN to the risks and expense of central venous cannulation.     

The effect of different macronutrient infusions on appetite, ghrelin and peptide YY in parenterally fed patients

BACKGROUND & AIMS: Patients receiving parenteral nutrition (PN) still feel hungry despite adequate provision of calories intravenously. It is not known whether PN or its constituent macronutrients acutely affect appetite and to what degree this may be mediated by ghrelin and peptide YY (PYY). METHODS: Six medically stable patients (four men) with intestinal failure receiving PN received an isocaloric 200 kcal infusion on three separate occasions following a 12 h fast. The infusions consisted of either carbohydrate (10% dextrose), fat (10% intralipid) or mixed protein/carbohydrate (PN). Changes in ghrelin and peptide YY levels and changes in subjective symptoms of hunger, satiety and nausea during each macronutrient infusion were assessed. RESULTS: None of the three infusions acutely affected subjective symptoms of hunger, satiety and nausea (P>0.05 ANOVA). Ghrelin levels decreased significantly during dextrose [-19.1 (-35.9, -12.4), regression coefficient (95% CI), P<0.001] and parenteral nutrition infusions [-18.2 (-26.8, -9.6), P<0.001]. Lipid infusion had no effect on ghrelin levels but led to a significant decrease in PYY [-0.076 (-0.0123, -0.028), P=0.004]. Dextrose and PN infusion had no significant effect on PYY levels. CONCLUSIONS: Dextrose and PN infusions decrease ghrelin levels. Lipid infusion does not affect ghrelin levels but in contrast to oral nutrients leads to a significant decrease in PYY. Despite these changes, in patients receiving PN, macronutrient infusions do no acutely affect appetite.     

Administration of peripheral parenteral nutrition: a prospective study comparing rotation of venous access sites with ultrafine cannulas

Peripheral veins have been used successfully for patients requiring short- to medium-term total parenteral nutrition. This study prospectively compares two methods of peripheral parenteral nutrition (PPN). Forty-six patients requiring parenteral nutrition (PN) were identified prospectively. Fifty courses of PPN were prescribed using a standardized PPN formula of 9.3 g nitrogen, 1400 kCal, 2500 ml (KABI II, Pharmacia). Patients were randomized to receive PPN via 23G, 15 cm flexane catheters (Nutriline) inserted into an antecubital vein which remained in-situ with a continuous infusion over 24 h, or to receive 12-h cyclical infusions through peripherally sited 18G catheters (Venflon) which were removed postinfusion and reinserted into the contralateral forearm on alternate days. Data collected included duration, complications and cost of materials for each prescribed course. A scoring system to determine patient anxiety and depression and a questionnaire regarding patients' perspectives were evaluated.Fifty courses were prescribed, 26 by rotation of veins (RV) and 24 by Nutriline (N). Mean duration offeeding was 7.9 and 8.6 days, respectively; cost of materials were comparable 6.48/day (RV) vs 5.17/day (N); 2 RV patients failed to complete their course (no access [P< 0.05], whilst 9 N patients failed to complete their course (4 severe phlebitis, 2 no venous access, 2 septicaemia, 1 dislodged). Five patients required CPN (RV, N 3) while 4 remaining patients were fed by an alternative PPN method. The overall incidence of anxiety was 20% and of depression 16%, with no significant difference between groups. The majority of patients (87%) found mobility restricted.Twelve-hourly infusions via alternate forearm veins were significantly more successful than continuous infusions via Nutriline, both in terms of completion of the prescribed course and less venous morbidity. This study confirms that rotation of forearm veins allows affordable and successful PN administration to the majority of patients, with low PN-related morbidity.     

The prevalence of coagulation abnormalities in hospitalized patients receiving lipid-based parenteral nutrition

BACKGROUND: Vitamin K is not a component of the multivitamin preparation added to parenteral nutrition (PN) solutions, and hospitalized patients receiving parenteral nutrition support are at risk of developing vitamin K deficiency. METHODS: In this study, 84 consecutive patients receiving PN were followed up prospectively to determine the incidence of a raised international normalized ratio (INR). All patients received lipid in their PN, which contains approximately 30 microg of vitamin K/100 mL. RESULTS: Patients were followed up for the course of PN or up to 4 weeks if they needed longer total parenteral nutrition. A raised INR compared with baseline developed in 3.6% of patients. All elevations were mild, and no patients developed clinical bleeding. CONCLUSIONS: It may be unnecessary to routinely supplement patients with vitamin K if they are receiving a lipid emulsion containing significant amounts of vitamin K. For patients receiving warfarin therapy, it will be important for nutrition support services to be aware of the vitamin K content of the lipid emulsion they are using as patients receiving a multivitamin preparation containing vitamin K and lipid emulsion may receive increased amounts of vitamin K, which could lead to warfarin resistance.     

Nutrition support in acute pancreatitis: a systematic review of the literature

BACKGROUND: Failure to use the gastrointestinal (GI) tract in patients with acute pancreatitis may exacerbate the stress response and disease severity, leading to greater incidence of complications and prolonged hospitalization. The objectives of this study were to determine the optimum route for nutrition support, whether nutrition therapy is better than no artificial nutrition support, whether specific additives to enteral or parenteral therapy can further enhance their efficacy, and whether methodologic differences in delivery of enteral nutrition (EN) influence tolerance. METHODS: A computerized search was performed of MEDLINE, Cochrane database, EMBASE, and reference lists of pertinent review articles for prospective randomized trials in adult patients with acute pancreatitis that evaluated interventions with nutrition therapy. Primary outcome data and surrogate endpoint parameters (for nutrition indices, stress markers, and measures of the inflammatory/immune response) were extracted in duplicate independently. Where appropriate, meta-analysis was performed by random-effects model. RESULTS: From 119 articles screened, 27 randomized controlled trials were included and analyzed. In patients admitted for acute pancreatitis, meta-analysis of 7 trials showed that use of EN was associated with a significant reduction in infectious morbidity (risk ratio [RR] = 0.46; 95% confidence interval [CI], 0.29 - 0.74; p = .001) and hospital length of stay (LOS; weighted mean difference [WMD] = -3.94; 95% CI, -5.86 to -2.02; p < .0001), a trend toward reduced organ failure (RR = 0.59; 95% CI, 0.28-1.27; p = .18), with no effect on mortality (RR = 0.88; 95% CI, 0.43-1.79; p = .72) when compared with use of parenteral nutrition (PN). Results from individual studies suggest that EN in comparison to PN reduces oxidative stress, hastens resolution of the disease process, and costs less. Insufficient data exist to determine whether EN improves outcome over standard therapy (no artificial nutrition support) in patients admitted for acute pancreatitis. However, in those patients requiring surgery for complications of acute pancreatitis, meta-analysis of 2 trials indicates that provision of EN postoperatively may reduce mortality (RR = 0.26; 95% CI, 0.06 - 1.09; p = .06) compared with standard therapy. PN provided early within 24 hours of admission was shown to worsen outcome, whereas PN provided later after full-volume resuscitation appeared to improve outcome when compared with standard therapy. In early individual studies, specific supplements added to EN, such as arginine, glutamine, omega-3 polyunsaturated fatty acids, and probiotics, may be associated with a positive impact on patient outcome in acute pancreatitis, compared with EN alone without the supplements, but studies are too few to make strong treatment recommendations. Supplementation of PN with parenteral glutamine was shown to reduce oxidative stress and improve patient outcome (reduced duration of nutrition therapy and decreased hospital LOS) compared with PN alone in patients with acute pancreatis. A wide range of tolerance to EN exists, irrespective of known influences such as mode (continuous vs bolus) and level of infusion within the GI tract (gastric vs postpyloric). CONCLUSIONS: Patients with acute severe pancreatitis should begin EN early because such therapy modulates the stress response, promotes more rapid resolution of the disease process, and results in better outcome. In this sense, EN is the preferred route and has eclipsed PN as the new "gold standard" of nutrition therapy. When PN is used, it should be initiated after 5 days. The favorable effect of both EN and PN on patient outcome may be further enhanced by supplementation with modulators of inflammation and systemic immunity. Individual variability allows for a wide range of tolerance to EN, even in severe pancreatitis.     

Fistuloclysis: case report and literature review.

Enterocutaneous fistulae are a common postoperative entity, causing serious complications such as sepsis, malnutrition, and electrolyte and fluid abnormalities. Because sepsis coupled with malnutrition is the leading cause of death in these patients, it is especially important to provide nutrition support. Although parenteral nutrition (PN) is widely used in these patients, it is not without risks, because PN is known to cause liver dysfunction, among other problems. We report a case in which a male patient with an enterocutaneous fistula, having experienced increased liver enzymes receiving PN, began receiving enteral nutrition (EN) via a feeding tube placed in the fistula. Known as fistuloclysis, this method provided adequate nutrition and improved his serum albumin and prealbumin levels, body weight, and liver function tests. Upon stabilization of his nutrition status, he was able to undergo successful surgical repair of the enterocutaneous fistula. According to our experience and that of others, we recommend that patients with high-output enterocutaneous fistulae be considered for EN via fistuloclysis after nutrition stabilization with PN; then the fistulae can be surgically repaired if not spontaneously healed. Use of EN via fistuloclysis, if used appropriately, avoids the complications of long-term PN and may promote faster fistula healing.     

Impact of infusion frequency on quality of life in patients receiving home parenteral nutrition

Home parenteral nutrition (HPN) may be needed as a long-term therapy for patients with chronic intestinal failure whose clinical condition does not allow complete weaning of the parenteral nutrition (PN) solution. HPN is a time-consuming and clinically complex therapy and can negatively affect quality of life (QOL). The level of dependency on HPN, specifically, infusion frequency, has been proposed as a factor that may have an effect on QOL in patients receiving HPN. The primary aim of this qualitative review is to identify the impact of HPN frequency (days per week of HPN infusion) on QOL measurements in adult patients receiving HPN. A comprehensive literature search was completed in PubMed and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases. Primary clinical research studies were included if they were conducted in adult patients receiving HPN and included the assessment of the associations between the frequency of HPN infusion and QOL measurements. Six articles ultimately met the criteria for this review. There was variability among the studies, including use of different tools to measure QOL. However, all six studies suggest that a reduction in HPN frequency may be associated with an improvement in QOL. Whenever patients’ clinical situation allows, a reduction in HPN frequency should be considered to improve QOL in patients receiving HPN.