Nutritional support of the pediatric trauma patient

Of all the interventions available to aid recovery of the injured child, few have the power of proper nutritional support. Healing after trauma depends not only on restoration of oxygen delivery, but on "substrate delivery," or provision of calories to support metabolic power and specific nutrients to allow rebuilding of injured tissue. Failure to deliver adequate substrate to the cells is revealed as another form of shock. Nutritional interventions after trauma are most effective when informed by the specific ways that children diverge physiologically (metabolic rate, biomechanics, physiological response to trauma) from adults. This review describes these responses and outlines a general strategy for safely delivering energy and specific substrates to protect and heal injured children, regardless of body size and type of injury.     

Advances in ventilatory support of the pediatric surgical patient.

Severe respiratory failure in newborn and pediatric patients is associated with significant morbidity and mortality. Basic science laboratory investigation has led to advances both in our understanding of ventilator-induced lung injury and in optimizing the supportive use of conventional ventilation strategies. Over the past few years, progress has been made in alternative therapies for ventilating both children and adults with severe respiratory failure. This review focuses on recent laboratory and clinical data detailing the techniques of permissive hypercapnia, high frequency oscillatory ventilation, inhaled nitric oxide, intratracheal pulmonary ventilation, and liquid ventilation. Some of these modalities are becoming commonplace, and others may have much to offer the clinician if their benefit is clearly demonstrated in future clinical trials.     

儿童肿瘤患者的营养支持

随着医疗水平的不断提高,手术、放疗、化疗极大地提高了儿童恶性肿瘤的治愈率[1]。目前在发达国家总体治愈率超过70%,预计2010年可到85%。但与此同时,因肿瘤本身或肿瘤治疗副作用的影响所导致的营养不良,特别是蛋白质/热量营养不良(PEM),削弱了患儿对各种治疗的耐受性,增加并发     

肥胖危重患儿的营养支持

肥胖危重患儿营养支持更具挑战性,除原发疾病的危重状态外,由肥胖带来的一系列病理生理改变、器官功能损伤导致的共患疾病使肥胖危重患儿的营养风险更高,临床病情更复杂,代谢状态更多变。采用间接能量测定仪监测肥胖危重患儿静息能量消耗,据此评估其能量需求成为临床“金标准”。充分蛋白质供给,合理碳水化合物与脂类热卡比例,客观、适宜的动态监测与评估,及时的营养方案调整是危重肥胖患儿营养支持成功的基础。     

小儿肝、肾功能不全的营养支持

1肝、肾在营养代谢中的作用肝脏是维持生命代谢活动的重要器官,它几乎参与了所有营养物质的代谢。其中主要营养要素有蛋白质、脂肪、碳水化合物、维生素等。肝脏在调节和维持蛋白质、脂肪和糖代谢方面起着决定性作用,肝功能障碍可直接影响三大营养物质的代谢。此外,肝脏还参与胆汁酸分泌,各种激素(甾类,单胺类)和维生素(维生素D)的代谢。肾脏在营养代谢中也起着重要作用,主要为维持内环境代谢平衡和排泄各种代谢产物,肾脏还参与部分激素和维生素D的代谢。肾功能障碍主要引起蛋白质氮排泄障碍,各种代谢产物(磷酸,有机酸)的体内堆积和内环境…     

Nutritional support for pediatric patients with inflammatory bowel disease

Pediatric patients with ulcerative colitis and Crohn's disease often suffer from malnutrition and growth failure. This is particularly true in pubertal children. Chronic insufficient nutrient intake is most often the cause of growth failure. Both parenteral nutrition and defined enteral formulas are available to rehabilitate patients with malnutrition and growth failure. Assessment of nutritional status and growth and the use of parenteral nutrition and defined enteral formulas to reverse malnutrition, growth failure, and inflammation in pediatric patients with inflammatory bowel disease are discussed.     

Nutrition support in a surgical patient

Nutrition has very important role to play during health and disease state in human beings. Neonates and younger children are more prone to develop nutritional deficiencies. They have very critical reserves and are rapidly growing. Any surgical insult leads to multiple nutritional problems. Careful planning of nutritional management in a surgical patient is mandatory. Nutritional support should start from the day when the child develops the surgical condition to withstand stress of disease and surgical procedure. In the postoperative period nutritional support should start as early as possible. Start with small amount and build up gradually till the normal enterai nutrition (EN) is tolerated. When EN is not tolerated parenteral nutrition (PN) should be considered. Parenteral nutrition on short term basis is very important to tide over the crisis due to postoperative complications. Parenteral nutrition on long term basis is required in short bowel syndrome resulting from resection of large part of the gut. During PN, enterai nutrition should be continued in small amounts in order to maintain the integrity of mucosal lining of the gut. Enterai nutrition is more physiological and can provide adequate amount of immunonutrients, minerals and vitamins.     

Support of respiratory failure in the pediatric surgical patient

Severe respiratory failure in newborn and pediatric patients is associated with significant morbidity and mortality. Basic science laboratory investigation has led to advances in the understanding of ventilator-induced lung injury and in optimizing the supportive use of conventional ventilation strategies. Over the past few years, progress has been made in alternative therapies for supporting children and adults with severe respiratory failure. This review will focus on recent laboratory and clinical data regarding the techniques of lung protective ventilator strategies, inhaled nitric oxide, liquid ventilation, and extracorporeal life support (ECLS, ECMO). Some of these modalities are commonplace, while others may have much to offer the pediatric clinician if their benefit is clearly demonstrated in future clinical trials.     

Recent advances in the surgical management of the single ventricle pediatric patient

A standardized approach to the patient with single ventricle anatomy (SVA) is presented in this article. Regardless of the specific anatomic subtype, patients with SVA share common risk factors for early and late mortality and morbidity. Management of the SVA patients requires a plan to avoid development of these risk factors. Neonatal palliation is directed at relieving any systemic obstruction and appropriate limitation of pulmonary blood flow. The application of a standardized approach to the neonate with SVA, followed by staged palliation to a completion Fontan procedure should result in improved early and late outcome.     

Renal dysfunction in the pediatric surgical patient: When to intervene

Renal dysfunction is very common in the pediatric surgical critical care patient, with an estimated incidence of up to 35% in the PICU population. It impacts multiple other organ systems, particularly ventilation, and adds to the morbidity and mortality in children with multisystem organ dysfunction. In this article, we review the definitions and stages of renal failure in the pediatric population, identify which of these are more likely to require renal replacement therapy, and identify the indications for the different types of intervention. In addition, the complications of each form of therapy, along with management options, will be discussed. Finally, we will discuss the immediate and long-term outcomes for pediatric patients from neonates to adolescents.     

Heparin-induced thrombocytopenia in a pediatric patient receiving extracorporeal support and treated with argatroban.

INTRODUCTION: Heparin-induced thrombocytopenia (HIT) is rare in the pediatric population, with a majority occurring in the pediatric intensive care unit setting. All reported cases have been associated with the use of unfractionated heparin. Because unfractionated heparin is the anticoagulant of choice for extracorporeal life support, the development of HIT in these patients can be devastating. We report a case of HIT with evidence of small-vessel arterial thromboembolism in a 17-month-old child receiving extracorporeal membrane oxygenation and continuous renal replacement therapy successfully treated with argatroban. CASE: The patient was a 17-month-old boy with severe respiratory failure secondary to asthma and mucus plugging that failed conventional and unconventional ventilation. Venovenous extracorporeal membrane oxygenation was initiated, and within 24 hrs, there was a precipitous decrease in the platelet count, with the development of cutaneous ischemia involving his lower limbs. Heparin-associated antibodies were positive. Argatroban was started, and the child maintained on extracorporeal membrane oxygenation and continuous renal replacement therapy, with resolution of the cutaneous ischemia and rebound of the thrombocytopenia. DISCUSSION: HIT is rare in the pediatric population. Recognition of HIT is vital because withdrawal of heparin is the first and most important therapy. For patients on extracorporeal membrane oxygenation or continuous renal replacement therapy who develop HIT, synthetic thrombin inhibitors (hirulogs) have been reported as an alternative. However, little information on their use in extracorporeal life support has been published, particularly in the pediatric population. CONCLUSION: This report documents a pediatric case of HIT successfully treated with argatroban, allowing continuation of the venovenous extracorporeal membrane oxygenation and continuous renal replacement therapy, with resolution of the thromboembolic ischemia and thrombocytopenia.     

Nutritional support at home and in the community.

Technical developments in feeding, together with the growth of support structures in the community has lead to a steady increase in the number of children receiving home enteral tube feeding and home parenteral nutrition. In many cases the adverse nutritional consequences of disease can be ameliorated or prevented, and long term parenteral nutrition represents a life saving intervention. Careful follow up of children receiving home nutritional therapy is necessary to establish the ratio of risks to benefits. A considerable burden is sometimes placed on family or other carers who therefore require adequate training and ongoing support. The respective responsibilities of different agencies relating to funding and support tasks require more clear definition.     

Hypotonic versus isotonic maintenance fluid administration in the pediatric surgical patient,

Intravenous fluid administration has been occurring for well over one hundred years for a variety of pediatric disease processes. Surprisingly, clinicians have yet to agree upon a standardized intravenous solution. There is ongoing debate regarding the administration of isotonic versus hypotonic fluids as maintenance solutions. In this article, we will review what is known about different maintenance solutions, discuss the potential complications with their use, and summarize the available evidence to help guide clinicians in their choice of maintenance fluids for their patients.     

Intravenous nutrition for the pediatric patient.

Nutritional management of infants and children differs from that of adults because of the extra requirements for growth and the limitations of physiological immaturity. Although parenteral nutrition (PN) is an accepted practice and a potentially life-saving therapy for pediatric patients who cannot be fed through their gastrointestinal tract, it is associated with the risk of serious metabolic, mechanical, and infectious complications. Candidates for PN should be selected according to well-defined indications, with initial nutritional assessment and with careful attention given to fluid, electrolyte, vitamin, trace element, and caloric requirements. Total calories should be administered so that the nonprotein-calorie to gram-nitrogen ratio is in the range of 150 to 250:1. Although short-term supplemental nutritional support can be administered through a peripheral vein, long-term total PN is best delivered by central venous access. PN should be initiated and monitored in accordance with well-established protocols. The lowest complication rate and highest cost-effectiveness are achieved by an interdisciplinary team that includes one or more nurses, dietitians, pharmacists, and physicians. The development of safe, reliable, and miniaturized intravenous pumps with built-in monitors has made home parenteral nutrition possible and desirable in selected patients.     

Nutritional issues in pediatric inflammatory bowel disease.

Malnutrition, characterized by weight loss, growth failure and micronutrient depletion, are prominent features of inflammatory bowel disease (IBD) in the pediatric age group. Accurate evaluation of the patient's nutritional status and appropriate nutritional support, whether enteral or parenteral, constitute integral parts of the management of the growing child with IBD. Over the past two decades, a number of studies have supported the potential use of nutritional therapy to induce remission and to control disease activity in symptomatic Crohn's disease. More recently, preliminary studies on the use of dietary supplements of marine-oil-derived omega-3 fatty acids have also indicated a beneficial effect in IBD patients. In parallel with these clinical trials, scientific research has recently focused on the concept that specific dietary alterations can modulate the immune response. Components of the diet that may have particular relevance to mucosal immunity and the pathogenesis of IBD include polyunsaturated fatty acids, nucleotides, and amino acids such as glutamine and arginine. Future research in the interactions between specific nutrients and the immune system will likely increase our understanding of the causes of IBD, as well as enhance the development of novel nutritional therapies for IBD patients.