肠外营养监测及并发症处理

肠外营养（PN）是不能通过口或肠道为患儿提供足够营养时,所采取的一项挽救生命的治疗措施,可预防或改善营养不良,并保证患儿的生长发育需要。相比经口喂养或肠内营养,PN花费多,并可引起严重并发症。因此,需要严密监测,建立多学科的营养支持团队,避免所提供的营养不均衡或营养过度,严格进行无菌操作,以减少导管相关感染,有可能的情况下尽可能强化肠内营养,减少PN的量和时间。     

Overview of pediatric short bowel syndrome

Short bowel syndrome (SBS) is a malabsorptive state occuring as a result of surgical resection or congenital disease of a significant portion of the small intestine . The amount of resection or remaining bowel generally dictates the degree of malabsorption and consequentely the need for specialized enteral nutrition or parenteral nutrition (PN). Intestinal failure in the context of SBS is defined as a dependence on PN to maintain minimal energy and fluid requirement for growth in children. Common causes of SBS in infants and children include necrotizing enterocolitis, midgut volvulus, intestinal atresia, and gastroschisis. Early identification of patients at risk for long-term PN dependency is the first step toward avoiding severe complications. Close monitoring of nutritional status, steady and early introduction of enteral nutrition, and aggressive prevention, diagnosis, and treatment of infections such as central venous catheter sepsis and bacterial overgrowth can significantly improve the prognosis. Intestinal transplantation is an emerging treatment that may be considered when intestinal failure is irreversible and children are experiencing serious complications related to TPN administration.     

Parenteral Nutrition in paediatrics

The provision of nutrients intravenously or Parenteral Nutrition (PN), has been one of the biggest therapeutic progress over the last 50 years. PN has increased survival rates in children with gastro-intestinal and extra-intestinal diseases not tolerating oral or enteral nutrition. Moreover PN decreases malnutrition and therefore increases survival. PN related complications have been minimized thanks to advances in equipment, training and expertise, however, this treatment still has substantial risks. PN in paediatrics should be delivered by expert multidisciplinary nutrition team to ensure appropriate use, delivery, monitoring and weaning.In this review we will take the reader through the ESPGHAN/ESPEN guidelines, at present the main reference for paediatric PN.     

早产儿胃肠外营养相关性胆汁淤积的治疗现状

胃肠外营养是救治早产儿及危重新生儿的重要措施.近年来,随着围生期抢救技术的提高,越来越多的早产儿得以存活,极低出生体重儿、超低出生体重儿逐渐成为新生儿疾病谱的重要组成部分。这些早产儿常有胃肠道发育不成熟或合并其他疾病,在出生后的相当长一段时间内需要部分或完全的胃肠外营养支持。由于胃肠外营养的使用,为此类患儿提供了生存机会,大大降低了病死率,但其引起的胃肠外营养相关性胆汁淤积,则成为早产儿的主要并发症之一,严重影响患儿的生存质量。该文就早产儿胃肠外营养相关性胆汁淤积的治疗现状作一综述。     

新生儿肠道外营养相关性胆汁淤积的危险因素

肠道外营养（PN）是危重新生儿救治的重要支持、治疗手段,肠道外营养相关性胆汁淤积（PNAC）是其常见合并症。该文从非PN 营养成分及PN 营养成分相关角度综述新生儿PNAC 的危险因素。PNAC 危险因素主要包括早产、小于胎龄、延长的PN、疾病（主要是新生儿败血症及坏死性小肠结肠炎）、延迟喂养或低肠道内营养比例、持续PN 输注,以及氨基酸、脂肪乳种类/用量、能量供给量及部分微量元素含量等。     

新生儿围手术期的营养支持

目的评估新生儿围手术期应用胃肠外营养(PN)支持的临床疗效,为营养支持的合理运用提供依据。方法对30例围手术期新生儿进行营养评估,营养不良者在肠内营养的基础上辅以PN,总结PN的组成、供给量、配制顺序、使用途径,并监测体质量、实验室指标、预后及防治并发症。结果 30例病例中,26例痊愈,4例好转。PN治疗后,患儿体质量、血浆白蛋白较前略有增加(P均<0.05),肝转氨酶、黄疸、血脂、尿素氮、前白蛋白、总胆汁酸均无明显变化。结论 PN支持方案安全、有效,实施方便;对于蛋白质营养不良新生儿围手术期的PN支持,应适当增加氨基酸的供给量。     

Irreversible intestinal failure

Intestinal failure (IF) can be defined as the reduction of functional gut mass below the minimal amount necessary for digestion and absorption adequate to satisfy the nutrient and fluid requirements for maintenance in adults or growth in children. In developed countries, IF mainly includes individuals with the congenital or early onset of conditions requiring protracted or indefinite parenteral nutrition (PN). Short bowel syndrome was the first commonly recognized cause of protracted IF. The normal physiologic process of intestinal adaptation after extensive resection usually allows for recovery of sufficient intestinal function within weeks to months. During this time, patients can be sustained on parenteral nutrition. Only a few children have permanent intestinal insufficiency and life-long dependency on PN. Non-transplant surgery including small bowel tapering and lengthening may allow weaning from PN in some cases. Hormonal therapy with recombinant human growth hormone has produced poor results while therapy with glucagon-like peptide-2 holds promise. Congenital diseases of enterocyte development such as microvillus inclusion disease or intestinal epithelial dysplasia cause permanent IF for which no curative medical treatment is currently available. Severe and extensive motility disorders such as total or subtotal intestinal aganglionosis (long segment Hirschsprung disease) or chronic intestinal pseudo-obstruction syndrome may also cause permanent IF. PN and home-PN remain are the mainstays of therapy regardless of the cause of IF. Some patients develop complications while receiving long-term PN for IF especially catheter related complications (thrombosis, sepsis) and liver disease. These patients may be candidates for intestinal transplantation. This review discusses the causes of irreversible IF and emphasizes the specific medico-surgical strategies for prevention and treatment of these conditions at several stages of IF.     

New approaches to parenteral nutrition in infants and children

Parenteral nutrition (PN) has become a mainstay in the treatment of children with intestinal failure or conditions that preclude enteral feeding. Estimated energy and protein requirements can usually be met, unless the patient is fluid volume restricted or glucose intolerant. Although PN is generally well tolerated, in some patients it is still associated with a significant morbidity. Complications include metabolic disturbances, venous access device infection or dysfunction, venous thrombosis and cholestatic liver disease. Patients need to be carefully monitored for evidence of micronutrient deficiencies or excesses. There is a close relationship between line sepsis and thrombosis. Strict aseptic technique is the key to preventing line infections. Recurrent sepsis and thrombosis may eventually lead to loss of venous access and may jeopardize the long-term delivery of PN. Chronic cholestatic liver disease is common in premature infants with gastrointestinal problems, recurrent sepsis and lack of enteral feeding. The aetiology is multifactorial. Early enteral feeding is the most effective strategy in preventing PN-associated liver disease. New specialized nutrient solutions and lipid emulsions promise improved clinical outcomes. However, long-term clinical data are not yet available in children. In recent years, nutrition support teams have improved clinical and economic outcomes by encouraging the appropriate use and monitoring of PN therapy. In patients with intestinal failure, parent-administered home PN has become an alternative to long-term hospitalization. Apart from a positive effect on the quality of life of patient and family, home PN is cost-effective and reduces the risk of nosocomial infections and catheter-related complications.     

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??The incidence of malnutrition in critically ill children is always high??and parenteral nutrition??PN?? support is one of the important way to improve infants’nutrition status. The proper venous access and management is the fundamental assurance to infusion of PN. Properly venous access should be selected according to the concentration??osmotic pressure??pH and duration of parenteral nutrition. Venous accesses consist of peripheral venous access and central venous accesses??and central venous accesses consist of percutaneously inserted central catheter access?? peripherally inserted central catheter access and port. It will reduce complications effectively to choose suitable venous access??handle and manage inserted catheter well.