Éducation des familles et de l'enfant en nutrition artificielle à domicile

The techniques of artificial nutrition came of age since the seventies (1969 for enteral nutrition and 1973 for parenteral nutrition). Artificial nutrition has considerably modified the outcome of a great number of children with severe digestive tract pathologies or many other disorders making impossible or ineffective oral food administration. There are currently two techniques of artificial nutrition: enteral nutrition (the most physiological using the digestive tract) and parenteral nutrition (by central venous line, more demanding and more complications). Home parenteral and enteral nutrition emerged with new realities: increase in the number of children needing a nutritional assistance, increase in the number of indications and a constant need to make autonomous the child and the family leading to a better quality of life. The best care for these children needs a multidisciplinary approach (physicians, nurses, dieteticians, pharmacists, speech therapist, psychologists…) and a close relation between primary care and hospital. This also requires a significant investment of parents who are sometimes assisted by private nurses. Parents are thus educated with techniques of enteral nutrition and parenteral nutrition: use of the material, training with the care, learning the action to be taken in case of problem. They have thus a role of caregiver: heavy responsibility necessary to the return at home of their child. The educational role of the hospital team thus takes a paramount importance with the aim to provide an optimal home return and the most adequate care by the family.     

腹部大手术后不同时期肠内营养的临床研究

24例腹部大手术病人随机分为三组,术后分别接受普通静脉输液、早期肠内营养(术后第1天开始)及晚期肠内营养(肠功能恢复后开始).观察病人术后并发症发生情况,营养指标(体重、氮平衡、血清白蛋白、转铁蛋白)变化及对肠内营养的耐受性.结果发现:早期和晚期肠内营养均能改善病人的营养状况,减少术后并发症的发生;与晚期肠内营养相比,早期肠内营养具有更好的节氮效应,而对肠内营养的耐受性相同.结果表明腹部大手术后行肠内营养时,以早期应用为好.     

早期肠内营养对重症脑血管病病人呼吸机相关性肺炎的影响

目的 :探讨早期肠内营养(EEN)对重症脑血管病病人呼吸机相关性肺炎的影响,以及对病人营养状态、肠内营养耐受性、胃液PH值、消化道出血发生率的影响。方法 :本研究为前瞻性分析。研究对象为2014年3月至2017年5月我院神内重症收治接受鼻饲饮食及机械通气治疗共72例脑血管病病人。其中,36例在发病24小时内给予肠内营养支持治疗(早期组),36例发病24 h后给予肠内营养支持治疗(对照组)。比较两组病人治疗后7天呼吸机相关性肺炎发生率、脱机成功率、肠内营养并发症发生率、消化道出血发生率、治疗后第7天血清白蛋白、血清前白蛋白、治疗后28天存活率等临床指标变化,并分析入院时、入院1 d、3 d、7 d、14 d胃液PH值变化。结果 :早期组呼吸机相关性肺炎发生率、肠内营养并发症发生率、消化道出血发生率均低于对照组,血清白蛋白、前白蛋白、脱机成功率、存活率均高于对照组。早期给予肠内营养后,胃液PH值显著升高。结论 :早期肠内营养支持治疗能改善病人营养状态,有助于降低呼吸机相关性肺炎的发生率,提高脱机成功率,降低病死率,改善病人预后。早期肠内营养支持治疗导致胃液PH升高,能降低胃肠道并发症发生率,降低消化道出血发生率。     

Feeding the gut early after digestive surgery: results of a nine-year experience

BACKGROUND AND AIMS: Early enteral nutrition (EEN) after surgery should be preferred to parenteral feeding, but its clinical use is limited for concerns about possible gastrointestinal (GI) adverse effects and feeding tube-related complications. Thus we evaluated our experience focusing on safety and tolerance of early postoperative jejunal feeding and possible risk factors for gastrointestinal adverse effects. METHODS: 650 subjects treated with EEN after major digestive surgery for cancer were prospectively studied. EEN was started within 12 hours after operation via a naso-jejunal (NJ) feeding tube or a catheter-feeding jejunostomy. The rate of infusion was progressively increased to reach the nutritional goal (25 kcal/kg/day) within the 4th postoperative day. Rigorous treatment protocols for diet delivery and EEN-related GI adverse effects were applied. RESULTS: 402 patients had a jejunostomy and 248 patients a NJ tube. EEN-related GI adverse effects were observed in 194/650 patients (29.8%). In 136/194 patients, these events were successfully handled by treatment protocols. Overall the nutritional goal was achieved in 592/650 patients (91.1%). Fifty-eight (8.9%) subjects had to be switched to parenteral feeding because of refractory intolerance to EEN. Intra-abdominal surgical complications and low serum albumin (<30 g/L) were the two major factors affecting tolerance. Severe jejunostomy-related complications occurred in 7/402 (1.7%) patients. EEN-related mortality was 0.1% (1/650). CONCLUSIONS: The use of the gut early after surgery is safe and well-tolerated and it should represent the first choice for nutritional support in this type of patients.     

匀浆膳联合酸奶在重型颅脑损伤患者中的临床应用

目的探讨重型颅脑损伤患者应用匀浆膳联合酸奶行肠内营养治疗的临床效果。方法ICU重型颅脑损伤患者200例急症手术后随机分为两组：研究组给予匀浆膳联合酸奶治疗；对照组给予匀浆膳治疗。伤后48小时开始分别给予鼻饲额定热卡的两种肠内营养治疗，每日消耗不足部分辅以肠外营养补充。比较各营养指标、胃肠功能障碍指标、意识恢复程度及预后。结果研究组各营养指标均高于对照组，各种胃肠道并发症的发生均少于对照组，预后优于对照组。结论重型颅脑损伤患者给予匀浆膳联合酸奶行肠内营养治疗可有效地改善患者的营养状况，减少胃肠道并发症，提高生存率，有利于患者的康复。     

Early transpyloric enteral nutrition in critically ill children

OBJECTIVE: We compared the tolerance of early (within the first 24 h after admission to the pediatric intensive care unit) and late transpyloric enteral nutrition in critically ill children. METHODS: We performed a prospective observational study including all critically ill children fed using transpyloric enteral nutrition. The clinical characteristics, energy intake, tolerance, and complications of nutritional delivery between the children with early (first 24 h) and late (after 24 h, range 1-43 d) transpyloric enteral nutrition were compared. RESULTS: Transpyloric nutrition was started within the first 24 h in 202 (38.5%) of the 526 children. There were no differences in the diagnoses, incidence of organ disturbances, doses of vasoactive drugs, or mortality between the two groups. There were no differences in the maximum number of calories delivered or in the duration of the nutrition between children with early and late transpyloric nutrition. The incidence of abdominal distention was lower in the children receiving early transpyloric nutrition (3.5%) than in those receiving nutrition at a later date (7.8%; P < 0.05). Moreover, 6.3% of patients presented diarrhea, with no difference being found between the two groups. CONCLUSION: Early transpyloric enteral nutrition is well tolerated in critically ill children and is not associated with an increase in incidence of complications.     

Nutrition périopératoire : protocoles de soins

Based on texts written by experts, the objective of this paper is to propose a practical approach to nutrition for clinicians, according to the nutritional status of patients and the evaluation of surgical risk. Any patient with a nutritional grade greater than or equal to 2 should benefit from nutritional support. Indeed, current data confirm that preoperative and early nutritional support in surgery at risk can reduce significantly postoperative morbidity for patients with non-malnourished (immunonutrition in cancer surgery GI), and the morbidity and mortality in malnourished patients (enteral nutrition when possible). A preoperative oral intake is recommended 2 to 3 hours before elective surgery for clear fluids and 6 hours for a light meal. Moreover, a preoperative oral intake of carbohydrates (maltodextrin 12.5%) is recommended (except in diabetic patients). Postoperatively, early oral feeding (within 24 hours) is recommended in the absence of cons to surgery. Glutamine is recommended in case of postoperative complications.     

不同肠内营养方式对呼吸机相关性肺炎的影响

目的 研究不同肠内营养方式对机械通气患者营养状况、肠内营养耐受性、并发症及呼吸机相关性肺炎的影响.方法 选择64例重症呼吸衰竭机械通气患者为观察对象,随机分为两组,鼻胃管组和鼻肠管组,各32例;两组均给予肠内营养制剂,不足部分由肠外营养补充;观察两组患者在治疗前后营养指标的演变,比较两组患者肠内营养并发症、肠道耐受性、呼吸机相关性肺炎的发生率、机械通气时间和住ICU时间.结果 治疗前后的前白蛋白鼻胃管组患者为(161.8±19.1)、(193.7±27.0)mg/L,鼻肠管组患者为(182.5±29.4)、(214.32.4)mg/L;治疗前后转铁蛋白鼻胃管组患者为(228.3±42.1)、(266.3±23.1)mg/L,鼻肠管组患者为(223.1±26.2)、(272.6±25.5),治疗前后比较,差异均有统计学意义(P＜0.05);鼻胃管组与鼻肠管组:腹胀腹泻发生率为25.0％、15.6％,高血糖发生率为28.1％、6.2％,应激性溃疡发生率为6.2％、3.1％,肝损害发生率为6.2％、3.1％,差异均无统计学意义;鼻肠管组反流率及呼吸机相关性肺炎发生率均为6.2％,低于鼻胃管组的31.2％、18.7％(均P＜0.05);鼻肠管组机械通气时间、住ICU时间为(6.5±1.1)、(8.9±1.8)d,短于鼻胃管组的(9.8±2.3)、(13.4±2.4)d,差异均有统计学意义(P＜0.01).结论 肠内营养对机械通气患者的营养状况的改善有帮助;经鼻肠管方式行肠内营养的机械通气患者肠道耐受性好,呼吸机相关性肺炎发生率低.     

肠内营养在维护门静脉高压症术后患者肠道黏膜屏障功能中的作用

目的了解肠内营养在维护门静脉高压症术后患者肠道黏膜屏障功能中的作用和地位。方法40例门静脉高压症手术患者随机进入肠内(EN)或肠外营养(PN)组,术后分别接受肠内外营养,观察两种营养方式对患者内脏蛋白合成能力、肝功能及其储备、胃肠功能、内毒素水平、肠道细菌移位和乳果糖/甘露醇比值等方面的影响。结果两种营养方式均能改善患者的营养状况。EN术后并发症少,在刺激肠道蠕动,减轻内毒素水平,防止肠道菌群移位,维护肠黏膜屏障方面优于PN,且差异显著(P<0.05)。结论EN是维护此部分患者肠道黏膜免疫屏障功能稳定的有效方式。     

早期肠内营养联合双歧杆菌在消化道穿孔病人中的应用研究

目的:探讨早期肠内营养(EEN)联合双歧杆菌在急诊消化道穿孔病人中的应用效果。方法:将59例急诊消化道穿孔手术病人采用随机数字表法分为试验组(EN加双歧杆菌,n=31)和对照组(TPN,n=28)。试验组病人于术后第1天(24 h)起给予EN支持;对照组于术后第1天开始行肠外营养(TPN)支持治疗。统计两组病人的平均住院时间、入住ICU时间、并发症发生率、炎性指标(血清C-反应蛋白)和营养学指标(前清蛋白、清蛋白)水平。结果:试验组病人平均住院时间,入住ICU时间、平均肠功能恢复时间和开始进食时间均较对照组明显缩短(P0.05)。手术前后两组病人营养学指标无显著性差异(P0.05)。术后第4天,试验组病人C-反应蛋白较对照组显著降低(P0.05),术后切口感染裂开发生率较对照组显著降低(P0.05),其余并发症发生率无显著性差异(P0.05)。结论:早期给予EN联合双歧杆菌治疗,可明显缩短消化道穿孔病人术后肠功能恢复时间,缩短住院日,减少感染发生率,改善病人预后。     

不同营养制剂的选择对急性脑卒中患者的影响

目的：探讨急性脑卒中患者采用短肽型肠内营养制剂逐步过渡到含膳食纤维的整蛋白型肠内营养制剂的＂序贯营养支持＂疗法是否比单纯采用整蛋白型肠内营养制剂的＂常规营养支持＂疗法更有利于患者营养状况的改善。方法：将105例急性脑卒中伴吞咽障碍的患者随机分为研究组和对照组,研究组（采用＂序贯营养支持＂疗法）54例,对照组（采用＂常规营养支持＂疗法）51例。观察两组患者入院第1、7、14、21、28天时腹胀（与文章里的指标不同）、腹泻等消化道症状发生情况及营养状态（要写出指标）。结果：研究组入院第7、14天时的消化道症状发生率明显低于对照组,营养评定指标显著高于对照组;入院第21、28天时两组差异无统计学意义。结论：急性患者采用短肽型肠内营养制剂逐步过渡到含膳食纤维的整蛋白型肠内营养制剂的＂序贯营养支持＂疗法比单纯采用整蛋白型肠内营养制剂的＂常规营养支持＂疗法更有利于患者病后第1-2周时营养状况的改善。     

鼻空肠管和鼻胃管在重型颅脑损伤患者早期肠内营养中应用效果的比较

目的 比较鼻空肠管和鼻胃管在重型颅脑损伤患者早期肠内营养中的应用效果.方法 采用随机数字表法将40例重型颅脑损伤需行早期肠内营养支持的患者随机分为鼻空肠管组和鼻胃管组,每组20例,比较营养支持后两组患者的生化指标、胃肠道耐受和并发症发生情况.结果 营养支持前后,两组患者血清白蛋白、血糖和淋巴细胞计数水平的组间差异均无统计学意义（P均＞0.05）.营养支持后14 d,鼻空肠管组患者的血糖水平较营养支持前明显降低（P=0.0001）.营养支持1周内,鼻空肠管组患者反流（P=0.001）、腹胀（P=0.011）的发生率均明显低于鼻胃管组患者.结论 鼻空肠管对重型颅脑损伤患者早期肠内营养支持效果优于鼻胃管.     

老年颅脑损伤病人早期肠内营养支持的应用研究

目的：评价早期胃肠道营养支持在老年颅脑损伤治疗中应用的安全性和有效性。方法：将31例老年颅脑损伤病人随机分为肠内营养支持组（n=16)和肠外营养支持组（n=15)，在营养支持前一天及营养支持后测血清白蛋白，血糖，肝肾功能，电解质，每天观察相关并发症情况。结果：与肠外营养比，早期肠内营养病人血清白蛋白水平增加，GPT和血糖减低，并发症少。结论：老年颅脑损伤病人实施肠内营养支持是安全和有效的，优于肠外营养。     

Comment réaliser et surveiller une nutrition postopératoire ?

Nutritional supply is necessary in post operative patients who can not assure a normal oral feeding, equivalent to 60 % of their needs, in the 9 days following surgical procedure. In a normal well-feed population, nutritional supply in a shorter post-operative period is whithout influence on mortality and morbidity. On the other hand in undernourished patients nutritional support seems to decrease morbidity. However, the definition of this group using simple means remains difficult. After elective surgery, comparison between total parenteral nutrition and enteral nutrition does not show any important difference. However in the case of post tranmatic surgery, infectious morbidity and intensive care and hospital stays are lower when enteral nutrition is used. The lack of difference following elective surgery is likely due to a small number of patients and the low rate of complications. Enteral nutritional support must be chosen when ever possible. Currently, it is not possible to affirm the porportion of each nutrient when nutrition is performed at the post-operative phase. Optimal glucose supply is around 4 to 6 mg/kg/min and the calorie to nitrogen ratio from 200 to 150/1. Some specific nutrient seem to be of interest especially alpha keto glutarate which can be theoretically employed as a substitute for glutamine. This substrate seems to decrease septic complications and delay of wound healing.Nutritional assessment and effectiveness of feeding regimen is very difficult during the post-operative phase. Only, the confrontation of several methods allows to have a good approach of the nutritional status. Among visceral proteins, transthyretin has the highest sensitivity and predictive specificity during a stable inflammatory process. Muscle strength and bio electrical impedance measurements seem of interest but need further studies. Subjective assessment at the preoperative period remains the best method of nutritional assessment but requires trained observers.     

Home enteral nutrition in patients with Acquired Immunodeficiency Syndrome

14 patients in advanced stages of HIV infection (1 ARC, 13 AIDS; sex: 1 female, 13 male; age 37.8 +/- 6.3 years; body mass index (BMI): 17.4 +/- 2.4 kg/m(2)) were followed prospectively while receiving home enteral nutrition (observation period: 62 +/- 75 days). Artificial nutrition was indicated because of severe weight loss (9-38 kg within 6-48 months, n = 7) or cerebral toxoplasmosis with eating and swallowing disorders (n = 7). In all patients a defined formula diet (175 +/- 17.7 kJ/kg body weight) was administered through an endoscopically placed gastrostomy tube (PEG). Home enteral nutrition was well tolerated by all patients and no significant PEG-related complications occurred. Enteral nutrition resulted in significant increases in body weight (p < 0.005), body cell mass (BCM, p < 0.05), total body fat (TBF, p < 0.005), serum albumin concentration (p < 0.05), and serum total iron-binding capacity (transferrin, p < 0.01). Conclusion: Home enteral nutrition via PEG is safe and well tolerated in patients with advanced HIV-related immunodeficiency and is capable of improving nutritional state including BCM.     

消化道肿瘤术后早期应用含膳食纤维肠内营养的临床研究

目的：探讨消化道肿瘤术后早期应用含膳食纤维肠内营养的可行性、安全性和临床效果。方法：62例伴营养不良的消化道肿瘤病人,随机分为肠内营养（EN组,n=32）和常规补液（对照组,n=30）两组。所有病例在营养支持前、后各测定一次体重、肝肾功能、血糖、电解质、血浆蛋白、Hb、免疫球蛋白、淋巴细胞计数和血胃泌素,临床观察生命体征、胃肠道功能恢复情况及各种不良反应。结果：所有病例在研究期间无死亡、无严重并发症、无明显肝肾功能改变。营养支持后EN组血浆白蛋白、前白蛋白和转铁蛋白水平明显升高（P＜0.05),体重下降减缓,血胃泌素水平在肠道营养后明显升高（P＜0.05),所有病例的免疫功能均有改善,临床观察EN组肛门恢复排气时间较TPN和对照组显著缩短（P＜0.05)。结论：消化道肿瘤术后早期应用含膳食纤维的肠内营养支持完全、可行,并能改善机体营养状态,同时刺激胃肠道激素分泌,有利于促进和维护胃肠道功能。     

Quand et comment conduire une nutrition entérale au cours de l’anorexie mentale ?

Lifesaving treatment in patients with anorexia nervosa and compromised nutritional status is controversial. Enteral nutrition, via a nasogastric tube can be useful in this situation. The digestive tract can be used better than parenteral nutrition. Enteral nutrition can also be used in a situation with moderate malnutrition and stable body weight despite an adequate psychological treatment. In all cases, this treatment should be discussed and accepted with the patient. Polymeric standard solutions can be used, taking care of the level of protein which should not be too high. The start of enteral nutrition is progressive, in order to avoid the risk of Refeeding Syndrome. Vitamins and phosphorus should be added to the enteral nutrition during the first few days. Complications of treatment is not frequent with these patients and are presented. Enteral nutrition should be not too long and should be decreased in the same time that oral nutrition progressively increases. The results of literature show that, enteral nutrition does not deteriorate the psychological state of the patients and is found to be accepted more positively than forced feeding orally in the initial critical phases, and is less dangerous in terms of metabolic tolerance. For these reasons, enteral nutrition should be included in the armament of treatment of anorexia nervosa.     

Assistance nutritionnelle des hépatopathies aiguës : hépatite alcoolique et cirrhose

The role of short-term artificial nutrition (either parenteral or enteral) in alcoholic hepatitis and cirrhosis is reviewed.Although there are no controlled trials comparing enteral and parenteral nutrition in cirrhosis, the former is to be preferred. In controlled trials, enteral nutrition has proven to be safe, to improve nutritional status (as far as it increases the protein-energy intake), and (in one study) to decrease the short-term mortality of advanced cirrhotics.Several nutritional approaches to the treatment of alcoholic hepatitis have been attempted. The early expectations of the intravenous administration of standard amino acid solutions have not been confirmed in subsequent trials. It is difficult to discriminate between the effects of enteral nutrition upon alcoholic hepatitis and those upon the underlying cirrhosis. Recent studies comparing the effect of enteral feeding and corticosteroids (considered as the gold standard therapy) in the short-term survival of severe alcoholic hepatitis patients indicate that both treatments may be equally effective. These data have to be confirmed in further trials, as well as the potential synergistic effect of enteral feeding and steroids in these patients.     

早期肠内营养对吉兰-巴雷综合征病人呼吸机相关性肺炎的影响

目的:探讨早期肠内营养(EEN)对吉兰-巴雷综合征(GBS)病人呼吸机相关性肺炎(VAP)的影响。方法:本研究为前瞻性分析。选取2011年5月至2017年5月河北大学附属医院NICU收治接受鼻饲饮食及机械通气治疗共36例GBS病人。其中,18例在机械通气24 h内给予EN支持(早期组),18例机械通气24 h后给予EN支持(对照组)。比较两组病人营养状态、肠内营养并发症发生率、VAP发生率、机械通气时间、NICU停留时间、治疗后APACHEⅡ评分、病死率等临床指标变化。结果:早期组VAP发生率、机械通气时间、NICU停留时间、治疗后APACHEⅡ评分均低于对照组,营养状态指标优于对照组。同时,腹泻、消化道出血、应激性高血糖等肠内营养并发症发生率相对较低,病死率较低,但无统计学意义。结论:早期应用EN支持治疗,可改善病人营养状态,有助于降低呼吸机相关性肺炎的发生率,缩短脱机时间,降低病死率,改善病人预后。     

老年重症肺炎病人营养支持治疗的疗效观察

目的:探讨两种不同的营养支持治疗对老年重症肺炎病人临床治疗疗效的影响。方法:将我院收治的老年重症肺炎病人84例随机分为两组,每组各42例。一组肠内营养(EN)组病人给予EN以鼻饲营养液治疗;另一组采用EN+肠外营养(PN)治疗为EN+PN组。治疗第4周,比较两组病人的营养指标改善情况、肺炎治愈率以及治疗期间并发症的发生率。结果:EN+PN组病人治疗后血红蛋白和清蛋白明显高于EN组,两组比较差异有显著性统计学意义(P0.05)。两组病人治愈率分别为92.86%和95.24%,无显著性差异(P0.05)。EN组病人的不良反应发生率明显高于EN+PN组(16.67%vs 7.14%),差异有显著性统计学意义(P0.05)。结论:采用EN+PN治疗的方法更加容易改善老年重症肺炎病人的营养指标,且不良反应发生率较低。