危重患儿肠内营养中断的临床研究

目的:了解PICU患儿肠内营养中断原因及其与预后的关系。方法:回顾性研究2019年1月至6月所有入住中国医科大学附属盛京医院PICU的患儿,分析患儿基本喂养情况及肠内营养中断的频次、时间、原因,统计分析营养中断对患儿预后的影响。结果:共纳入471例患儿,入住PICU时中度营养不良发生率20.0%(94例),重度营养不良...     

Fungal endocarditis in critically ill children

All cases of infective endocarditis occurring from January 1990 to December 1996 at our institution were reviewed, with a special focus on fungal endocarditis. Five critically ill children with fungal endocarditis and eleven children with bacterial endocarditis were recorded. The proportion of fungal endocarditis in our series was 5/16 (31%) and Candida albicans (4/5) was the most common fungal pathogen. Only one patient required heart surgery because of a loose patch but all the others were treated only by medical management for cure. The hospital survival rate was 80% (4/5) and the overall long-term survival rate was 60% (3/5) with only one death directly related to fungal infection. Conclusion Despite the small number of cases, a sole medical approach including amphotericin B and long-term fluconazole prophylaxis for the treatment of fungal endocarditis in critically ill children seems to offer an alternative to surgical treatment which may be kept for failure of medical treatment. Received: 19 May 1998 and in revised form: 8 November 1998 / Accepted: 11 November 1998     

Persistent hyperglycemia in critically ill children

OBJECTIVES: To determine the prevalence and prognostic significance of hyperglycemia among critically ill nondiabetic children. STUDY DESIGN: We performed a retrospective cohort study using point-of-care blood glucose measurements, hospital administrative databases, and a computerized information system; 942 nondiabetic patients admitted to our Pediatric Intensive Care Unit (PICU) from October 2000 to September 2003 were included. The prevalence of hyperglycemia was based on initial PICU glucose measurement, highest value within 24 hours, and highest value measured during PICU stay up to 10 days after the first measurement. Primary outcome was in-hospital death with PICU lengths of stay (LOS) as secondary outcome. RESULTS: Through the use of three cutoff values (120 mg/dL, 150 mg/dL, and 200 mg/dL), the prevalence of hyperglycemia was 16.7% to 75.0%. The relative risk (RR) for dying increased for maximum glucose within 24 hours >150 mg/dL (RR, 2.50; 95% confidence interval (CI), 1.26 to 4.93) and highest glucose within 10 days >120 mg/dL (RR, 5.68; 95% CI, 1.38 to 23.47). LOS was decreased for admission glucose >120 mg/dL and 150 mg/dL but increased for all threshold values for maximum glucose within 10 days. CONCLUSIONS: Hyperglycemia occurs frequently among critically ill nondiabetic children and is correlated with a greater in-hospital mortality rate and longer LOS.     

危重患儿的高糖性高渗血症

应激性高血糖及其所致的高糖性高渗血症是儿科急救中较为常见的危重症之一。其中创伤、手术、缺氧、休克及多脏器功能衰竭者更易发生高血糖[1 ] ,心肺复苏后伴高血糖的危重患儿预后极差。但高血糖以及高糖性高渗血症常被临床忽略 ,其对机体的危害性也尚未引起临床医师的重视。本文就笔者医院的研究结果和临床经验 ,对危重症发生高糖性高渗血症的原因、病理生理、临床表现以及诊断和治疗 ,谈谈看法和体会。1　危重症发生高血糖的原因1 1　胰岛素拮抗致高血糖　危重患儿应激性高血糖的产生主要是创伤、缺氧、休克、感染等应激原的突发强烈刺…     

Transfusion therapy in critically ill children

Critically ill children in pediatric intensive care units are commonly indicated for blood transfusion due to many reasons. Children are quite different from adults during growth and development, and that should be taken into consideration. It is very difficult to establish a universal transfusion guideline for critically ill children, especially preterm neonates. Treating underlying disease and targeted replacement therapy are the most effective approaches. Red blood cells are the first choice for replacement therapy in decompensated anemic patients. The critical hemoglobin concentration may be higher in critically ill children for many reasons. Whole blood is used only in the following conditions or diseases: (1) exchange transfusion; (2) after cardiopulmonary bypass; (3) extracorporeal membrane oxygenation; (4) massive transfusion, especially in multiple component deficiency. The characteristics of hemorrhagic diseases are so varied that their therapy should depend on the specific needs associated with the underlying disease. In general, platelet transfusion is not needed when a patient has platelet count greater than 10,000/mm3 and is without active bleeding, platelet functional deficiency or other risk factors such as sepsis. Patients with risk factors or age less than 4 months should be taken into special consideration, and the critical thrombocyte level will be raised. Platelet transfusion is not recommended in patients with immune-mediated thrombocytopenia or thrombocytopenia due to acceleration of platelet destruction without active bleeding or life-threatening hemorrhage. There are many kinds of plasma-derived products, and recombinant factors are commonly used for hemorrhagic patients due to coagulation factor deficiency depending on the characteristics of the diseases. The most effective way to correct disseminated intravascular coagulation (DIC) is to treat the underlying disease. Anticoagulant therapy is very important; heparin is the most common agent used for DIC but the results are usually not satisfactory. Antithrombin III, protein C, or recombinant thrombomodulin has been used successfully to treat this condition. For reducing the risk of organism transmission and adverse reactions resulting from blood transfusion, the following measures have been suggested: (1) replacement therapy using products other than blood (e.g., erythropoietin, iron preparation, granulocyte colony-stimulating factor); (2) special component replacement therapy for specific diseases; (3) autotransfusion; (4) subdividing whole packed blood products into smaller volumes to reduce donor exposure; (5) advances in virus-inactivating procedures. To avoid viral transmission, vapor-heated or pasteurized products and genetic recombinant products are recommended. Cytomegalovirus (CMV)-seronegative blood, leukoreduced and/or irradiated blood are recommended for prevention of CMV infection, graft-versus-host-disease and alloimmunization in neonate and immunocompromised patient transfusion. There is no reason to prescribe a plasma product for nutritional supplementation because of the risk of complications. The principle: complications of transfusion must be avoided, the rate of blood exposure should be reduced and the safety of the transfused agents or components should be maintained must always be kept in mind.     

危重病患儿心肌损伤的研究进展

在危重病发展过程中心肌损伤是不可避免的,它严重威胁危重病患儿的生命安全.本文就危重病患儿心肌损伤的诊断、生物标志物及治疗3个方面的研究进展作一综述.     

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??Intra-hospital transport??IHT?? is an inevitable and important part of intensive care unit??ICU?? treatment. IHT is frequently required in order to perform diagnostic or therapeutic procedures for critically ill children. The incidence of adverse events??AEs??during IHT of critically ill children is very high. The decision to transport a critically ill child is based on an assessment of the potential benefits and risks. Specialized training?? perfect clinical evaluation??appropriate equipment??use of checklist and monitoring during transport may decrease adverse events and increase safety in IHT.     

Acquired carnitine abnormalities in critically ill children

In order to characterize the role of carnitine during metabolic stress, we prospectively determined carnitine profiles in plasma and urine on admission, days 2, 5, 10 and 15, among 28 critically ill children free of any known conditions associated with secondary carnitine deficiency. More than 25% of plasma and 50% of urinary carnitine measurements were abnormal; 96% (27/28) of patients displayed on at least one occasion an abnormal [<−2 SD or >+2 SD] carnitine value in plasma. Three children had extremely low [<10 μmol/l] free carnitine (FC) levels in plasma. Plasma esterified and FC levels on admission were not related to the risk of mortality [PRISM score], to muscle lysis [CK values], and to the caloric intake. Levels of FC and esterified carnitine in plasma were unrelated to those measured in urine. Conclusion Abnormal plasma and urine carnitine measurements are frequently found in critically ill children; the biological significance of these perturbations remains unclear. Caution must be exercised before concluding that an abnormal carnitine value is indicative of an underlying hereditary metabolic disorder in this population. Received: 7 March 1996 / Accepted: 14 April 1997     

强化胰岛素治疗儿童应激性高血糖

危重儿常伴应激性高血糖,这种急性一时性的高血糖可产生有害的病理生理效应。在重症监护病房已经推广应用强化胰岛素治疗应激性高血糖并取得较好的疗效,但在儿童应用仍存在争议。在儿科重症监护病房推行强化胰岛素治疗,根据不同的年龄段采用不同的血糖控制目标从而调节胰岛素的用量,较好的控制了血糖,减少了死亡率及并发症的发生率,促进疾病恢复,改善预后。     

Energy expenditure in critically ill children.

OBJECTIVE: To assess the measured resting energy expenditure pattern over time in a group of critically ill children who were admitted to a pediatric intensive care unit and to determine whether a hypermetabolic response, i.e., >10% above predicted, occurred in a pattern similar to that observed in adults. A secondary aim was to compare the accuracy of a newly derived prediction equation specific to the pediatric intensive care unit and the measured resting energy expenditure. DESIGN: A prospective, clinical, observational study. SETTING: A pediatric intensive care unit of a tertiary care medical center. PATIENTS: Forty-four children (29 males, 15 females) ages 2 wks to 17 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: During the course of their stay in the pediatric intensive care unit, 44 patients' measured resting energy expenditure was assessed using indirect calorimetry 94 times at up to three time points. The first measurement was at a mean time of 25 +/- 10 (+/-sd) hrs after admission, the second at 73 +/- 16 hrs, and the third immediately before discharge, which occurred at a mean of 193 +/- 93 hrs after admission. Measured energy expenditure varied only slightly (7% to 10%) from the first to second and the second to third measurements. Evidence for hypermetabolism was not apparent. Generally, the prediction equations performed well. Mean measured resting energy expenditure for all measurements was 821 +/- 653 kcals/24 hrs. The Schofield equation estimate was 798 +/- 595 kcals/24 hrs and the White equation estimate was 815 +/- 564 kcals/24 hrs (p = not significant). Nineteen (20%) measurements were >110% above the age-appropriate Schofield-predicted equation, and 30 measurements (32%) were <90% below that predicted by Schofield. Consequently, 45% of measured resting energy expenditure measurements were within 90% to 110% of that predicted by the Schofield equation. The White equation was inaccurate (not within 10% of measured resting energy expenditure) in 66 of 94 measurements (70%). The discrepancy was greatest (100%) in children with measured resting energy expenditure <450 kcal/24 hrs. CONCLUSION: The hypermetabolic response apparent in adults was not evident in these critically ill children. Currently available prediction equations cannot substitute for indirect calorimetry measurement of energy expenditure in guiding nutritional support in pediatric intensive care units.     

危重患儿代谢特点及营养需求

危重患儿由于处于急性应激高分解状态,基础代谢率明显增加,对营养素需要增加,加之摄入不足(厌食,进食能力丧失,胃肠功能障碍等),丢失过多(呕吐、腹泻、肠吸收不良,消化道造漏,短肠综合征等),体内营养素贮存很快耗尽,常发生急性蛋白质-热能营养不良(protein energy malnu-tritio