长期肠外营养与胆汁淤积症相关因素的临床分析

目的:分析危重症新生儿肠外营养(PN)相关性胆汁淤积症(PNAC)的临床特点及影响因素,探讨其预后.方法:在我院接受PN治疗时间超过2周的婴儿64例,其中发生PNAC 15例(PNAC组)和未发生PNAC(对照组)49例.所有病儿均明确原基础疾病治疗恢复情况以及PN实施情况,特别是在PN期间有无肠道喂养以及何时开始喂养等,计算每天PN补充热量及各种营养成分.对发生胆汁淤积症病儿均进行常规保肝、利胆治疗2～4周,期间每周监测血生化、肝功能,并监测经皮胆红素.治疗结束后根据情况每2～4周复查肝功能和血生化及肝B超.所有病儿均随访至6个月.结果:①本组PNAC总发生率为23.4%.PNAC组中,体质量＜2000g者占80.0%;而对照组中占42.9%,两组比较有显著性差异(P＜0.05).②PN第1周内完全禁食者,PNAC组为80.0%,对照组为22.4%,两组比较有显著性差异(P＜0.05).③PNAC组中预后良好者为73.3%,而对照组为95.9%,两组比较有显著性差异(P＜0.05).结论:新生儿长期PN相关性胆汁淤积症的发生与否,与病儿出生时体质量、PN过程中是否尽早进行胃肠内营养密切相关.     

Urogastrone reduces gut atrophy during parenteral alimentation

Urogastrone (UG) exerts trophic effects on the intestine and may play a role in maintaining normal intestinal structure and function. Since administration of nutrients parenterally results in intestinal hypoplasia and hypofunction, the aim of this study was to determine the effects of UG on intestinal structure and function in parenterally fed rats. Central venous catheters were placed into 28 Sprague-Dawley rats. Group I (n = 10) received TPN alone. Group II (n = 8) received TPN and 15 micrograms/day of UG and group III (n = 10) received rat chow ad libitum. The animals that received urogastrone had significantly greater (p less than 0.05) intestinal weight (25.6 +/- 2.5 mg/cm vs 22.6 +/- 3.0 mg/cm), mucosal weight (8.4 +/- 1.4 mg/cm vs 6.2 +/- 0.9 mg/cm), mucosal protein content (6.2 +/- 1.7 mg/cm vs 2.7 +/- 0.6 mg/cm), villous height (427 +/- 27 microns vs 293 +/- 75 microns), crypt cell production rate (14.5 +/- 1.4 metaphases/hr vs 12.3 +/- 0.7 metaphases/hr) and sucrase specific activity (6.5 +/- 2.6 vs 3.7 +/- 2.0) than animals receiving only TPN. However, these parameters remained less than in chow-fed animals. Thus, simultaneous infusion of UG prevents, in part, intestinal hypofunction and hypoplasia which occurs during TPN. This may be due to maintenance of mucosal proliferative activity and brush border enzyme activity.     

急性胰腺炎的肠内及肠外营养支持

急性胰腺炎 (acutepancreatitis ,AP)是一种可伴有全身多器官功能障碍的疾病 ,由于起病急骤、病情重、并发症多 ,病死率高。AP以蛋白质分解、糖原异生和脂肪动员增强为特征的超高代谢反应 ,使患者出现严重营养不良 ,防御免疫能力降低 ,感染机率增高[1,2 ] ,而使并发症和病死率增高。这种超高代谢反应可能与急性胰腺炎患者分解代谢激素和炎症介质的大量释放有关。因而对于胰腺炎的营养支持应提高到代谢支持水平上 ,代谢支持的目的是使代谢紊乱控制到一定程度内 ,减少其对机体的不利一面 ,调节炎症介质反应和改善免疫功能。代谢支持并不仅是…     

Reduced alternative complement pathway control protein levels in anorexia nervosa: response to parenteral alimentation

Serum levels of 16 proteins, including 11 component and control proteins of the complement system were determined before and after nutritional repletion in five female patients with severe malnutrition secondary to anorexia nervosa. Before parenteral alimentation significantly decreased serum levels were found for IgG, IgM, transferrin, Clq, C2, C3, factor B, beta lH, C3b inactivator, properdin, and C4 binding protein. A significant increase in posttreatment serum levels compared with pretreatment levels were found for transferrin, C3, factor B, beta lH, and C3b inactivator. Of the proteins measured, the C3b amplification loop control and component proteins, beta lH, C3b inactivator, C3, and factor B rose to the normal range in response to therapy most rapidly. In the absence of an acute phase reaction, these proteins appear to be particularly good indices of malnutrition and its response to therapy.     

Formation of Maillard reaction products in parenteral alimentation solutions

Terminal heat sterilization of glucose-amino acid solutions produces Maillard reaction products. Since deleterious effects are associated with the ingestion of these compounds, their presence in parenteral nutrition solutions should be avoided. We measured the extent of Maillard product formation in 25% glucose + 4.25% amino acid solutions (+/- added electrolytes) sterilized by membrane filtration. Maillard product formation increased with time and temperature of storage. In the absence of added electrolytes, the average loss of amino acids to Maillard products at 4 degrees after 1, 7 and 30 days storage was 0.35, 0.62, and 1.51%, respectively. Losses of 0.74, 1.07 and 2.88% were noted at 4 degrees in the presence of added electrolytes. The average loss of amino acids in mixtures stored for 1, 7 and 30 days at 25 degrees in the absence of electrolytes was 0.83, 2.99 and 4.63%, respectively, and 1.52, 3.36 and 7.43 in the presence of added electrolytes, Mixtures stored at 60 degrees for 24 hours without added electrolytes showed an average loss of 8.03% of amino acids, whereas an 11.5% loss was noted in the presence of added electrolytes. Proline and amino acids with hydrophobic side chains reacted more slowly than other amino acids, while tryptophan and amino acids with aliphatic hydroxy side chains reacted most rapidly. The addition of electrolytes increased the rate of Maillard product formation at all temperatures. The data indicated that 25% glucose + 4.25% amino acid solutions should be stored for only a minimal period of time, preferably at 4 degrees, prior to use.     

Free amino acid levels in the blood of patients undergoing parenteral alimentation.

Free amino acid levels were determined in the blood of patients undergoing parenteral alimentation. During amino acid infusions, alanine, valine, glycine, isoleucine, leucine, proline, threonine, serine, methionine, phenylalanine, and lysine levels increased. Bivariate regression analysis was then done to determine the average rise in each amino acid when 1 mmole/hr of that amino acid was infused and when 1 mmole/hr of glucose was infused. This analysis was done on both arterial plasma and arterial wh-le blood increments. The average rise in the amino acid level with 1 mmole of infusion per hour varied from 32 to 133 mumole/liter. Only alanine levels were positively correlated with glucose infusion, while the branched chain levels were all negatively correlated. In no instance could a significant positive arteriovenous difference across the forearm be correlated with the infusion of an amino acid, despite amino acid levels as much as five times normal. Methionine, proline, valine, threonine, and lysine showed the greatest rise in blood concentration per millimole of amino acid infused per hour suggesting that their degradation or use in protein synthesis was limited. While the blood concentration rise in glycine was only about half as much per millimole per hour infused as was found in the previously mentioned group of amino acids, high rates of infusion of this amino acid resulted in large increments inglycine levels. It may be desirable to reduce the amounts of these amino acids in parenteral amino acid formulations.     

Observations of vitamin A toxicity in three patients with renal failure receiving parenteral alimentation

Elevated serum retinol concentrations have been previously reported in patients with renal failure, although overt clinical toxicity has been described only rarely. We present three patients with renal failure receiving total parenteral nutrition (TPN) who developed biochemical and clinical findings of hypervitaminosis A. Improvement followed deletion of vitamin A from the TPN. These cases demonstrate that patients with renal failure may be at risk for symptomatic vitamin A toxicity if given TPN with standard retinol supplementation. Such patients should be carefully observed clinically and biochemically if supplementation is given.     

A comparison of essential and general amino acid infusions in protein-depleted patients receiving parenteral alimentation.

Six malnourished patients were studied during intravenous nutrition therapy to compare the efficiency of essential and general amino acids when given as the sole nitrogen source during intravenous nitrogen therapy. A cross-over design was used so that each patient received both essential amino acids plus arginine and histidine and a general amino acid solution in random order. Glucose provided the remainder of the energy and both infusions contained 2 g of amino acid per 100 kcal. Each patient's daily urea nitrogen production was greater during infusion of the general amino acid solution. Consequently, nitrogen intake minus urea nitrogen production was significantly greater when the essential amino acid solution was infused. Plasma amino acid levels were determined on each patient during both essential and general amino acid infusion. Abnormalities tend to reflect the composition of the amino acid solutions as well as their administration directly into the systemic circulation bypassing the portal circulation.     

Enteral alimentation: administration and complications

Tube feeding is commonly used for providing essential calories and nutrients to the patient otherwise unable to eat. In the last two decades there has been significant expansion in the number and quality of enteral formulas. In this review, we evaluate the indications for each major class of formula, and survey complications associated with formulas and devices that deliver formula. Recommendations for future research are listed.     

Recommandations pour une alimentation saine

Conclusion Afin de tenir compte de ces recommandations pour notre alimentation quotidienne, il faut adapter aussi bien les menus domestiques destinés à la famille que les menus des cantines sur les lieux de travail, et ceci de façon simultanée. Ce but peut être atteint sans modifier nos traditions alimentaires, ni même notre approvisionnement.Le respect de ces directives permettra d'équilibrer rapidement notre alimentation et adapter notre consommation à nos besoins réels.     

Newer products and formulas for alimentation.

Adequate nutritional support for the critically ill patient has evolved over the past 150 years from a time when starvation was accepted practice for patients with fever. Three to four thousand calories and other essential nutrients can now be safely provided each day to patients with infection or other critical illness. Nutrients may be provided in meals, administered by specialized enteral feedings, or infused intravenously. Nutrient mixtures with a high proportion of carbohydrate and protein appear the best dietary therapy to maintain body protein and support other organ systems and and cellular functions. New products and formulas offer the physician a wide variety of techniques for providing adequate nutrition to all patients with critical illness.     

前白蛋白和视黄醇结合蛋白在肠外营养评估中的意义

目的 :研究前白蛋白和视黄醇结合蛋白在肠外营养评估中的意义。　方法 :对 40例胃肠疾病病人在肠外营养支持前和 TPN 1周后测定血浆中的前白蛋白、视黄醇结合蛋白、转铁蛋白、白蛋白。　结果 :血浆前白蛋白和视黄醇结合蛋白浓度在肠外营养支持治疗 1周后明显增加 (P<0 .0 0 1) ,而白蛋白和转铁蛋白浓度没有改变 (P>0 .0 5 )。　结论 :前白蛋白和视黄醇结合蛋白作为评估肠外营养疗效的指标 ,比白蛋白、转铁蛋白更加敏感。     

Partial peritoneal alimentation in an infant

We provided partial peritoneal alimentation to a 1.69-kg 11-month-old premature infant who had no available central venous access, depleted peripheral venous access, and gastrointestinal dysfunction. A cuffed silastic catheter was surgically inserted into the suprahepatic space. An alimentation solution was continuously infused into the peritoneum for 28 days to supplement peripheral venous and nasogastric alimentation and contributed 42 +/- 15% of total calories daily. Weight gain was achieved, but complications included hypoglycemia, hypophosphatemia, intravascular dehydration, catheter site leakage, ascites, and hydrocele. At autopsy 11 months later, lipid accumulation was present in the upper peritoneum and the hilar regions of the lungs secondary to preexisting lymphatic obstruction. Partial peritoneal alimentation may be feasible when other access routes are inadequate, but lymphatic obstruction is a contraindication to the peritoneal administration of lipid emulsions.