醫(yī)學(xué)課件危重患兒的營養(yǎng)支持

危重患兒的營養(yǎng)支持昆明市兒童醫(yī)院PICU李斌12營養(yǎng)支持在危重病人中的應(yīng)用營養(yǎng)不良與危重癥關(guān)系1危重癥營養(yǎng)支持原則2不良影響與監(jiān)測3營養(yǎng)支持的實(shí)施4營養(yǎng)支持為何重要危重病+差的營養(yǎng)＝？34營養(yǎng)不良與危重癥的關(guān)系危重患兒發(fā)生營養(yǎng)不良是常見的臨床現(xiàn)象.16-20%患兒入院48小時內(nèi)存在主要營養(yǎng)物質(zhì)不良.60%有低蛋白血癥人體測量結(jié)果：72％，主觀判斷46％ImpactofstarvationNegativenitrogenbalance,furtherwtlossMorphologicalchangesinthegut(Mucosalthickness,CellproliferationandVillusheight)Functionalchanges(Increasedpermeability&Decreasedabsorptionofaminoacids)Enzymatic/HormonalchangesDecreasedsucraseandlactaseImpactonimmunityCellular:DecreasedTcells,atrophiedgerminalcenters,mitogenicproliferation,differentiation,Thcellfunction,alteredhomingHumoral:Complement,opsonins,Ig,secretoryIgA(70-80%ofallIgproducedissecretoryIgA)Increasedbacterialtranslocation56預(yù)后體重下降35-40%，病死率接近100%危重病+差的營養(yǎng)＝？為何會發(fā)生急性蛋白質(zhì)能量營養(yǎng)不良？78急性蛋白質(zhì)能量營養(yǎng)不良APEM基礎(chǔ)代謝率明顯增加應(yīng)激高分解狀態(tài)營養(yǎng)素需求增加丟失過多攝入不足基礎(chǔ)疾病9代謝病理糖元分解糖異生糖利用降低血糖增加蛋白分解糖異生負(fù)氮平衡優(yōu)先動用FFA↑TG↑糖蛋白脂肪W(wǎng)henshouldnutritionsupportbestartedinthePICU?10營養(yǎng)評估既往史體檢飲食史實(shí)驗(yàn)室檢驗(yàn)11NutritionFocusedAssessmentPastmedicalhistoryasitimpactsnutritionalstatusandoutcomesAnthropometricmeasures:weight,length,headcircumference(forchildren<3yearsofage)Dietaryintakehistory:asavailablefromparentsorprimarycaretakers,historyoffeedingproblems,lossofappetite,recentweightlossLaboratoryvalues:CHEM-10,totalprotein/albumin,asavailableNutritionbasedexamtoidentifynutritiondeficiencylesionsHistoryofandneedforfurthernutritioneducationforspecializedformulaordiet.12childrenatincreasednutritionalriskHypermetabolicstates:trauma:closedheadinjury,spinalcordinjuryPost-surgicalpatientsCardiorespiratoryillness:congenitalheartdefects,bronchopulmonarydysplasia,cysticfibrosisGastrointestinaldiseaseanddysfunction:shortgutsyndrome,exacerbationofinflammatoryboweldiseasewithhistoryofPEM,hepaticfailure,biliaryatresia,pancreatitisNeurologic,musculardisease:geneticsyndromes,Guillan-Barre',musculardystrophy,historyofCP/MRrequiringG-tubefeedings13IndicationsforNutritionSupportinthePICU:AllPICUpatientswillbescreenedbythePICUnutritionistwithin72hoursofadmissiontodetermineiftheyareatnutritionriskorinneedofnutritionsupportviatheenteralorparenteralroute.14如何進(jìn)行？

經(jīng)腸道還是全靜脈？

1516TPN適應(yīng)癥胃腸道功能障礙的重癥患兒；手術(shù)或解剖問題胃腸道禁止使用的重癥患兒；存在有尚未控制的腹部情況，如腹腔感染、腸梗阻、腸瘺等。早期復(fù)蘇階段、血流動力學(xué)尚未穩(wěn)定或存在嚴(yán)重水電介質(zhì)與酸堿失衡；嚴(yán)重肝功能衰竭，肝性腦??；急性腎功能衰竭存在嚴(yán)重氮質(zhì)血癥；嚴(yán)重高血糖尚未控制。相對禁忌GI解剖、功能良好，具備腸道喂養(yǎng)通路→EN17危重病人營養(yǎng)支持時機(jī)選擇重癥病人常合并代謝紊亂與營養(yǎng)不良，需要給予營養(yǎng)支持（C級）重癥病人的營養(yǎng)支持應(yīng)盡早開始（B級）（預(yù)計(jì)5－7天內(nèi)不能經(jīng)口攝食者應(yīng)及早開始營養(yǎng)支持）如可進(jìn)行？熱量及營養(yǎng)素的分配18DeterminingCalorieandProteinNeedsEstimatebasalenergyneeds(BEE)-RefertoTable1DetermineStressFactor-RefertoTable2

TotalCalories=BEEXStressFactor

Estimatepatient'sproteinrequirements-RefertoRDAs-Table3

TotalProtein=ProteinRDAsXStressFactor

Continuetoevaluateandadjustrecommendationsbasedonnutritionmonitoring.19CalculationofCatch-UpGrowthintheTermInfantandChildKcal/kg=RDA(kcal/kg)forweightage*xIdealweight(kg)**/Actualweight*Ageatwhichpresentweightisatthe50th%-ile

**50th%-ileforageoridealbodyweightforheight20Table1.BasalEnergyNeedsforInfantsandChildren

21Age1wkto10moAge11to36moAge3to16yrMetabolicRateMetabolicRateMetabolicRateWeight(kcal/day)Weight(kcal/day)Weight(kcal/day)(kg)MaleorFemaleMaleFemale(kg)MaleFemale3.52029.0528509158597994.02289.5547528209538984.525210.05665472510469965.027810.558656630113910925.530511.060558635123111906.033111.562460540132512896.535812.064362445141813877.038412.566264650151214867.541013.068266555160615848.043713.570168460169916808.546314.072070365179317769.049014.573972270188618749.551415.0758741751980197310.054015.577876010.556616.079778211.059316.5816802BACKTable2.DeterminingStressFactor22ClinicalConditionStressFactorMaintenancewithoutStress

Fever

Routine/electivesurgery,minorsepsis

Cardiacfailure

Majorsurgery

Sepsis

Catch-upGrowth

Traumaorheadinjury1.0-1.2

12%perdegree>37C

1.1-1.3

1.25-1.5

1.2-1.4

1.4-1.5

1.5-2.0

1.5-1.7BACKTable3.RecommendedDietaryAllowancesforInfantsandChildren

23

AgeWeightHeightCaloriesProteinFluid

(years)(kg)(lbs)(cm)(in)(kcal/kg)(gm/kg)(ml/kg)Infants0.0-0.561360241082.2140-1600.5-1.09207128981.5125-145Children1-3132990351021.23115-1254-6204411244901.290-1107-10286213252701.070-85Males11-14459915762551.070-8515-186614517669450.850-60Females11-144610115762471.070-8515-185512016364400.850-60BACK24能量供應(yīng)20kal×Wt50kal×Wt100kal×Wt>20Kg部分第二個10Kg第一個10Kg胃腸外營養(yǎng)支持期間熱卡推薦量(kcal/d)體溫每增高1°C,熱量需增加12%;心力衰竭時需增加5-25%;大手術(shù)時需增加20-30%;嚴(yán)重?cái)⊙Y時需增加40-60%;燒傷時需增加100%。

25StageClinicalGoalsHospitalDayNutritionalTargetsIFluidResuscitation&restoretissueperfusion.Day#1to2Fluidandelectrolytemanagement.IIMetabolicResuscitation:limitproteincatabolism&elevatedglucoselevels;HypermetabolicphasewhichmaycontinuewithinfectionDay#2to9AchieveBEEforenergywithsignificantproteinsource;NextstepprogresstoBEEXstressfactor(Table1&Table2)astolerated.IINutritionalRecovery-recoveryrepletion,increasingactivityandgrowthDay#7to10andbeyondFulltargetsatBEEXinjuryfactororevenhigherusingRDAtable(Table3)orcatch-upgrowthoncestresssubsidesandgrowthresumes.

Forinfants&malnourishedInitiatenutritionbyDay#3AchieveBEEXStressfactorbyDay#5-6.

Forolderchildren&goodnutritionalstatuspriortoadmissionInitiatenutritionbyDay#3-5.AchieveBEEXStressfactorbyDay#5-8.NutritionalSupportTargetsforthePICUPatient26危重病人的營養(yǎng)供給原則葡萄糖：一般占非蛋白質(zhì)熱卡的50-60％，應(yīng)根據(jù)糖代謝狀態(tài)進(jìn)行調(diào)整（C級）脂肪：一般為非蛋白質(zhì)熱卡的40％-50％；攝入量可達(dá)，應(yīng)根據(jù)血脂廓清能力進(jìn)行調(diào)整，脂肪乳劑應(yīng)勻速緩慢輸注（B級）蛋白質(zhì)：供給量一般為，約相當(dāng)于氮；熱氮比100－150kcal:1gN（B級）Fat30-35%G.S50%Protein15-20%能量分配ComplicationsofoverfeedingExcessCO2production&increasedminuteventilationPulmonaryedema&respiratoryfailureHyperglycemia,whichmayincreaseinfectionratesLipogenesisduetoincreasedinsulinproductionImmunosuppressionHepaticcomplications:fattyliver,intrahepaticcholestasis2728對于不活動的重癥患者能量消耗“允許性低熱卡”29水與電解質(zhì)碳水化合物脂肪蛋白質(zhì)維生素微量元素MacronutrientsMicronutrients營養(yǎng)底物Nutrients碳水化合物（葡萄糖）Dextrose-BeginPNat10-15%dextrose.Advanceby2.5-5%inolderinfantsandchildrenandby5-10%perdayinadolescentsuntilanendpointofD12.5%dextroseforPPNorgenerallybetween20-25%dextroseforCPN,asneededtomeetnutritionalneeds.Provisionofexcesscarbohydratecaloriesmayleadtothefollowingadverseeffects:hyperglycemia,hepatotoxicity,cholestasis,glycosuria,osmoticdiuresisInsulinUse-Ageneralguidelineisadditionof1unitofregularinsulinper10gramsofcarbohydratecalories.3031碳水化合物（葡萄糖）葡萄糖輸注速率開始可逐漸增至6-7mg/kg.min;使用小劑量外源性胰島素時葡萄糖輸注速率可達(dá)。32腸外營養(yǎng)：脂肪乳脂肪乳是等滲的，單位體積含熱卡量高脂肪乳和葡萄糖組成的雙重能量系統(tǒng)比單一能量系統(tǒng)代謝更為有效，達(dá)到氮平衡所消耗的能量相對較少，與葡萄糖同時應(yīng)用具有更好的節(jié)氮效應(yīng)補(bǔ)充必需脂肪酸，防止EFA的缺乏↑CO2產(chǎn)生減少，RQ減輕33脂肪乳劑脂肪推薦攝入量：占總攝入熱量的30-40％用量：從開始,每1～2天增加0.5g/kg,總量不超過。輸注速度20%脂肪乳劑的試驗(yàn)速率為。特別注意：危重疾病腎衰竭檢查：脂肪廓清等血脂代謝血漿TG（max：3-4mmol/l）34蛋白質(zhì)/氨基酸（氮）首次：，每日可增加，營養(yǎng)液中所含氨基酸的氮量(g)與非蛋白熱卡(kcal)之比最好為1:150-200穩(wěn)定持續(xù)、優(yōu)化的蛋白質(zhì)補(bǔ)充是營養(yǎng)支持的重要策略35發(fā)揮特殊營養(yǎng)素的藥理作用Glutamine－免疫增強(qiáng)ω-3FA（FO）－炎癥反應(yīng)調(diào)控RecommendedIntakeCalcium

(mEq/kg)Phosphorus

(mEq/kg)Preterm,TermInfants3.0-4.03.0-4.0OlderChildren(10-40kg)1.0-31.0-3Adolescents(>40kg)1.0-1.51.0-1.536RecommendedParenteralCalcium&PhosphorusIntakeParenteralElectrolyte&Vitamin/MineralGuidelinesinPediatricPatients37ElectrolyteorNutrientPretermInfantsTermInfantsChildrenandAdolescentsSodium(mEq)2.0-6.0(average3.0)mEq/kg2-4mEq/100mlPotassium(mEq)2.0-6.0(average3.0)mEq/kg2-3mEq/100mlChloride(mEq)2.0-8.0(average4.0)mEq/kg2-3mEq/100mlCalcium(mEq)2-4mEq/kg0.5-2mEq/100mlPhosphate(mEq)1.5-3mEq/kg1.5-2.5mEq/100mlMagnesium(mEq)0.2502.0(average1.0)mEq/kg0.3-0.5mEq/100mlMVI-Pediatric

<2.5kg2cc/kg/day>2.5kg5cc/dayPTESSolution0.2cc/kg/day(upto1cc)>40kg,usATESSelenium(mcg)1-2mcg/kg/dayMVIPediatricSolutioncontainsper5ml38VitaminContentAscorbicAcid80mgVitaminA2300IUVitaminD400IUThiamine(B1)1.2mgRoboflavin(B2)1.4mgPyridoxine(B6)1mgNiacinamide17mgPantothenicacid5mgVitaminE7IUFolicAcid140mcgVitaminB121mcgBiotin20mcgVitaminK0.2mgPediatricTraceElementSolution(PTES)per0.2ml39Zinc300mcgCopper20mcgChromium0.17mcgManganese5mcgNutrientRequirementsinPulmonaryFailureCalories:don’toverfeedwhenweaningtopreventincreasedCO2production(Provide25-30kcal/kgorrestingenergyexpenditure)Protein:1.5-2g/kgAminoacidsmayincreaseventilation,increaseO2consumption.Fat:OMEGA3FAmaybeanti-inflammatoryandalterimmunestatusinsepsis/ARDS40NutrientRequirementsinliverFailureCalories:caloricrequirementsaffectedbyacutenessofdisease,seriousnessofinjury,absorption,otherorganfailure,sepsis;25-35kcals/kgorREEProtein:wellnourished/lowstress:.8g/kg;malnourished/withmetabolicstress:upto1.5g/kgCHO:~70%non-proteincalories;inacutefailure,mayneedcontinuousglucoseinfusionChronic:mayhavediabetes/hypoglycemiarequiringcontrolledCHOandinsulin;insepticptshypoglycemiaoccursin50%ofcirrhoticsFAT:30%non-proteincalories;MCTmaybehelpfulwithLCTmalabsorption41NutrientNeedsinMODSCalories:35kcal/kgorREEProtein:upto1.5-2.0g/kgFat:30%nonproteincalories;↑MCTifbilesaltdeficient;N3vsN6Micronutrients:evaluateindividuallyFluid:basedonfluidstatus42NutritionImplicationsofARFARFcausesanorexia,nausea,vomiting,bleedingARFcausesrapidnitrogenlossandleanbodymassloss(hypercatabolism)ARFcauses↑gluconeogenesiswithinsulinresistanceDialysiscauseslossofaminoacidsandproteinUremiatoxinscauseimpairedglucoseutilizationandproteinsynthesisImpairedConversionandresultantdeficienciesofGly,Ala(Tubularprotectant)&Arg(Preservesrenalperfusion)……..AASupplementationhelpsrenalperfusionandGFRanddiuresis.4344完全胃腸外營養(yǎng)的途徑操作方便且全身繼發(fā)感染的危險性小。輸注葡萄糖的最高濃度為12.5%完全胃腸外營養(yǎng)的患兒單靠外周靜脈途徑很難在單位時間內(nèi)提供足夠的液體及熱量維持靜脈輸液時間短?？墒褂渺o脈套管針延長了穿刺靜脈使用的時間。經(jīng)外周靜脈途徑的胃腸外營養(yǎng)只適用于:1、短期需營養(yǎng)支持2、輕度急性蛋白質(zhì)能量營養(yǎng)不良患兒的圍手術(shù)期3、不能接受中心靜脈插管4、暫時不能確定禁食時間5、使用中心靜脈導(dǎo)管前后6、糖利用障礙的患兒外周靜脈45中心靜脈:

操作復(fù)雜所需導(dǎo)管價高易出現(xiàn)機(jī)械合并癥存在全身感染和血栓的危險可輸入高濃度葡萄糖(>12.5%)；單位時間內(nèi)可提供較高的熱卡和較大量的液體；中心靜脈開放維持時間長；液體外滲發(fā)生率低；一般選用頸內(nèi)靜脈、鎖骨下靜脈、大隱靜脈及貴要靜脈放置單腔或多腔中心靜脈導(dǎo)管。Complications:InfectionHepaticdysfunctionMetaboliccomplications:hyperglycemia,hypoglycemia,acidosis,hypomagnesemia,hyperlipidemia,hypocalcemiaTracemetaldeficienciesMechanicalcomplications:dysrrhythmias,venousthrombosis,airembolism&skinsloughsBilirubindisplacementbyintralipid46Monitoring:DailyweightRoutinenursingobservationsLaboratoryinvestigations:-CBC-Urine(sugar,acetone)-Electrolytes-Transaminases,alkalinephosphataseandbilirubinlevels-Urea&creatinine-LipidlevelsFatinfusionshouldbestopped2-4hoursbeforetakingbloodsamples(8hoursforlipidtests)4748營養(yǎng)支持中的血糖控制SSC推薦：感染與感染性休克患者應(yīng)控制血糖≤150mg/dl任何形式的營養(yǎng)支持，應(yīng)配合強(qiáng)化胰島素治療，嚴(yán)格控制血糖水平≤150mg/dl并應(yīng)避免低血糖發(fā)生－中華醫(yī)學(xué)會重癥醫(yī)學(xué)會2005,549胃腸外營養(yǎng)的終止原發(fā)病好轉(zhuǎn),考慮恢復(fù)經(jīng)胃腸喂養(yǎng)時,應(yīng)給予胃腸道充分的“復(fù)蘇”時間及條件?？上冉?jīng)口、經(jīng)胃管或經(jīng)腸管給予等滲葡萄糖液,由1-2ml/kg/次開始,每日三次；逐漸增至8次/日;當(dāng)患兒在24小時內(nèi)耐受量達(dá)20-30ml/kg時,可把喂養(yǎng)液改為2:1稀釋奶,若仍能耐受,繼用1:1稀釋奶,逐漸過度到全奶。增加胃腸內(nèi)喂養(yǎng)量及喂養(yǎng)液性質(zhì)時,逐漸減少胃腸外營養(yǎng)液量;當(dāng)經(jīng)腸喂養(yǎng)量>50ml/kg/d時,即可停用胃腸外營養(yǎng)。此交替過程至少也需一周的時間。50腸內(nèi)營養(yǎng)選擇原則：如腸道具有功能，應(yīng)首選經(jīng)腸喂養(yǎng)BUT:“Alltheroutesareabnormal.Doingitbadlyorpoorlyaddsrisks.”－GriffthsGR對仍需要液體復(fù)蘇、內(nèi)臟低灌注仍然存在的危重癥患者暫不宜使用Benefitsofenteralnutritioninpediatricpatientsinclude:PhysiologicalpresentationofnutrientsTrophiceffectsontheGItractStimulationandmaintenanceofthegutmucosaReducedmetabolicandinfectiouscomplicationsImprovedhepaticfunctionversusparenteralnutritionSimplifiedfluidandelectrolytemanagementMore"complete"nutritionMayreducetheincidenceofpathogenentryorbacterialtranslocationintotheperitonealcavityorcirculationLessexpensive51PatientFactorsFormulaFactorsAge

Diagnosis

Associatednutritionalproblems

Nutritionalrequirements

GastrointestinalfunctionOsmolality

Renalsoluteload

Caloricdensityandviscosity

Nutrientcomposition:type&amountofCHO,Fatandprotein

Productavailabilityandcost5253腸內(nèi)營養(yǎng)時機(jī)血流動力學(xué)穩(wěn)定、具有功能性腸道患者應(yīng)及早開始適量的腸內(nèi)營養(yǎng)（C）－中華醫(yī)學(xué)會危重癥分會2006－ESPENguidelinesonENinICU2006－CanadaGuideline24～48hrs內(nèi)開始喂養(yǎng)54腸內(nèi)營養(yǎng)不耐受EN不耐受的特點(diǎn)胃殘余量過多惡心，嘔吐腹脹，絞痛腹瀉大約30%~60%ICU病人由于EN不耐受中斷腸內(nèi)營養(yǎng)DeJongheBetal.CCM.200129:204MontejoJCetal.CCM.1999;27:1447MentecHetal.CCM.2001;29:195555EN禁忌或不宜應(yīng)用不能進(jìn)食沒有EN通路未解決的腹部問題GI功能腸梗阻嚴(yán)重GI出血梗阻性內(nèi)臟血管疾病，EN可引起或加重腸道缺血嚴(yán)重腹脹：IAH等嚴(yán)重腹脹、腹瀉，處理無改善－暫停用56Age/WeightInitialInfusionRateDailyIncreasesGoalRate2.0-15kg2-15cc/hr

(1cc/kg/hr)2-15cc/hrq4-8hr

(1cc/kg)15-55cc/hr16-30kg8-25cc/hr

(0.5-1cc/kg/hr)8-16cc/hrq4-8hr

(0.5cc/kg)45-90cc/hr30-50kg15-25cc/hr

(0.5cc/kg/hr)15-25cc/hrq4-8hr

(0.5cc/kg)70-130cc/hr>50kg25cc/hr25cc/hrq4-8hr90-150cc/hrIntermittentTubeFeedingProgression57Age/WeightInitialVolumesDailyIncreasesGoalVolume2.0-15kg5-30ccq3-4hr5-30ccq6-8hr50-200q4hr12-30kg20-60ccq4hr20-60ccq6-8hr150-350ccq4hr30kg30-60ccq4h30-60ccq6-8hr240-400ccq4hr58

FormulasKcal/ccPRO

(gm/cc)FAT

(gm/cc)CHO

(gm/cc)CommentsHumanMilk.67.011.040.068VitaminDsupplementrequiredStandard

Enfamil20.67.015.038.069whey:caseinratio60:40Enfamil24.80.018.045.084whey:caseinratio60:40Similac20.67.015.036.072whey:caseinratio48:52Similac24.80.022.043.085whey:caseinratio48:52Lactofree.67.015.037.069milk-based,forlactoseintoleranceSoy

Prosobee.67.020.036.068formilkproteinallergy;lactoseintoleranceIsomil.67.018.037.068formilkproteinallergy;lactoseintoleranceSpecialized

Pregestimil.67.019.028.091forgeneralizedmalabsorptionPortagen.67.022.030.074forlongchainfattyacidmalabsorptionNutramigen.67.019.026.090forallergytointactmilk&soyproteinAlimentum.67.019.038.068forgeneralizedmalabsorptionSimilacPM60/40.67.016.038.069lowRSL;Ca:PhosratiosimilartohumanmilkPretermEnfamilPremature.80.024.041.089forpreterminfantsbelow2000gramsEnfaCare.73.020.039.078dischargepretermformulafor1styearPediatricEnteral

Kindercal1.06.034.044.135forchildren1-10years:containsfiberPediaSure1.0.030.050.110forchildren1-10yearsofage59病例患兒，女，10歲。以發(fā)燒4天，抽搐，昏迷3天為主訴入院。入院前4天發(fā)燒，體溫oC，伴流清涕。咽痛、次日下午突然抽搐，昏迷不醒，抽搐每天5-6次，每次持續(xù)3-5分鐘.于抽搐當(dāng)日到當(dāng)?shù)蒯t(yī)院就診，診斷“病毒性腦炎”，給予安定止驚，20%甘露醇150ml，每日二次靜脈推注降顱壓，10%葡萄糖500ml+能量合劑，每日一次靜點(diǎn)，penicilin320萬u每日2次靜脈。抽搐無緩解，且高燒至39-40oC,病后未進(jìn)食，嘔吐咖啡樣物而轉(zhuǎn)我院。60體格檢查:一般狀差，深昏迷，體重26kg,皮膚彈性差，眼窩凹陷，雙眼瞼閉合不良，雙瞳孔等大，直徑，光反應(yīng)遲鈍，雙眼球結(jié)膜水腫，呼吸略深大，呼吸32次/分，雙肺少許干鳴音。心音有力，節(jié)律規(guī)整，心率82次/分。腹部不脹，肝、脾未觸及，腸鳴減弱。四肢肌張力正常，肢端稍涼，雙膝反射減弱，腦膜刺激征陰性。61血常規(guī):WBC8.8x109/L,N0.3L0.68HB108g/L尿常規(guī):蛋白陽性，酮體+，糖陰性。便常規(guī):潛血(十十)。肝功:谷草轉(zhuǎn)氨酶45u/L，血尿素氮。動脈血?dú)?pH7.36,PaCO22.1kPaPaO213kPa，HCO310mmol/L,電解質(zhì)：鈉140mmol/L，鉀3.5mmol/L，氯110mmol/L輔助檢查:62入院診斷:病毒腦炎、代償性代謝性酸中毒合并呼吸性堿中毒63胃腸外營養(yǎng)因患兒入院當(dāng)日處于深昏迷，頻抽，且伴應(yīng)激性消化道出血，不能經(jīng)消化道攝入營養(yǎng)，故于入院頭3天給予全胃腸道外營養(yǎng)?；純河酗B內(nèi)水腫且伴有脫水，又因高燒不感蒸發(fā)多，采取邊脫邊補(bǔ)原則，在發(fā)病急性期保持患兒處于輕度脫水狀態(tài)，64入院第一天補(bǔ)液，患兒體重26kg，入液量為1000+500+120＝1620ml高熱增加30％，腦水腫時減30％。糾酸：5%碳酸氫鈉（ml)=ABEx體重(kg)x0.5=14X26x0.5=182ml，首次給予1/3量(60ml)，用10%葡萄糖稀釋成1.4%碳酸氫鈉210ml,留200ml備用。熱卡：26*25＝650kal糖60％：＝357kal相當(dāng)于糖：357/4＝90g脂肪：＝195kal相當(dāng)于脂肪：195/9＝21g20％FAT＝100ml氨基酸：＝相當(dāng)于：＝23g％aa:=360ml6566靜脈營養(yǎng)剩余液1210(1620一200一210)ml:①6.25%復(fù)合氨基酸