课件：ICU血糖管理.ppt

ICU患者血糖的管理与监测,血糖的来源和去路,血糖 3.89 6.11,CO2+H2O,其他糖,肝，肌糖原,脂肪，氨基酸等,肝糖原,非糖物质,食物糖,消化吸收,分解,糖异生,氧化分解,糖原合成,磷酸戊糖途径等,脂类，氨基酸代谢,血糖水平的调节,升糖激素： 胰高血糖素，肾上腺皮质激素，肾上腺髓质激素，生长激素，甲状腺素，性激素，,降糖激素： 胰岛素(体内唯一降低血糖的激素),胰岛素与血糖,胰岛素对糖代谢的调节： 促进组织细胞对葡萄糖的摄取和利用； 加速葡萄糖合成为糖原，储存于肝和肌肉； 抑制糖异生； 促进葡萄糖转变为脂肪酸，储存于脂肪组织,血糖水平异常,一 高血糖 糖尿病 应激状态下的高血糖状态 二 低血糖,应激状态下发生高血糖的原因,反向调节激素产生增加,诱发炎症反应的细胞因子产生 增多，诱发胰岛素抵抗,外源性因素的作用进一步促使高血 糖的发生（激素，含糖液体）,高血糖,高血糖的危害,最佳目标血糖水平？,是否血糖水平在正常范围内就能降低死亡率？ 什么样的血糖水平可使ICU患者获益最大？,血糖控制史上的“里程碑”,2009年,2008年,2001年,NICE SUGAR研究,Surviving Sepsis Campaign,强化血糖控制,血糖控制-强化胰岛素治疗,前瞻性随机对照试验 外科ICU机械通气成人患者1548例 随机分为： 强化胰岛素治疗组 传统治疗组,强化胰岛素治疗组 维持血糖80110 mg/dL (4.46.1 mmol/L) 传统治疗组 血糖高于215mg/dL(12 mmol/L)输注胰岛素 维持在180200mg/dL(1011mmol/L) .,Intensive insulin therapy in the critically ill patients (危重患者的强化胰岛素治疗) Van den Berghe G, et al.N Engl J Med 2001; 345: 13591367.,血糖控制-强化胰岛素治疗,血糖控制-强化胰岛素治疗,Van den Berghe G, et al: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 13591367.,入住后天数 入院后天数,住院生存率,ICU生存率,血糖控制 -强化胰岛素治疗,随后分析表明，尽管将血糖控制在80110 mg/dL (4.46.1 mmol/L)最佳 但是与高血糖比较，目标为血糖 150 mg/dL (8.3 mmol/L)也能改善预后,In conclusion, the use of exogenous insulin to maintain blood glucose at a level no higher than 110 mg per deciliter reduced morbidity and mortality among critically ill patients in the surgical intensive care unit, regardless of whether they had a history of diabetes 无论有无糖尿病病史，应用胰岛素将血糖水平控制在6.1 mmol/L以下能降低外科ICU患者死亡率,Van den Berghe G, et al: Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 13591367.,2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,1. We recommend that, following initial stabilization, patients with severe sepsis and hyperglycemia who are admitted to the ICU receive IV insulin therapy to reduce blood glucose levels (Grade 1B). 2. We suggest use of a validated protocol for insulin dose adjustments and targeting glucose levels to the 150 mg/dl range (Grade 2C). 3. We recommend that all patients receiving intravenous insulin receive a glucose calorie source and that blood glucose values be monitored every 12 hours until glucose values and insulin infusion rates are stable and then every 4 hours thereafter (Grade 1C). 4. We recommend that low glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may overestimate arterial blood or plasma glucose values (Grade 1B).,2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,1.We recommend that, following initial stabilization, patients with severe sepsis and hyperglycemia who are admitted to the ICU receive IV insulin therapy to reduce blood glucose levels (Grade 1B) 我们建议，初步稳定后，发生高血糖的严重脓毒症的ICU患者应接受静脉胰岛素治疗来降低血糖水平 (Grade 1B),2.We suggest use of a validated protocol for insulin dose adjustments and targeting glucose levels to the 150 mg/dl range (8.3mmol/L) (Grade 2C) 我们建议使用有效的方案来调整胰岛素剂量，目标血糖水平为 150 mg/dl (8.3mmol/L) (Grade 2C),2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,3.We recommend that all patients receiving intravenous insulin receive a glucose calorie source and that blood glucose values be monitored every 12 hours until glucose values and insulin infusion rates are stable and then every 4 hours thereafter (Grade 1C) 我们建议，所有接受静脉注射胰岛素患者应接受葡萄糖为热量来源，并且每1-2小时监测血糖值，直到血糖水平和胰岛素输注率稳定后每4小时监测血糖值(Grade 1C),2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,4. We recommend that low glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution, as such measurements may overestimate arterial blood or plasma glucose values (Grade 1B) 由手指血糖测得的低血糖水平应持谨慎态度，因为这种测量获得的数值可能高于动脉血或血清值(Grade 1B),2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,Can controlling blood sugar levels in the ICU save your life?,Tue Mar 24, 2009 Landmark studies published in New England Journal of Medicine and CMAJ（Canadian Medical Association Journal）,L to R: Investigator Dr. Vinay Dhingra discusses the SUGAR study with research co-ordinators Susan Logie and Laurie Smith along with Canadian project manager Denise Foster.,控制血糖水平能拯救ICU患者的生命吗？,发表在新英格兰和加拿大医学会杂志上研究的里程碑,NICE SUGAR研究 ：Background 背景,A parallel-group, randomized, controlled trial involving adult medical and surgical patients admitted to the ICUs of 42 hospitals: 38 academic tertiary care hospitals and 4 community hospitals Involving 42 hospitals from four countries and two continents Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control 大样本，随机，对照试验 42家医院的外科和内科成人ICU患者，38学院的三级保健医院，4个社区医院 四个国家和两个大洲 6104例随机分成2组，强化胰岛素治疗组3054例和传统治疗组3050例,NICE SUGAR研究 ：Two target ranges groups,强化胰岛素治疗组the intensive (i.e., tight) control 目标血糖水平81108 mg/dL (4.56.0 mmol/L) 传统治疗组the conventional control 目标血糖水平180mg/dL(10.0mmol/L)及以下,方法,Control of blood glucose was achieved with the use of an intravenous infusion of insulin in saline. 静脉注射胰岛素控制血糖 In the group of patients assigned to undergo conventional glucose control, insulin was administered if the blood glucose level exceeded 180 mg per deciliter (10.0 mmol per liter); insulin administration was reduced and then discontinued if the blood glucose level dropped below 144 mg per deciliter (8.0 mmol per liter). 在传统治疗组如果血糖水平超过10.0mmol/L;应用胰岛素。如果血糖水平低于8.0mmol/L胰岛素用量减少，然后停止,NICE SUGAR研究 ：结论,经过总计6030例患者的校验，强化血糖控制在4.5-6.0 mmol/L者的所有主要或次要考察指标都显著差于常规治疗组（血糖小于10 mmol/L） 强化血糖控制组90天病死率明显升高 p = 0.02， 根据危险因素进行校正后病死率仍有显著差异 ； 强化血糖控制组存活时间缩短 p = 0.04，强化血糖控制组死于心血管病因的比例更高) ； 强化血糖控制组发生严重低血糖的患者比例明显升高 (p 0.001) ； 同时，强化血糖控制组在 90天内ICU住院日及总住院日；新发单一或多器官功能衰竭患者比例；机械通气时间，肾脏替代时间，血培养阳性率和输血比例等诸多方面也没有显示出和常规治疗组之间的差异。,90天存活率,The probability of survival, which at 90 days was greater in the conventional-control group than in the intensive-control group (hazard ratio, 1.11; 95% confidence interval, 1.01 to 1.23; P = 0.03). 90天存活率强化胰岛素组低于传统治疗组,ICU留住时间,During the 90-day study period, there was no significant difference between the two groups in the median length of stay in the ICU 在90天的研究期间，2组ICU平均留住时间没有显著差异,器官功能衰竭，机械通气时间和 肾脏替代疗法,The number of patients in whom new single or multiple organ failures developed were similar with intensive and conventional glucose control (P = 0.11) 新发生的单个或多器官功能衰竭，2组相似 There was no significant difference between the two groups in the numbers of days of mechanical ventilation and renal replacement therapy 机械通气时间和肾脏替代疗法没有显著差异,最佳目标血糖水平,In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg(10.0 mmol or less per liter) or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter(4.5 to 6.0 mmol per liter). 这次大样本国际随机实验显示：在ICU患者强化胰岛素治疗增加死亡率，与4.5-6mmol/dl的目标血糖水平相比 ，10mmol/dl及以下的血糖水平能降低死亡率 On the basis of our results, we do not recommend use of the lower target in critically ill adults. 推建目标血糖水平为10mmol/dl及以下,否定了强化胰岛素治疗，肯定NICE-SUGAR trial,the second largest randomized study sample (to our knowledge) in the history of critical care medicine, it would clearly provide level I evidence to guide clinicians in their decision making at the bedside NICE SUGAR研究为临床医生的工作提供了一级证据 This detrimental intensive insulin therapy (IIT) mortality effect in the NICE-SUGAR trial occurred in all subgroups, including surgical patients. As such, when considering a diverse population of ICU patients, the IIT express has surely come to its last stop（强化血糖可以休矣！）.,Do not treat hyperglycemia unless the glucose level increases higher than 180 mg/dL; when you do treat hyperglycemia, aim for a target blood glucose concentration between 144 and 180 mg/dL. Until a study can provide level I evidence that a better approach exists, this should remain the standard of care 重症患者血糖不高于10 mmol/L可不处理，如果一定要控制血糖，目标血糖应该是8-10 mmol/L，除非之后出现更好的1级证据，否则NICE-SUGAR研究就是标准方案,What Is a NICE-SUGAR for Patients in the Intensive Care Unit?,血糖监测和血糖控制,常规测纸片法 化验室用血清法 监测血糖值 初期频繁监测血糖(每3060min) 血糖稳定后定期监测(每4h) 控制血糖的方法： 持续输注胰岛素和葡萄糖,微量泵持续泵入普通胰岛素,基础治疗 生理盐水50 ml+胰岛素50 u，其含量为1U /ml，使用微量泵泵入,泵入速率1 ml/h即1U /h 调整方法 入院时同时送检实验室血糖及纸片法血糖测定，明确血糖增高，启动治疗 肠外营养 补充胰岛素按常规剂量 （1：46），再根据患者血糖水平调整比例,血糖控制,要求在1224h内使血糖达到控制目标 血糖测定连续3次以上达控制目标,测定频率可改为4h一次 起始剂量46U/ h 血糖以每小时46mmol/ L 速度下降 如果2 h 血糖不能满意下降, 提示患者对胰岛素敏感性下降, 胰岛素剂量宜加倍至1012U/ h 若血糖下降速度过快, 则根据情况减少胰岛素的泵入 初始血糖值30 mmol/L，先皮下注射 5 u，再静脉泵入,应用肠内营养的患者,以营养泵输入肠内营养液，固定输入速度 血糖偏高患者可选用适合糖尿病患者的营养剂（果糖，如：瑞代）,行CRRT的患者,CRRT可影响血糖水平 选用无糖配方的置换液 CRRT时加强血糖检测，CRRT时每2小时测一次血糖,恢复三餐饮食的患者,危重期患者不进食血糖控制较容易,血糖波动较小 而患者恢复进食后要加用三餐胰岛素,可以按0. 41. 0 U/ kg 给予胰岛素总量 40 %50 %作为胰岛素基础量;或者按0. 2 U/ kg 胰岛素作为基础量 余下5060 %按早、中、晚各1/ 3