课件：患者血糖的监测与管理.ppt

ICU患者血糖的监测与管理,内容提要,危重症患者血糖的变化,危重症患者高血糖的危害,最佳的血糖控制水平,护理,小结,危重症患者血糖的变化,危重症患者高血糖的危害,最佳的血糖控制水平,护理,小结,血糖水平的调节,降糖激素,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、,胰岛素(体内唯一降低血糖的激素),3.896.11,血糖水平异常,糖代谢障碍血糖水平紊乱 一 高血糖 糖尿病：type1，type 2，特异型糖尿病， 妊娠糖尿病 应激状态下的高血糖状态 二 低血糖,危重症患者高血糖的原因,高龄,糖的摄入 糖尿病,应激状态,肥胖症,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,危重症患者血糖的变化,危重症患者高血糖的危害,最佳的血糖控制水平,护理,小结,高血糖增加患者的感染机会,高血糖组,正常血糖组,74例烧伤无糖尿病患者,高血糖组,正常血糖组,2467例糖尿病患者行开胸心脏手术后胸骨感染的比较,高血糖增加患者的感染机会,积极管理危重症患者合并的应激性高血糖有利于减少并发症的发生.,黄镇河 卢君强 黎丽萍 陈立波 血糖水平对ICU 危重症患者近期预后的影响J 实用医学杂志2008.24 (4) :2829,ICU患者高血糖的危害,Hyperglycemia occurs in up to 90 % of critically ill patients and is associated with increased morbidity and mortality in virtually all subgroups of intensive care unit (ICU) patients. 超过90 的危重病人会发生高血糖，并且会增加几乎所有亚组ICU患者的发病率和死亡率,危重症患者血糖的变化,危重症患者高血糖的危害,最佳的血糖控制水平,护理,小结,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？,危重病人血糖控制史上的“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,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110 mg/dL（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.,强化胰岛素治疗-低血糖,强化胰岛素治疗可使低血糖发生率增加60% ( 低血糖定义为2.2mmol /L) 多发生在禁食、病情极危重或胰岛素过量时 (特别是危重患者多有意识障碍或接受机械通气、镇静类药物等从而使低血糖的症状、体征不典型) 可导致神经系统不可逆性损害，严重的脑损害，甚至死亡。,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）,This is the question a team of critical care physician researchers at VGH set out to answer several years ago. Their work is published today in the New England Journal of Medicine and Canadian Medical Association Journal (CMAJ). The results call for an urgent review of international clinical guidelines.,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HCAMJ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。,,LOGO,NICE SUGAR研究 ：结论,经过总计6030例患者的校验，强化血糖控制在81-108 mg/dl者的所有主要或次要考察指标都显著差于常规治疗组（血糖述评180 mg/dl） 强化血糖控制组病死率明显升高 强化血糖控制组存活时间缩短 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 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。,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/l的目标血糖水平相比 ，10mmol/l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/l及以下,血糖控制可以总结为过去是“七（mmol/L）上八（mmol/L）下”，现在是“八九不离十（mmol/L）。 一定要避免可能增加低血糖风险的强化血糖控制方案。 低血糖危害更大，避免低血糖的发生。 可能存在一个“sweet spot位点”，既能够避免低血糖的危害又能够防止严重代谢障碍导致的不良后果，尽管目前还没有证据能够证明它的存在。 “sweet spot点”是目前危重病研究领域中的一个新课题, 需要医护人员共同参与, 并进行深入的研究。,危重症患者血糖的变化,危重症患者高血糖的危害,最佳的血糖控制水平,护理,小结,正确监测血糖,快速血糖仪和试纸应置于干燥处保存，定期校正，防止潮湿，以免影响血糖值的准确性。,使用75%酒精消毒皮肤，需待手指末端皮肤干燥后再采血，否则水分稀释血液，而且酒精会对测试纸上的氧化