(翻译)2015AAGBI糖尿病患者围手术期管理.docx

GuidelinesPeri-operative management of the surgical patient with diabetes2015Association of Anaesthetists of Great Britain and Ireland2015AAGBI糖尿病患者围手术期管理英国和爱尔兰麻醉医师协会Membership of the Working Party: P. Barker, P. E. Creasey, K. Dhatariya,1 N. Levy, A. Lipp,2M. H. Nathanson (Chair), N. Penfold,3 B. Watson and T. Woodcock1 Joint British Diabetes Societies Inpatient Care Group2 British Association of Day Surgery3 Royal College of AnaesthetistsSummaryDiabetes affects 1015% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c 69 mmol.mol1); deciding if the patient can be managed by simple manipulation of pre-existing treatment duringa short starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurateand well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guideline is to provide detailed guidance on the peri-operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.摘要糖尿病影响着近10% 15% 的手术患者，并且，接受外科手术的糖尿病患者的手术并发症发生率、死亡率和住院天数都相对较高。现代的针对伴有糖尿病的手术患者的管理重点是：通过术前评估和对糖尿病病情的强化管理（糖化血红蛋白 69 mmol.mol-1）；如果患者可以简单地采用之前既有的调整方案加之一定的饮食控制就能管理好血糖水平，就不要采取可调节的胰岛素静脉输注；当后者是唯一选择需要使用时要注意安全性，例如急诊患者、手术后预期不能马上恢复正常饮食的患者、糖尿病控制很差的患者等。另外，医疗保健专业人员之间以及和患者之间的沟通准确是当务之急，整个过程都需要沟通顺畅。大多数糖尿病患者都有多年的对自己血糖的管理经验了，本指南的目的是对糖尿病患者围手术期处理提供详细的指导，这对麻醉师很有特殊的意义，并且确保现行指南的一致性。IntroductionThe demographics describing the dramatic increase in the number of patients with diabetes are well known. Patients with diabetes require surgical procedures more frequently and have longer hospital stays than those without the condition 2. The presence of diabetes or hyperglycaemia in surgical patients has been shown to lead to increased morbidity and mortality, with perioperative mortality rates up to 50% greater than the non-diabetic population 2. The reasons for these adverse outcomes are multifactorial, but include: failureto identify patients with diabetes or hyperglycaemia 3, 4; multiple co-morbidities including microvascular and macrovascular complications 5; complex polypharmacy and insulin prescribing errors 6; increased peri-operative and postoperative infections 2, 7, 8; associated hypoglycaemia and hyperglycaemia 2; a lack of, or inadequate, institutional guidelines for management of inpatient diabetes or hyperglycaemia 2, 9; and inadequateknowledge of diabetes and hyperglycaemia management amongst staff delivering care 10.Anaesthetists and other peri-operative care providers should be knowledgeable and skilled in the care of patients with diabetes. Management of diabetes is a vital element in the management of surgical patients with diabetes. It is not good enough for the diabetic care to be a secondary, or sometimes forgotten, element of the peri-operative care package.指南简介众所周知流行病学调查显示糖尿病患者的数量在急剧增加。糖尿病患者需要外科手术更频繁，并有更长的住院时间。相对于非糖尿患者群，患有糖尿病或高血糖的外科患者相应的发病率和死亡率会增加，比起非糖尿病患者，围手术期死亡率增加 50%。导致上述不良结果的原因是多方面的，包括：未能确定患者患有糖尿病或高血糖；包括微血管和大血管并发症的多种疾病；多重用药的复杂性和胰岛素处方错误；围手术期和术后感染的增加；伴有低血糖或高血糖；对糖尿病或高血糖住院管理制度知识的缺乏；对于糖尿病和高血糖患者管理知识匮乏尤其是在护理方面。麻醉师和围手术期护理人员对于护理糖尿病患者应该具有详尽的知识和熟练的技能。对于伴有糖尿病的外壳患者的管理中糖尿病护理是至关重要的环节，在围手术期的护理中是第一位的。Previous guidelinesIn April 2011 NHS Diabetes (now part of NHS Improving Quality) published a document: NHS Diabetes Guideline for the Peri-operative Management of the Adult Patient with Diabetes, in association with the Joint British Diabetes Societies (JBDS) 1 (an almost identical version, Management of Adults with Diabetes Undergoing Surgery and Elective Procedures: ImprovingStandards, is available at .uk/JBDS/JBDS.htm). This comprehensive guideline provided both background information and advice to clinicians caring for patients with diabetes. Some of the recommendations in that document were due for review in the light of new evidence and, in addition, it was felt that anaesthetists and other practitioners caring for patients with diabetes in the peri-operative period needed shorter, practical advice. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) offered to co-author this shortened guideline, in collaboration with colleagues involved with the 2011 document. The previous 2011 NHS Diabetes guidelines will also be updated in 2015.先前的指南在2011年4月NHS和JBDS发表了一版成年糖尿病患者围手术期管理指南。这版详尽的指南提供了背景知识以及对于糖尿病患者护理的建议。这些建议很多出自循证医学证据，并且表明，麻醉师和临床医生对于糖尿病患者的围手术护理需要更精简贴近实际的建议。结合2011版的这版指南，AAGBI出版了这版更精简的指南。之前的2011NHS糖尿病指南在2015也会更新。The risks of poor diabetic controlStudies have shown that high pre-operative and perioperative glucose and glycated haemoglobin (HbA1c) levels are associated with poor surgical outcomes. These findings have been seen in both elective and emergency surgery including spinal 11, vascular 12, colorectal 13, cardiac 14, 15, trauma 16, breast17, orthopaedic 18, neurosurgical, and hepatobiliary surgery 19, 20. One study showed that the adverse outcomes include a greater than 50% increase in mortality,a 2.4-fold increase in the incidence of postoperative respiratory infections, a doubling of surgical site infections, a threefold increase in postoperative urinary tract infections, a doubling in the incidence of myocardial infarction, and an almost twofold increase in acute kidney injury 2. Paradoxically, there are some data to show that the outcomes of patients with diabetes maynot be different from, or may indeed be better than, those without diabetes if the diagnosis is known before surgery 21. The reasons for this are unknown, but may be due to increased vigilance surrounding glucose control for those with a diagnosis of diabetes.糖尿病控制不佳的风险研究结果表明围手术期和手术期间的高血糖、高糖化血红蛋白水平与患者术后预后不佳关系密切，这种预后不佳无论是择期手术还是急诊手术均有体现，这些手术包括脊髓、血管、结肠直肠、心脏、创伤、乳腺、整形、神外以及肝胆手术等。一项研究显示这些不良结局包括：死亡率增加50%、术后呼吸道感染增加2.4倍、手术部位感染加倍、尿道感染增加三倍、心肌梗死的发生率加倍，急性肾损伤几乎增加两倍。矛盾的是，也有一些数据表明术前诊断明确的伴有糖尿病的患者和普通患者的预后没有差别，甚至更好。但是这是什么原因还不得而知，也许是因为患者之前已明确诊断为糖尿病，对血糖的管理有更为积极的控制。Referral from primary care and planning surgery 从初级保健到计划手术的转诊 The aim is to ensure that diabetes is as well controlled as possible before elective surgery and to avoid delays to surgery due to poor control. The Working Party supports the consensus advice published in the 2011 NHS Diabetes guideline that the HbA1c should be 69 mmol.mol1 (8.5%) for elective cases 1, and that elective surgery should be delayed if it is 69 mmol.mol1, while control is improved. Changesto diabetes management can be made concurrently withreferral to ensure the patients diabetes is as well controlled as possible at the time of surgery. Elective surgery in patients with diabetes should be planned with the aim of minimising disruption to their self-management.其目的是确保糖尿病在择期手术前尽可能地控制良好，避免因为血糖控制不佳而手术延期。遵循2011 版的 NHS 糖尿病指南，择期手术情况下 HbA1c 应 69 mmol.mol-1（8.5%），当HbA1c 69 mmol-1 时，手术应延迟到血糖控制有所改善的时候。糖尿病管理策略可以适时改变以确保手术期患者的糖尿病可以尽可能地控制到最好。伴有糖尿病的手术患者的择期手术计划应该尽可能地把对患者自我管理的破坏降到最低。 Recommendation: Glycaemic control should bechecked at the time of referral for surgery. Information about duration, type of diabetes, current treatment and complications should be made available to the secondary care team.建议：转诊手术时应检查血糖控制水平、病程、类型、现有治疗方案和并发症。Surgical outpatient clinicThe adequacy of diabetes control should be assessed again at the time of listing for surgery, ideally with a recorded HbA1c 69 mmol.mol1); and most patients with diabetes requiring emergency surgery. Variable-rate intravenous insulin infusions should be administered and monitored by appropriately experienced and qualified staff. An example of a VRIII regimen is provided in Appendix 1.可调节的静脉胰岛素输注（VRIII）的应用可调节的静脉胰岛素输注（VRIII）对于以下人群是首选：需要节食至少一餐的患者；没有胰岛素注射史的 I 型糖尿病患者；糖尿病控制不佳（定义为糖化血红蛋白 69 mmol.mol-1）；需急诊外科手术的多数糖尿病患者。可调节的静脉胰岛素输注（VRIII）应用和监测应该由有经验的专业的医护人员进行。VRIII规则的示范见附件1.Intra-operative care and monitoring 术中看护与监测 The aim of intra-operative care is to maintain good glycaemic control and normal electrolyte concentrations,while optimising cardiovascular function and renal perfusion. If possible, multimodal analgesia should be used along with appropriate anti-emetic prophylaxis,to enable an early return to a normal dietand the patients usual diabetes regimen.术中看护与监测的目的是维持良好的血糖水平和正常的电解质浓度，同时优化心血管功能和肾脏灌注。如果可能的话，可以将多种模式镇痛与适当的抗呕吐预防机制一起进行，使患者早日恢复正常的饮食规律和常规糖尿病治疗。 Recommendation: An intra-operative CBG range of 610 mmol.l1 should be aimed for (an upper limit of 12 mmol.l1 may be tolerated at times, e.g. if the patient has poorly controlled diabetes and is being managed by a modification of his/her normal medication without a VRIII). It should be understood by all staff that a CBG within the range of610 mmol.l1 is acceptable and that there is no requirment for a CBG of 6 mmol.l1 to be the target.The CBG should be checked before induction of anaesthesia and monitored regularly during the procedure (at least hourly, or more frequently if the results are outside the target range). The CBG, insulin infusion rate and substrate infusion should be recorded on the anaesthetic record. Some charts use colour-coded areas to highlight abnormalresults requiring further intervention or a change of treatment (see Appendix 2).*提示：术中血糖应控制在6-10mmol.l-1 (特殊情况下最高控制在12 mmol.l-1 例如：血糖控制较差没有接受VRIII治疗，正在调整治疗方案的糖尿病患者)医护人员需要明确血糖范围在6-10mmol.l-1 都是可以接受的，没有必要以控制在6 mmol.l-1 为目标。血糖水平应在麻醉前检查并且在术中不断监测（至少每小时一次，如果血糖超出目标范围要增加监测频次）。血糖、胰岛素注射速率和基质输入需要记录在麻醉记录上。一些图标需要用颜色区分标示不正常的数值以便于后续调整或改变治疗方案（见附件2）Management of intra-operative hyperglycaemia and hypoglycaemiaIf the CBG exceeds 12 mmol.l1 and insulin has been omitted, capillary blood ketone levels should be measured if possible (point-of-care devices are available). If the capillary blood ketones are 3 mmol.l1 or there is significant ketonuria ( 2+ on urine sticks) the patient should be treated as having diabetic ketoacido ketoacidosis(DKA). Diabetic ketoacidosis is a triad of ketonaemia 3.0 mmol.l1, blood glucose 11.0 mmol.l1,and bicarbonate 15.0 mmol.l1 or venous pH 7.3.Diabetic ketoacidosis is a medical emergency and specialisthelp should be obtained from the diabetes team.If DKA is not present, the high blood glucose should be corrected using subcutaneous insulin (see below) or by altering the rate of the VRIII (if in use).If two subcutaneous insulin doses do not work, a VRIII should be started.术中低血糖和高血糖的管理如果未使用胰岛素血糖超过12mmol.l-1 需检测血酮水平（可用床旁诊断）如果血酮大于3mmol.l-1 或者有明显的酮尿（大于+）,需要视为糖尿病酮症酸中毒处理。血酮大于3mmol.l-1 血糖超过11mmol.l-1 电解质 15.0mmol.l-1 或者PH7.3即可诊断。糖尿病酮症酸中毒是急性并发症需要糖尿病专业人员处理。如果没有发生酮症，需要采取皮下胰岛素注射降低血糖（见下文）或者改变VRIII输注速率（已采用的情况下）。如果两次皮下胰岛素注射后没有起效，需要