重症患者血糖如何管理

重症患者血糖如何管理,内容（outline）,重症患者应激性高血糖重症患者的血糖管理肠内营养与血糖管理,重症患者应激性高血糖,1877年Claude Bernard 首次提出“stress hyperglycemia” 是ICU病人很常见的代谢改变，不论既往是否有糖尿病血糖升高与应激的严重程度相关,应急时三类物质代谢特点,1, 糖代谢2,脂肪动员3,蛋白质分解 合成,Crit care clin .2001 jan;17(1);107-24 Stress-induced hyperglycemia .,ICU内应激性高血糖（SHG）发生率高于普通病房,Non-critically ill medical/surgical: 33-38%1,2Intensive care units (ICU): 29% - 100%3Episodes of glucose 110 mg/dL: 100%Episodes of glucose 200 mg/dL: 31%Mean glucose 145 mg/dL: 39%,Umpierrez G et al. J Clin Endocrinol Metabol 2002,87:978-982Levetan CS et al. Diabetes Care 1998;21:246-249.Krinsley JS. Mayo Clin Proc 2003;78:1471-1478.Falciglia M et al. Crit Care Med 2009; 37:3001-3009.,甲状腺素儿茶酚胺胰岛素胰高血糖素,应激,代谢亢进,胰岛素受体减少导致胰岛素不敏感而非胰岛素绝对量或相对量减少,SHG的发生机理,Crit care clin .2001 jan;17(1);107-24 Stress-induced hyperglycemia .,糖生成 速度: 5mg/kg/min (正常时2mg/kg/min) 糖利用 速度受限，2-3mg/kg/min (即10%GS 150ml/h) 无效循环: 2-3倍于正常 血糖浓度增加，即应激性高血糖（SHG）,SHG的特点,应激性高血糖,细胞内氧化作用,自由基与过氧化物产生,诱导单核细胞炎症因子表达,细胞因子释放,损伤中性粒细胞与巨噬细胞的杀伤能力及补体功能,应激性高血糖对机体的影响,Normoglycemia Known diabetes New Hyperglycemia,1.7%,3.0%,16.0%*,Mortality (%),P 0.01,Umpierrez GE et al. J Clin Endocrinol Metabol 2002;87:978-982.,Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes,Total Inpatient Mortality,Krinsley JS. Mayo Clin Proc 2003;78:1471-1478.,Hyperglycemia and mortality in the ICU,Mix- ICU (Stamford)回顾分析: Oct.1, 1999Apr.4, 2002，n=1826,1 Furnary AP, et al. Ann Thorac Surg 1999;67:352362. 2 Van den Berghe et al. N Engl J Med 2001;345:1359-1367.3 Krinsley JS et al. Chest. 2006;129:644-650.4 Newton CA et al. Endocr Prac 2006:12(suppl 3):43-48.,Cost Savings Associated with Managing Hospital Hyperglycemia,Furnary1 $5,580 per CABG patient per stay (length of stay and incidence of wound infection)Van den Berghe2 2,638 per patient per ICU stay (average ICU stay: 8.6 days conventional treatment vs. 6.6 days intensive treatment)Krinsley3 $1.3M annual cost savings for a 305-bed community based hospital (14-bed ICU)Newton4 - $1.9 M annual cost saving for a 750 bedtertiary care center in North Carolina (non-ICU).Nurse case manager-based program,重症患者的血糖管理,Intensive insulin therapy in the critically ill patients,1548 ICU 病人 研究期间 12 months 传统治疗: 血糖 180-210 mg/dl 强化治疗: 血糖 80-110 mg/dl 胰岛素: 0-50 IU/h iv 总死亡率: 10.6% vs. 20.2% (p=0.005),强化治疗: 降低MOF-相关的死亡率!,van den Berghe G, et al. N Engl J Med. 2001;345:135967,2008年指南血糖控制,使用经过验证的方案调整胰岛素的剂量,使得血糖150mg/dl（2C，新增）接受胰岛素的患者应接受葡萄糖作能源,1-2小时测量1次血糖,直到稳定后改为4小时1次（1C，修订） 原推荐: 每30-60mins测量1次血糖(D)对从毛细血管取样获得的低血糖的解释要谨慎,这些测量可以过高评价动脉或血浆的血糖水平（1B，新增）,Normoglycemia in Intensive Care EvaluationSurvival Using Glucose Algorithm Regulation (NICE-SUGAR) a collaboration of the Australian and New Zealand Intensive Care Society Clinical Trials Group,背景,方法,两组患者血糖水平,Outcome,亚组分析,结论（Conclusions）,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 or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter. (ClinicalT number, NCT00220987.),ESPEN PN Guidelines 2009,Indication of PN:Patients should be fed as starvation or underfeeding in ICU patients = associated with increased morbidity and mortality (C)All patients not expected to be on normal nutrition within 3d should receive PN within 24-48h if EN = contraindicated or not tolerated (C)Indication for PN supplementary to ENAll patients receiving less than their targeted EN after 2days should be considered for supplementary PN (C)Venous access:Central venous access = often required (full coverage of nutritional needs high osmolarity PN) (C)Peripheral access: for low osmolarity (850mOsm/L) (C)PN admixtures should be administered as a complete all-in-one bag (B),Singer et al.ESPEN guidelines on PN: Intensive Care, Clinical Nutrition 2009; in press,2012 sepsis guideline,血糖与重症患者的死亡率,死亡,肠内营养与血糖管理,控制高血糖,避免低血糖,缩小血糖波动,预防高血糖,减少碳水化合物增加胰岛素敏感性,预防应激性高血糖的处理,碳水化合物减少外源性葡萄糖输入总量 200g/day2. 减慢外源性葡萄糖输入速度3mg/kg/min3.减少葡萄糖供能比例（7：36：4）,预防应激性高血糖的处理,控制碳水化合物的总量比种类更为重要,ADA和DNSG/EASD指南推荐,减少碳水化合物增加胰岛素敏感性,预防应激性高血糖的发生,改变脂肪组分,增加胰岛素敏感性,改变脂肪组分,改变血脂组分,降低氧应激,C,C,C,C,C,C,C,C,C,C,C,C,C,C,C,C,C,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,H,O,C,O,-,PUFA双键多，易受攻击, - 6,PUFA的毒性最强 MUFA和SFA毒性很小,对单核细胞、内皮细胞的毒性,MUFA减轻氧自由基损伤,MUFA降低8-异前列腺素F2等氧化应激指标的水平,单不饱和脂肪酸膳食通过缓解氧化应激改善糖耐量正常人群的胰岛素敏感性。李萍等，中华内分泌代谢杂志，2010，Vol26，No.10,MUFA增加胰岛素敏感性,单不饱和脂肪酸膳食通过缓解氧化应激改善糖耐量正常人群的胰岛素敏感性。李萍等，中华内分泌代谢杂志，2010，Vol26，No.10,*P0.01,MUFA影响血脂,*,*,* P0.05,高单不饱和脂肪酸(MUFA)饮食降低总胆固醇(TC)水平 和低密度脂蛋白-胆固醇(LDL-C)水平。,单不饱和脂肪酸膳食通过缓解氧化应激改善糖耐量正常人群的胰岛素敏感性。李萍等，中华内分泌代谢杂志，2010，Vol26，No.10,Paniagua JA, et al. A MUFA-rich diet improves posprandial glucose, lipid and GLP-1 responses in insulin-resistant subjects. J Am Coll Nutr,2007；26（5）：434-44.,MUFA对糖尿病患者血糖与血脂的影响,含MUFA的膳食降低HBA1c、空腹血糖、血糖和胰岛素曲线下面积含MUFA的膳食改善胰岛素抵抗、减少GLP-1、降低空腹胰岛素原水平、提高HDL-c水平、提高Apo A-1和Apo B100,营养指南对肠内营养配方的建议,ESPEN Guidelines，2006 低碳水化合物、高单不饱和脂肪酸配方的肠内营养能更有助于血糖控制；有助于减少糖尿病病人心血管风险；有助于降低血甘油三酯和总胆固醇水平,糖尿病配方与普通配方,StandardHigh in rapidly-digested carbohydratesLow in fatLow in fiberMay compromise glycemic control in patients with diabetesMay require more time and medications to maintain blood glucose levels in good control,Diabetes SpecificModified carbohydratesModified fat: favor inclusion of monounsatura