ICU患者血糖的控制

ICU患者血糖的监测与管理,中南医院 ICU 李璐,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,胰腺胰岛细胞分泌对糖代谢的调节：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,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,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,患者血糖异常,应激状态下的高血糖状态合并胰岛素抵抗分解代谢加速,糖异生作用加强激活机体神经内分泌系统 致使代谢激素(儿茶酚胺、皮质醇、胰高血糖素、生长激素) 分泌异常细胞因子大量释放和胰岛素抵抗,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,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110 mg/dL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, 2009Landmark 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 hospitalsInvolving 42 hospitals from four countries and two continentsOf 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90天病死率明显升高 (27.5% vs. 24.9%, 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 (HR 1.11, 95%CI 1.01 1.23, 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 (6.8% vs. 0.5%, OR 14.7, 95%CI 9.0 25.9, p 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 ,于3 餐前以追加剂量的形式输入皮下,Protocol 控制方案,Manual ProtocolComputer-based Insulin Infusion Protocol,efficient low rate of hypoglycemic episodes,胰岛素输入方案：血糖目标80150 mg/dL（4.48.3mmol/dl）,起始血糖浓度,*FootnoteSource:Source,如