icu患者血糖的控制

1、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

2、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8011

3、0 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 conclusi

4、on, 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 se

5、vere 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 monitor

6、ed 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, pat

7、ients 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 sept

8、ic 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 obtaine

9、d 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-

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