1、ICU患者血糖的监测(jin c)与管理,中南(zhn nn)医院 ICU 李璐,第一页，共六十二页。,血糖的来源(liyun)和去路,血糖(xutng)3.89 6.11,CO2+H2O,其他(qt)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,第二页，共六十二页。,血糖(xutng)水平的调节,升糖激素(j s)：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(j s)：胰岛素(体内唯一降低血糖的激素),第三页，共六十二页。,胰岛素与血糖(xutng),胰腺胰岛细胞
2、分泌对糖代谢的调节(tioji)：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,第四页，共六十二页。,血糖水平(shupng)异常,糖代谢障碍(zhng i)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,第五页，共六十二页。,应激状态下发生(fshng)高血糖的原因,反向(fn xin)调节激素产生增加,诱发(yuf)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,第六页，共六十二页。,高血
3、糖的危害(wihi),第七页，共六十二页。,患者血糖(xutng)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(shn chn j s)分泌异常细胞因子大量释放和胰岛素抵抗,第八页，共六十二页。,ICU患者(hunzh)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 al
4、l subgroups of intensive care unit(ICU)patients.超过90 的危重病人会发生高血糖，并且(bngqi)会增加几乎所有亚组ICU患者的发病率和死亡率,第九页，共六十二页。,最佳目标血糖(xutng)水平？,是否血糖水平(shupng)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？,第十页，共六十二页。,血糖(xutng)控制史上的“里程碑”,2009年,2008年,2001年,NICE SUGAR研究(ynji),Surviving Sepsis Campaign,强化(qinghu)血糖控制,第十一页，共六十二页。,血糖(xu
5、tng)控制-强化胰岛素治疗,前瞻性随机对照试验外科(wik)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(wich)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.,第十二页
6、，共六十二页。,血糖(xutng)控制-强化胰岛素治疗,第十三页，共六十二页。,血糖(xutng)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(tinsh)入院后天数(tinsh),住院(zh yun)生存率,ICU生存率,第十四页，共六十二页。,血糖(xutng)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(zu ji)
7、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
8、 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(yxi)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.,第十五页，共六十二页。,2008-Surviving Sepsis Campaign:International guidelines for management of severe sepsis and septic shock,1.We reco
9、mmend 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
10、 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 gl
11、ucose 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).,第十六页，共六十二页。,2008-Surviving Sepsis Campaign:International guidelines for management of severe sepsis and septic shoc
12、k,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(fshng)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),第十七页，共六十二页。,2.We suggest use of a validate
13、d 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(yuxio)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,第十八页，共六十二页。,3.We
14、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(jiny)，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
15、，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,第十九页，共六十二页。,4.We recommend that low glucose levels obtained with point-of-care testing of capillary blood be interpreted with caution,as such measurements may
16、 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(ti du)，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,第二十页，共六十二页。,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
