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3.89～6.11CO2+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，ＨＣＧ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Ｂ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，type2，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降低免疫功能和增加感染性并发症，成为独立因素影响危重症预后长期慢性高血糖所致心脑肾血管损害，视网膜病变和神经病变减慢伤口愈合高血糖毒性……ＩＣＵ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Hyperglycemiaoccursinupto90%ofcriticallyillpatientsandisassociatedwithincreasedmorbidityandmortalityinvirtuallyallsubgroupsofintensivecareunit(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NICESUGAR研究SurvivingSepsisCampaign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80~110mg/dL(4.4~6.1mmol/L)传统治疗组血糖高于215mg/dL(12mmol/L)输注胰岛素维持在180~200mg/dL(10~11mmol/L).Intensiveinsulintherapyinthecriticallyillpatients(危重患者的强化胰岛素治疗)VandenBergheG,etal.NEnglJMed2001;345:1359–1367.血糖控制--强化胰岛素治疗平均跟踪23天结局强化胰岛素传统治疗ICU死亡5%8%住院死亡7%11%ICU留住5天以上11%16%机械通气14天以上8%12%需血滤/透析肾衰5%8%血行感染4%8%危重病多发性神经病29%52%血糖控制--强化胰岛素治疗VandenBergheG,etal:Intensiveinsulintherapyinthecriticallyillpatients.NEnglJMed2001;345:1359–1367.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80~110mg/dL(4.4~6.1mmol/L)最佳但是与高血糖比较，目标为血糖＜150mg/dL(8.3mmol/L)也能改善预后Inconclusion,theuseofexogenousinsulintomaintainbloodglucoseatalevelnohigherthan110mgperdeciliterreducedmorbidityandmortalityamongcriticallyillpatientsinthesurgicalintensivecareunit,regardlessofwhethertheyhadahistoryofdiabetes无论有无糖尿病病史，应用胰岛素将血糖水平控制在110mg/dL以下能降低外科ICU患者死亡率VandenBergheG,etal:Intensiveinsulintherapyinthecriticallyillpatients.NEnglJMed2001;345:1359–1367.2008---SurvivingSepsisCampaign:Internationalguidelinesformanagementofseveresepsisandsepticshock1.Werecommendthat,followinginitialstabilization,patientswithseveresepsisandhyperglycemiawhoareadmittedtotheICUreceiveIVinsulintherapytoreducebloodglucoselevels(Grade1B).2.Wesuggestuseofavalidatedprotocolforinsulindoseadjustmentsandtargetingglucoselevelstothe150mg/dlrange(Grade2C).3.Werecommendthatallpatientsreceivingintravenousinsulinreceiveaglucosecaloriesourceandthatbloodglucosevaluesbemonitoredevery1–2hoursuntilglucosevaluesandinsulininfusionratesarestableandthenevery4hoursthereafter(Grade1C).4.Werecommendthatlowglucoselevelsobtainedwithpoint-of-caretestingofcapillarybloodbeinterpretedwithcaution,assuchmeasurementsmayoverestimatearterialbloodorplasmaglucosevalues(Grade1B).2008---SurvivingSepsisCampaign:Internationalguidelinesformanagementofseveresepsisandsepticshock1.Werecommendthat,followinginitialstabilization,patientswithseveresepsisandhyperglycemiawhoareadmittedtotheICUreceiveIVinsulintherapytoreducebloodglucoselevels(Grade1B)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(Grade1B)2.Wesuggestuseofavalidatedprotocolforinsulindoseadjustmentsandtargetingglucoselevelstothe150mg/dlrange(8.3mmol/L)(Grade2C)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150mg/dl(8.3mmol/L)(Grade2C)2008---SurvivingSepsisCampaign:Internationalguidelinesformanagementofseveresepsisandsepticshock3.Werecommendthatallpatientsreceivingintravenousinsulinreceiveaglucosecaloriesourceandthatbloodglucosevaluesbemonitoredevery1–2hoursuntilglucosevaluesandinsulininfusionratesarestableandthenevery4hoursthereafter(Grade1C)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(Grade1C)2008---SurvivingSepsisCampaign:Internationalguidelinesformanagementofseveresepsisandsepticshock4.Werecommendthatlowglucoselevelsobtainedwithpoint-of-caretestingofcapillarybloodbeinterpretedwithcaution,assuchmeasurementsmayoverestimatearterialbloodorplasmaglucosevalues(Grade1B)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(Grade1B)2008---SurvivingSepsisCampaign:InternationalguidelinesformanagementofseveresepsisandsepticshockCancontrollingbloodsugarlevelsintheICUsaveyourlife?TueMar24,2009LandmarkstudiespublishedinNewEnglandJournalofMedicineandCMAJ（CanadianMedicalAssociationJournal）ThisisthequestionateamofcriticalcarephysicianresearchersatVGHsetouttoanswerseveralyearsago.TheirworkispublishedtodayintheNewEnglandJournalofMedicineandCanadianMedicalAssociationJournal(CMAJ).Theresultscallforanurgentreviewofinternationalclinicalguidelines.LtoR:InvestigatorDr.VinayDhingradiscussestheSUGARstudywithresearchco-ordinatorsSusanLogieandLaurieSmithalongwithCanadianprojectmanagerDeniseFoster.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NICESUGAR研究：Background背景Aparallel-group,randomized,controlledtrialinvolvingadultmedicalandsurgicalpatientsadmittedtotheICUsof42hospitals:38academictertiarycarehospitalsand4communityhospitalsInvolving42hospitalsfromfourcountriesandtwocontinentsOfthe6104patientswhounderwentrandomization,3054wereassignedtoundergointensivecontroland3050toundergoconventionalcontrol大样本，随机，对照试验42家医院的外科和内科成人ICU患者，