早會(huì)低血糖

1、糖尿病圍術(shù)期處理的幾個(gè)相關(guān)問題,山西醫(yī)科大學(xué)第二醫(yī)院麻醉科王利利,,糖尿病概述；病例分享；低血糖綜合征；圍術(shù)期血糖管理；,糖尿病（diabetes mullitus, DM）,（一）概述,概念：是一組由多病因引起的以慢性高血糖為特征的代謝性疾病，是由于胰島素分泌和（或）作用缺陷所引起；主要病理改變： 1.長期碳水化合物以及脂肪、蛋白質(zhì)代謝紊亂可引起多系統(tǒng)損害，導(dǎo)致眼、腎、神經(jīng)、心臟、血管等組織器官慢性進(jìn)行性病變、功能減

2、退及衰竭； 2.病情嚴(yán)重或應(yīng)激時(shí)可發(fā)生急性嚴(yán)重代謝紊亂，如糖尿病酮癥酸中毒（DKA），高滲高血糖綜合征；,（二）流行病學(xué)資料,目前，全世界范圍內(nèi)，糖尿病患病率、發(fā)病率和糖尿病患者數(shù)量急劇上升；國際糖尿病聯(lián)盟（IDF）統(tǒng)計(jì)： 2010年全世界糖尿病患者數(shù)2.85億 2011年上升到3.66億，增加近30%我國成年人糖尿病患病率達(dá)9.7%，而糖尿病前期的比例更高達(dá)15.5%；更為嚴(yán)重是我國約60%的糖

3、尿病患者未被診斷，已接受治療者，控制狀況也很不理性；糖尿病使心臟、腦和周圍血管疾病風(fēng)險(xiǎn)增加2-7倍； 《內(nèi)科學(xué)》第八版 2013年3月,目前糖尿病患者 約占外科手術(shù)住院患者的20 % Tamai D，Awad AA，Chaudbry HJ，et a1．Optimizing the medical management of diabe

4、tic patients undergoing surgery[J]．Corm Med，2006，70(10)：621-630．,,如果術(shù)前檢查不仔細(xì)，將導(dǎo)致部分糖尿病患者被遺漏。 這部分被遺漏者由于缺乏術(shù)前積極的胰島素治療和有效的血糖控制， 術(shù)后的病死率比正常人要高出18倍，比接受良好治療者也要高出3倍。 Umpierrez GE，Isaacs SD，Bazargan N ，et a1．Hyperglyce

5、mia：an independent maker of in-hospital mortality in patients with undiagnosed diabetes[J]．J Clin Endocrinol Metab，2002，87(3)：978—982．,（三）糖尿病診斷標(biāo)準(zhǔn)（WHO糖尿病專家委員會(huì)報(bào)告，1999）,糖化蛋白,1.糖化血紅蛋白（GHbA1）： 葡萄糖（其他糖）+血紅蛋白→不可逆的蛋白糖化反應(yīng)，

6、 有a、b、c三種，以GHbA1 c為主； 正常人GHbA1 c占血紅蛋白總量3%-6%，和血糖升高的程度及時(shí)間相關(guān)； 紅細(xì)胞在血液中的壽命120天，因此GHbA1 c反映患者近8-12周的平均血糖水平；2.糖化血漿白蛋白： 葡萄糖（其他糖）+白蛋白→糖化反應(yīng)形成果糖胺（FA）， 白蛋白在血漿中半衰期19天，F(xiàn)A反映患者近2-3周內(nèi)平均血糖水平；,IDF提出糖尿病管理五個(gè)要點(diǎn)（五駕馬車）：糖尿病教育，

7、醫(yī)學(xué)營養(yǎng)治療，運(yùn)動(dòng)治療，血糖監(jiān)測(cè)，藥物治療,治 療,二 病例分享,（一） 一般情況 患者，男性、52歲， 主因持續(xù)性干咳、乏力2月余 入院；,,現(xiàn)病史： 患者自稱2月前因淋雨后“感冒”而開始持續(xù)性刺激性干咳，痰少，無咳血。 2個(gè)月來一直自服抗“感冒”藥無明顯好轉(zhuǎn)，并伴有乏力、體重下降。 當(dāng)?shù)蒯t(yī)院拍胸片及相關(guān)檢查提示： 右肺近

8、肺門處高密度腫塊影，伴有肺不張。,,既往史： 糖尿病史8年，一直間斷服用消渴丸治療，血糖控制不佳。 無高血壓、冠心病、傳染病及過敏史；個(gè)人史： 吸煙史10余年，每日2包；,,纖維支氣管鏡檢查:支氣管肺癌糖尿病相關(guān)實(shí)驗(yàn)室檢查: 尿酮（—）；尿糖（—）；空腹血糖 10.5mmol/L。查體：右肺下野叩診稍濁，呼吸音減弱。雙側(cè)均未聞及干濕性羅音及哮鳴音。無胸膜摩擦音。,（二）

9、 術(shù)前準(zhǔn)備,患者自入院以來，血糖持續(xù)保持較高水平（空腹血糖在10.5—11.0mmol/L之間），依據(jù)內(nèi)分泌科會(huì)診意見，持續(xù)監(jiān)測(cè)血糖，裝胰島素泵。擬在裝胰島素泵的次日，在全麻氣管插管下行胸腔鏡輔助肺葉切除術(shù)。,（三） 手術(shù)過程,全麻氣管插管下，胸腔鏡探查見右肺中下葉巨大腫塊，上葉部分不張，肺門淋巴結(jié)腫大，胸膜部分粘連，胸腔鏡無法繼續(xù)手術(shù)，中轉(zhuǎn)開胸，肺門淋巴結(jié)腫大成塊，肺動(dòng)脈和肺靜脈包繞其中，無法游離，最終行右側(cè)全肺切除術(shù)，術(shù)中出血較多

10、，約1200ml。,手術(shù)開始2小時(shí)后，患者出現(xiàn)了EMERGENCY,手術(shù)開始后2小時(shí)，患者面色蒼白，嘴唇發(fā)青，全身大汗淋漓，額頭部汗珠如簧豆?fàn)睿穆始涌欤?10次/分，血壓120 /80mmHg，導(dǎo)尿1200ml。,,,麻醉醫(yī)生輸入5%GS 120ml，患者癥狀有所改善。急查血糖：17.1mmol/L。癥狀改善后1小時(shí)，患者的前述癥狀再次出現(xiàn)，輸入5%GS 140ml，癥狀好轉(zhuǎn)。但1小時(shí)后第三次出現(xiàn)上述癥狀，輸入5%GS 140ml

11、，癥狀好轉(zhuǎn)。隨后手術(shù)結(jié)束，1小時(shí)15分后患者蘇醒，帶管轉(zhuǎn)入ICU病房。,低血糖綜合征（Hypoglycemic Syndrome）,（一）概念,是一組多種病因引起的以靜脈血漿葡萄糖濃度過低， 臨床上以交感神經(jīng)興奮和腦細(xì)胞缺糖為主要特點(diǎn)的綜合征。 一般以血糖濃度低于2.8mmol/L（50mg/dl）作為低血糖的標(biāo)準(zhǔn)；,,,（二）低血糖綜合征的診斷：符合Whipple三聯(lián)癥,口服或靜脈注射葡萄糖后，癥狀可立即消失,低血

12、糖癥狀,發(fā)作時(shí)血糖低于2.8mmol/L,提示,,,在術(shù)中，當(dāng)糖尿病患者出現(xiàn)與糖尿病相關(guān)的癥狀時(shí)，應(yīng)先測(cè)血糖，再做處理。 搶救絕不僅僅是靜脈注射一次葡萄糖即可，如不繼續(xù)靜脈滴注足夠葡萄糖常常再度出現(xiàn)低血糖綜合征。,注：1u胰島素消耗8克糖,（三）臨床表現(xiàn),自主（交感）神經(jīng)過度興奮表現(xiàn)：交感神經(jīng)核腎上腺髓質(zhì)釋放腎上腺素、去甲腎上腺素和一些肽類物質(zhì)，表現(xiàn)為出汗、饑餓、感覺異常、腦功能障礙表現(xiàn)：大腦缺乏足量葡萄糖供應(yīng)時(shí)腦功能失調(diào)的一

13、系列表現(xiàn)；,（四）治療,低血糖的預(yù)防；低血糖的治療；,低血糖的治療,,四 糖尿病患者圍術(shù)期血糖的管理,（一）糖尿病患者術(shù)前準(zhǔn)備標(biāo)準(zhǔn),,,1. 空腹血糖以 維持在6.1-7.2mmol/L之間 （110-130mg/dl）， 不高于8.3mmol/L（150mg/dl）， 最高不超過11.1mmol/L（200mg/dl）。 2.無酮血癥或尿酮體陰性。 3.尿糖測(cè)

14、定為陰性或弱陽性。,,（二）低血糖相關(guān)風(fēng)險(xiǎn),CONCLUSIONS : Higher weight-based insulin doses are associated with greater odds of hypoglycemia independent of insulin type. However, 0.6 units/kg seems to be a threshold below w

15、hich the odds of hypoglycemia are relatively low. These findings may help clinicians use insulin more safely. Rubin DJ, Rybin D, Doros G, McDonnell ME. Weight-based, insulin dose-related hypoglyce

16、mia in hospitalized patients with diabetes. Diabetes Care. 2011;34(8):1723-1728.,,During continuous glucose monitoring, cardiac ischemia has been detected more frequently during hypoglycemia than either normoglyce

17、mia or hyperglycemia. Desouza C, Salazar H, Cheong B, Murgo J, Fonseca V. Association of hypoglycemia and cardiac ischemia. Diabetes. 2003:26(5):1485-1489.,,Development of spontaneous, but not iatrogenic,

18、hypoglycemia in patients experiencing acute myocardial infarction has been linked to increased mortality. Kosiborod M, Inzucchi SE, Goyal A, et al. Relationship between spontaneous and iatrogenic hypogly

19、cemia and mortality in patients hospitalized with acute myocardial infarction. JAMA. 2009;301(15):1556-1564.,Hyperglycemia is associated with increased mortality and morbidity in critically ill patients. Although hyperg

20、lycemia is associated with worse outcomes, the treatment of hyperglycemia with insulin infusions has not provided consistent benefits. Despite early results, which suggested decreased mortality and other advantages of “

21、tight” glucose control, later investigations found either no benefit or increased mortality when hyperglycemia was aggressively treated with insulin.,Because of these conflicting data, the optimal glucose concentration

22、to improve outcomes in critically ill patients is unknown. Current recommendations for perioperative glucose management from national societies are varied, but, most suggest that tight glucose control may not be be

23、neficial, while mild hyperglycemia appears to be well-tolerated Andra E. Duncan*，Hyperglycemia and Perioperative Glucose Management，Current Pharmaceutical Design, 2012, 18, 6195-6203,Others report that int

24、raoperative hyperglycemia, defined as the measurement of four consecutive blood concentrations greater than 200 mg/dL, was associated with significantly higher risk of mortality, as well as increased risk for cardiovascu

25、lar, respiratory, renal, neurologic morbidity. Outtara A, Lecomte P, Le Manach Y, et al. Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic pa

26、tients. Anesthesiology 2005; 103(4): 687-94,Fig. (2).Incidence of severe in-hospital morbidity between patients in whom intraoperative glycemic control was poor (4 consecutive glucose levels > 200 mg/dL) or tight. CV

27、= cardiovascular morbidity; Inf: infectious morbidity; Neuro = neurologic morbidity; Resp = respiratory morbidity. *P<0.05 versus tight control. Reprinted with permission. Anesthesiology 2005; 103: 687-94.,Duncan and

28、colleagues found that, although severe intraoperative hyperglycemia (average glucose concentration greater than 200 mg/dL) was associated with high risk of morbidity and mortality, glucose concentrations closest to

29、normoglycemia (average glucose of 140 mg/dL or less) were also associated with increased mortality and morbidity Duncan AE, Abd-Elsayed A, Maheshwari A, Xu M, Soltesz E, Koch CG. Role of intraoperative and posto

30、perative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology 2010; 112(4): 860-71.,Univariate analysis comparing risk of adverse outcome between decreasing incremental mean glucose l

31、evels during the initial postoperative period.*P􀀁0.001 overall between mean glucose levels for each individual outcome. #P􀀁 0.001 between glucose > 200 mg/dL and glucose 141 -170 mg/dL. Reprintedwi

32、th permission. Anesthesiology 2010; 112: 860.,7.7,7.8—9.4,9.5--11.1,11.1,Univariate analysis comparing risk of adverse outcome between decreasing incremental mean glucose levels during the intraoperative period.*PИ

33、577;0.001 overall between mean glucose levels for each individual outcome. #P􀀁 0.001 between glucose > 200 mg/dL and glucose 141 -170 mg/dL. Reprinted with permission. Anesthesiology 2010; 112: 860.,11.1,9.5

34、--11.1,7.8—9.4,7.7,11.1,9.5--11.1,7.8—9.4,7.7,,Interestingly, the lowest glucose concentrations during the intraoperative period were associated with an increase in complications. This differed markedly from the pattern

35、 of the postoperative period, where the risk of adverse outcomes consistently declined with decreasing glucose concentrations,Conclusions: Intensive insulin therapy to maintain blood glucose at or below 110 mg pe

36、r deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit.,AFTER OPERATION,AFTER OPERATION,Conclusions: In this large, international, randomized trial, we

37、 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 decil

38、iter. (ClinicalTrials.gov number, NCT00220987.),小 結(jié),糖尿病是一種常見的慢性??；控制高血糖的同時(shí)，一定注意低血糖的發(fā)生；低血糖和高血糖以及正常血糖相比，更容易引起心臟不良事件，一定程度的高血糖更有利于患者轉(zhuǎn)歸，但任何時(shí)候都不建議血糖高于11.1mmol/L；圍術(shù)期血糖控制標(biāo)準(zhǔn)： 術(shù)前（6、7、8, 1、2、3）， 術(shù)中（7、8、9）；,INTRODUCTIO

39、N,Hyperglycemia is associated with worse outcomes in critically ill hospitalized patients [1, 2]. Patients who are hyperglycemic following stroke have worse functional recovery and higher mortality [3, 4]. Critically ill

40、 patients who have suffered myocardial infarction are more likely to experience cardiogenic shock, congestive heart failure, or die, if they were hyperglycemic during hospital admission [5].,,In surgical patients, periop

41、erative hyperglycemia increases risk of postoperative mortality, and cardiovascular, respiratory, neurologic, and infectious morbidity [6-9]. Despite the fact that hyperglycemia increases risk for adverse outcome in many

42、 clinical conditions, treatment of hyperglycemia has not consistently improved outcomes. In fact, certain aggressive treatments of severe hyperglycemia have not provided a survival benefit and, in some instances, have e

43、ven increased mortality [10-12].,ADVERSE AFFECTS OF HYPERGLYCEMIA,Patients who experience major trauma, illness, or surgery often develop a hypermetabolic stress response, which is characterized by hyperglycemia and insu

44、lin resistance.The severity of the hyperglycemic response to major surgery may be affected by an individual’s ability to control blood glucose [13] and the magnitude of the surgery [14].,PREOPERATIVE GLUCOSE MANAGEMENT

45、OF DIABETIC PATIENTS,Approximately 27% of all people aged 65 years or older in the US are estimated to have diabetes mellitus.1,INTRAOPERATIVE GLUCOSE MANAGEMENT OF THE DIABETIC AND NONDIABETIC PATIENT,Hyperglycemia dev

46、elops in both diabetic as well as nondiabetic patients undergoing surgery, because of stress hyperglycemia. Other factors may also contribute to hyperglycemia during the perioperative period, including administration o

47、f dextrose-containing fluids (used to mix antibiotics, vasoactive medications, etc.), hypothermia [54], increased substrate availability in the form of lactate, and decreased exogenous insulin activity [55]. Additional

48、 factors contribute to hyperglycemia in patients undergoing cardiac surgery, including heparin administration [56] and administration of glucose-containing cardioplegic solutions [57].,血糖水平與臨床癥狀,拮抗激素分泌胰升糖素腎上腺素,出現(xiàn)低血糖癥

49、狀自主神經(jīng)癥狀,,543210,,,,,,,抑制內(nèi)源性胰島素分泌,4.6（82.8）,,,3.8(68.4),3.2-2.8(57.6-50.4),,,神經(jīng)生理功能異常喚醒障礙,,,3.0-2.4(54-43.2),,,,,2.8(50.4),認(rèn)知功能異常,不能完成復(fù)雜任務(wù),2.0(36),腦電圖發(fā)生變化,,<1.5(27.0),嚴(yán)重的低血糖意識(shí)障礙驚厥昏迷,,,靜脈血糖水平(mmol/L),,血糖

50、單位：mmol/L（mg/dl）,,Perioperative hypoglycemia has been reported when the exogenous basal insulin dose exceeded the basal requirement. Olson RP, Bethel MA, Lien L. Preoperative hypoglycemia in a patient rece

51、iving insulin detemir. AnesthAnalg. 2009;108(6): 136-138.,however, that hypoglycemia is an undesirable complication of intensive insulin therapy and should be avoided. In addition, the risk of increased glucose variabil

52、ity should be recognized, because of the associated increased risk for worse outcomes. Patients with diabetes mellitus experience chronic hyperglycemia and often require more intensive perioperative glucose management.

53、When diabetic patients are evaluated before surgery, appropriate management of oral hypoglycemic agents is necessary as several of these agents warrant special consideration. Current recommendations for perioperative g

54、lucose management from national societies are varied, but, most suggest that tight glucose control may not be beneficial, while mild hyperglycemia appears to be well-tolerated. Andra E. Duncan*，Hyperglycemia and Per

55、ioperative Glucose Management，Current Pharmaceutical Design, 2012, 18, 6195-6203,胰島素劑量反應(yīng)曲線,同時(shí)伴有曲線右移及曲線最大高度的降低，表明胰島素敏感性和反應(yīng)性均降低,單純曲線右移，表示胰島素的效應(yīng)器官對(duì)胰島素敏感性減低，需要增加胰島素的劑量才能達(dá)到最大反應(yīng),單純曲線高度降低，增加胰島素的劑量也不能達(dá)到最大的反應(yīng)高度，這提示靶器官對(duì)胰島素的反應(yīng)性降低。,