《ICU血糖管理课件》由会员分享，可在线阅读，更多相关《ICU血糖管理课件（45页珍藏版）》请在金锄头文库上搜索。
1、ICU血糖管理,ICU患者血糖的管理与监测,ICU血糖管理,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,ICU血糖管理,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,ICU血糖管理,胰岛素与血糖,胰岛素对糖代谢的调节： 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
2、织,ICU血糖管理,血糖水平异常,一高血糖 糖尿病 应激状态下的高血糖状态 二低血糖,ICU血糖管理,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,ICU血糖管理,高血糖的危害,ICU血糖管理,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,ICU血糖管理,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,ICU血糖管理,血
3、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,ICU血糖管
4、理,血糖控制-强化胰岛素治疗,ICU血糖管理,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,ICU血糖管理,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 conclusio
5、n, 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6.1 mmol/L以下能降低外科ICU
6、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,ICU血糖管理,2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,1. We recommend that, following initial stabilization, patients
7、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 patie
8、nts 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 te
9、sting of capillary blood be interpreted with caution, as such measurements may overestimate arterial blood or plasma glucose values (Grade 1B,ICU血糖管理,2008-Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock,1.We recommend that, following initial stabi
10、lization, 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,ICU血糖管理,2.We suggest use of a validated protocol for insulin dose adjustments and targeting
11、 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,ICU血糖管理,3.We recommend that all patients receiving intravenous insulin r
12、eceive 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 Campa
13、ign: International guidelines for management of severe sepsis and septic shock,ICU血糖管理,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)
14、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,ICU血糖管理,Can controlling blood sugar levels in the ICU save your life,Tue Mar 24, 2009Landmark studies published in New England Journal of Medi
15、cine and CMAJ（Canadian Medical Association Journal,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,发表在新英格兰和加拿大医学会杂志上研究的里程碑,ICU血糖管理,NICE SUGAR研究 ：Background 背
16、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 hospitals Involving 42 hospitals from four countries and two continents Of 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,ICU血糖管理
