ICU患者血糖的控制+09-8-1例析.ppt

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 血糖水平的调节 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，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 高血糖的危害 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 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” 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 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: 1359–1367. 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80~110 mg/dL (4.4~6.1 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 2008Surviving Sepsis Campaign: International guidelines for management of severe 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 monitored every 1–2 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). 2008Surviving Sepsis Campaign: International guidelines for management of se