泵入胰岛素血糖调节

泵入胰岛素血糖调节 使用胰岛素泵是目前最为有效的控制血糖的之一。但在临床应用过程中，涉及到很多技术问题，假如不能掌握这些知识，胰岛素泵的优点就很难显现。 1、每日胰岛素剂量的计算 应根据患者糖尿病分型、血糖水平以及体重情况确定，初始推荐剂量如下: (1)未接受过胰岛素治疗的患者胰岛素剂量的计算 根据不同的糖尿病类型胰岛素剂量设定为: 1型糖尿病:一日总量(单位),体重(公斤)×(0.4,0.5) 2型糖尿病:一日总量(单位),体重(公斤)×(0.5,0.8) 在使用过程中应根据血糖监测水平进行个性化剂量调整。 (2)已接受胰岛素治疗的患者胰岛素剂量的计算 已接受胰岛素治疗的患者可根据胰岛素泵治疗前的胰岛素用量计算，具体可根据患者血糖控制情况而定，并在使用过程中根据血糖监测水平进行个性化剂量调整。 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 一日总量(单位),用泵前胰岛素用量(单位)×(70%,100%) 2、胰岛素剂量分配 (1)基础量和基础输注率的设定 定义:基础量是指维持机体基础血糖代谢所需的胰岛素量。 基础输注率是指胰岛素泵提供基础胰岛素的速度，一般以胰岛素用量(单位)/小时示。 每日基础量=全天胰岛素总量×(40%,60%)(平均50,) 基础输注率与时间段应根据患者的血糖波动情况以及生活状况来设定。 基础输注率的设定模式较多，可根据血糖控制的需要设置为一个或多个时间段，临床大多分为3-6个时间段。往往1型糖尿病较2型糖尿病采用更多分段。 在运动或某些特殊情况时，可相应地设定临时基础输注率。 (2)餐前大剂量的设定 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 定义:在三餐前一次性快速输注的胰岛素量。 初始设定的餐前大剂量总量一般为初始全天胰岛素用量的50%。 按照三餐1/3，1/3，1/3分配，或者1/5，2/5，2/5分配。 特殊情况下根据饮食成分，特别是碳水化合物含量以及血糖情况个性化设定。 (3)剂量分配的注意事项 初始胰岛素泵治疗时，总剂量的50%为基础量，50%为餐前大剂量; 年轻的患者可采用基础量40%，餐前大剂量60%的方法来分配。 3、补充大剂量 定义:在临时加餐时所追加的一次性快速输注的胰岛素量。 计算临时进餐前追加量是根据食物中碳水化合物含量和碳水化合物系数(即该患者每1单位胰岛素所能平衡的碳水化合物克数)进行计算。 补充大剂量(单位) = 食物的碳水化合物含量(克)? 碳水化合物系数(克/单位) planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 4、校正大剂量 定义:纠正当前高于目标值的血糖时所补充的胰岛素量。当目前血糖高于目标血糖值时可以通过校正大剂量来加强血糖的控制。 校正大剂量 =(实测血糖减目标血糖)?胰岛素敏感系数 此处所指胰岛素敏感系数为该患者每一个单位胰岛素能降低的血糖(毫摩尔/升)值。胰岛素敏感系数根据全天胰岛素用量计算。 附录: 1、补充大剂量计算 定义:在临时加餐时所追加的一次性快速输注的胰岛素量。 计算临时进餐前追加量是根据食物中碳水化合物含量和每1单位胰岛素所能平衡的碳水化合物克数进行计算。 食物中碳水化合物含量通过中国食物成分表查阅。 补充大剂量=食物的碳水化合物重量?碳水化合物系数 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 碳水化合物系数可通过500/450原则计算(注:短效胰岛素用450，速效胰岛素用500)或者参考“每单位胰岛素可平衡的碳水化合物重量数据简表”(表1) 碳水化合物系数(克/单位胰岛素) =(500或450 克)? 每日胰岛素总量 表1 根据体重及每日胰岛素总量估算开始泵治疗时的基础量 体 每日胰岛素总量基 础 率 1单位胰岛素可平衡的碳水化重 (单位/日) 合物重量(克) (单位/ 小时)(公 斤) 45 25 0.3,0.5 18 50 28 0.4,0.6 16 30 0.5,0.6 15 54.5 59 33 0.5,0.6 14 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 64 35 0.6,0.7 13 68 38 0.6,0.8 12 73 40 0.6,0.8 11 77 43 0.7,0.9 10.5 82 45 0.8,1.0 10 86 48 0.8,1.1 9 91 52 0.9,1.2 8.7 100 58 1.0,1.3 8 109 66 1.1,1.4 7 2、校正大剂量 定义:纠正当前高于目标值的血糖时所补充的胰岛素量。当目前血糖高于目标血糖值时可以通过校正大剂量来加强血糖的控制。 校正大剂量 =(实测血糖减目标血糖)?胰岛素敏感系数。 胰岛素敏感系数根据全天胰岛素用量计算，表示每一单位胰岛素能降planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 低的血糖(毫摩尔/升)值。 可通过1500/1800原则或查表4得到。(注:短效胰岛素用1500，速效胰岛素用1800)。 胰岛素敏感系数(毫摩尔/升), (1500或1800) ? (每日胰岛素总量×18) 表2 应用短效胰岛素患者胰岛素敏感系数快速查阅表 当前每日胰岛素总胰岛素敏感系 量 数 (单位) (毫摩尔/升) 10 8.3 20 4.2 25 3.3 30 2.8 40 2.1 50 1.7 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 60 1.4 75 1.1 100 0.8 150 0.6 3、如何由胰岛素泵治疗转化为多次皮下注射胰岛素治疗 改为多次皮下注射需加10%-20%的剂量。 4、常规餐前大剂量 定义:在一段短时间内输注指定剂量的胰岛素。 用途:一般用来校正进食高碳水化合物、低脂、低蛋白质、少纤维素的食物或零食后的高血糖。 5、方波餐前大剂量 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 定义:餐前大剂量总量不变，在30分钟到8小时内均匀输注一个餐前大剂量。 用途:一般用于需要更长时间吸收的食物或延迟吸收，如长时间进餐，胃轻瘫等情况。通过延长输注胰岛素时间来适应血糖变化。 3、双波餐前大剂量 定义:餐前大剂量总量不变，分割成一个常规餐前大剂量和随后的一个方波餐前大剂量。 用途:当摄入同时含有容易消化部分和需要长时间才能吸收的混合食物时，可使用该功能。 二 摘要】 目的 探讨应用微量注射泵持续静脉泵入普通胰岛素控制危重患者的血糖水平的效果。方法 将2007年8月,2010年12月期间120例重症高血糖患者按入院时间序号随机分成观察组和对照组各60例，观察组采用微量注射泵持续静脉泵入胰岛素;对照组:传统小剂量持续静脉滴注胰岛素。结果 微量泵治疗组控制高血糖达标时间、理想血糖平均时间、低血糖发生率等，与对照组比较有显著差异(P<0.05)。结论 微量注射泵持续静脉泵入胰岛素可有效地控制危重患者的血糖，并持续稳定在所需范围内，是一种控制危重患者血糖更快、更安全的给药方法。 【关键词】 微量泵 胰岛素 危重症 ICU内危重患者在应激状态下的高血糖状态极为常见，高血糖对危重患者的危害严重，如何平稳有效地控制危重患者的血糖已成为了医疗工作者最关注的问题，自2007年8月我科引入微量注射泵持续静脉泵入胰岛素输注技术来控制危重患者的血糖，并定时监测血糖，同时根据血糖值调节泵速，绝大多数患者在使用此方法后，于24小时内能达到血糖满意控制，且持续、安全、有效地将患者的血糖控制在临床所需水平内。现将其方法报道如下。 1 资料与方法 1.1一般资料 全部病例为2007年8月,2010年12月我院ICU收治的高血糖危重患者共120例，其中男82例，女38例，年龄18—86岁，重症颅脑外伤38例，脑血管意外26例，严重多发伤24例，肺心病14例，急性胰腺炎12例，药物中毒6例。入选患者按照入院先后顺序随机分成微量泵治疗组和传统治疗组各60例，两组性别、年龄、病情、治疗等方面比较差异无显著性(P>0.05)。 planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card 1.2方法 1.2.1微量泵组 准备好微量注射泵，用50ml注射器抽取生理盐水40ml+普通胰岛素40U(其含量为lU/ml)，将微量泵接上电源，打开泵后电源开关，将配制胰岛素药液的50ml注射器，连接延长管和头皮针，排净空气，把注射器安装在微量泵注射器槽中。根据病人所测定的血糖值确定参数，将针头插入病人的静脉通路后，再启动泵即开始输注。同时所有入选病例均按治疗其原发病。 1.2.2传统治疗组 将小剂量胰岛素加入生理盐水或葡萄糖溶液中按普通输液方法持续滴注，同时所有入选病例均按指南治疗其原发病。 2 观察指标 空腹血糖在4.4,7.8mmol/L 范围内为达标目标，观察控制高血糖达标时间、理想血糖平均时间、低血糖发生率等。 3 统计学处理 所有数据采用SPSS11.5统计处理软件，计量资料以(x-?s)表示，组间比较采用t检验。 微量泵组与对照组比较P<0.05表示差异显著，有临床意义。 5 护理 继发性高血糖是重症监护病房患者的一种常见并发症，故入ICU病房的危重患者常规行电脑血糖监测，同时抽血标本送化验室检测血糖，以对比血糖值，对高血糖患者尽快采用微量注射泵入胰岛素治疗，以及早控制危重患者的应激性高血糖状况，泵入胰岛素期间，每间隔1-2小时监测电脑血糖，根据血糖值及时调节胰岛素泵入量、速率，使血糖值缓慢下 —3mmol/L。达到血糖值在目标范围内并维持，避免血糖骤升骤降，一般要求每小时下降2 减。泵注过程中加强巡视，避免泵管折叠、滑脱，保证输液通畅，注射器要贴上醒目的标签，做好查对工作。并注意胰岛素泵入效果及不良反应的观察并给予相应处理。 6 讨论 将血糖控制在4.4,7.8mmol/L范围内为达标目标。有研究显示，血糖控制在7.8mmol/L之内危重病人的生存机会是血糖在11.1mmol/L之上者的5.52倍[1]，血糖波动较大的危重病患者的死亡风险也较大[2]。 应用微量泵泵入胰岛素，有利于随时调整泵入剂量，又便于计算总量。微量注射泵能精确、微量、恒速、均匀、稳定地将胰岛素持续小剂量泵入体内，避免了传统输液滴注法的不良弊端，使血糖稳定下降。在微量泵泵入胰岛素期间频繁监测血糖，按血糖值及时调节胰岛素泵入速率，使患者的血糖始终控制在临床所需水平。 实践证明，应用微量泵持续静脉泵入胰岛素控制高血糖达标时间短、血糖波动幅度小、低血糖发生率低、安全系数高，在治疗应激状态高血糖方面取得了较好的临床效果，避免了高血糖的危害，减少了相关并发症的发生，提高了抢救成功率。 总之，微量注射泵静脉泵入胰岛素方法是控制危重患者高血糖状态较方便、较经济、较实用、较安全、较可靠的一种治疗方法。 参 考 文 献 [1] Verbruggen Scat, Joosten KFM, Castillo L,et al. Insulin therapy in the pediatric care unit[J].Clin Nutr, 2007,26: 677-690. [2] Egi M, Bellomo R, Stachosski E, et al. Variability of blood glucose concentration and short term mortality in critically ill patients[J].Anesthesiology,2006,105: 244-252. planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card planning, and government financing, and whole village relocation, and first built Hou split" of principles, insisted big community planning, and large district transformation, break administrative divisions boundaries, optimization town spatial structure, speed up new Community construction, formed new community live building, and intensive with ground project, and enterprise tax insurance running, and Expand employment and improve people's livelihood shed changed economic chain. The second, on poverty relief and development work in this battle the mission objectives for poverty alleviation in the file are already quite clear, was the previous two years (2016-2017) concentrated hard, three years after (2018-2020), consolidation and improvement, by the end of 2017, the County ... ... A poor village and ... ... Library district all "pick hat" and "five-ten", ... ... All the rural poor out of poverty, stability to achieve "two worry about three". To accomplish these tasks, win the battle for poverty alleviation, the key is to find out the way, selecting the right breakthrough, effectiveness in order to work on. (A) to accurately identify objects for poverty alleviation. XI General Secretary noted that the critical time of poverty lies in precision. How to do accurate? ' first task is to do basic work solid. Total demand is down to village, household, persons, County, town, and village books, card