急性心肌梗死高血糖的控制ppt课件

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,急性心肌梗死高血糖的控制,中山大学附属第一医院内分泌科,肖 海 鹏,欧洲心脏调查结果,-,分组,n=2107,n=2854,The Euro Heart Survey on diabetes and the heart，European Heart Journal (2004) 25, 18801890,GAMI:,急性,心梗患者中的糖代谢异常,心肌梗死患者,Bartnik,M, et al. J Intern Med. 2004 Oct;256(4):288-97.,GAMI,:,新诊断高血糖是心肌梗死后“无心血管事件存活”的预测因素,Bartnik,M, et al.,Eur,Heart J. 2004;25(22):1990-7.,中位数随访时间,:34,月,Diabetics with a non-ST elevation ACS have a worse outcome than,nondiabetics,In the OASIS registry of 8013 patients with a non-ST elevation acute coronary syndrome (unstable angina or non Q-wave myocardial infarction), 21 percent had diabetes. After a two year follow-up, diabetic patients had a significantly higher combined event rate (cardiovascular death, new myocardial infarction, stroke, new heart failure) than,nondiabetics,(relative risk 1.56). Data from,Malmberg, K,Yusuf, S, Gerstein, HC, et al. Circulation 2000; 102:1014.,Diabetes increases coronary mortality with and without a prior MI,In a seven year follow up of 1059 subjects with type 2 diabetes and 1378,nondiabetics, diabetics with or without a prior myocardial infarction (MI) had a greater mortality from coronary disease compared to,nondiabetics,(42 versus 16 percent for those with a prior MI and 15 versus 2 percent for those without a prior MI. The rate of coronary death and fatal and nonfatal MI in diabetics without a prior MI was the same as in,nondiabetics,with a prior MI, providing part of the rationale for considering type 2 diabetes a coronary equivalent. Data from,Haffner, SM,Lehto, S,Ronnemaa, T, et al, N,Engl,J Med 1998; 339:229.,Hyperglycemia and Outcome After Acute MI,Predictive Value of Admission Glucose,Fasting glucose within 24hrs of admission,HbA1c on admission,U-shaped curve,Intensive insulin therapy reduces mortality in patients with diabetes after myocardial infarction,The Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction (DIGAMI) trial randomly assigned 620 diabetic patients to routine care (control group) or intensive therapy with a continuous insulin infusion. After an average,followup,of 3.4 years, the mortality in the control group was directly related to the admission blood glucose concentration ( 234 mg/,dL,13,mmol,/L, 234 to 297 mg/,dL,13 to 16.5,mmol,/L, and 297 mg/,dL,16.5,mmol,/L) (p 0.001). The mortality in those treated with intensive insulin was significantly reduced (33 versus 44 percent in the control group) regardless of the blood glucose value at admission. Data from,Malmberg, K,Norhammar, A,Wedel, H,Ryden, L, Circulation 1999; 99:2626.,Relationship between admission glucose values andcrude 30-day and 1-year mortality in all patients,Admission glucose and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes Circulation 2005;111;3078,Direct comparison of risk-adjusted 30-day mortality in patients with and without recognized diabetes across range of glucose values.,Adminission,glucose and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes,Circulation 2005;111;3078,30-day Mortality,One-Year Mortality,Direct comparison of risk-adjusted 1-year mortality in patients with and without recognized diabetes across range of glucose values,Adminission,glucose and mortality in elderly patients hospitalized with acute MI :implications for patients with recognized diabetes,Circulation 2005;111;3078,Figure1:Kaplan-meier cumulative survival curves of patients with normal FG and,tertiles,of elevated FG,Fasting glucose is an important independent risk factor for 30-day mortality in patients with AMI :a prospective study Circulation 2005;111:754,U-shaped curve,血糖水平与,30,天死亡率,低血糖组：,11.0mmol/L,U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction,J Am,Coll,Cardiol,2005;46:178,U-shaped curve,血糖水平与,30,天内再发心梗或死亡率,低血糖组：,11.0mmol/L,U-shaped relationship of blood glucose with adverse outcomes among patients with ST-segment elevation myocardial infarction,J Am,Coll,Cardiol,2005;46:178,Predictive value of HbA,1,c,Relation of chronic and acute,glycemic,control on mortality in acute MI with DM,Am J,Cardiol,2005;96:183,HbA,1,c on admission may,NOT,independently,predict mortality ,this observation suggest that stress hyperglycemia is of primary importance,Value of,Glycemic,Control,Cumulative survival following intensive or conventional insulin treatment in the ICU,Patients discharged alive from the ICU (panel A) and from the hospital (panel B) were considered to have survived. In both cases, the differences between the treatment groups were significant. Data from Van den,Berghe, G,Wouters, P,Weekers, F, et al. Intensive insulin therapy in critically ill patients. N,Engl,J Med 2001; 345:1359.,Diabetes Mellitus, Insulin Glucose,in Acute Myocardial Infarction,BMJ1997;314:1512,DIGAMI Study,DIGAMI,设计方案,标准治疗组（,314,名）,Insulin only for indication,DIGAMI:,结果,血糖水平（,mg/,dL,）,DIGAMI,： 结果,HbA1c,的降低（,%,）,DIAMI,研究 结果,DIGAMI:,结果,死亡率,DIGAMI,2,研究,D,iabetes Mellitus,I,nsulin,G,lucose Infusion in,A,cute,M,yocardial,I,nfarction,Eur,Heart J 2005,；,26,：,650,DIGAMI-2:,研究,第二组（,473,名）,insulin iv for inpatients,Standard treatment for outpatients,1,2,3,DIGAMI,2 result,P 0.1,DIGAMI,2 result,P 0.1,Why?,Copyright restrictions may apply.,Malmberg, K. et al. Eur Heart J 2005 26:650-661; doi:10.1093/eurheartj/ehi199,Glucose control expressed as fasting blood glucose (A) and HbA1c (B),Independent baseline predictors for mortality,Figure3,Independent baseline predictors for mortality.,Fasting blood glucose represents updated values during the time of follow-up,HI-5,研究,The Hyperglycemia: Intensive Insulin Infusion In Infarction,(HI-5) Study,Diabetes Care 2006;29:765,HI-5,研究设计,1,2,胰岛素,/,葡萄糖输注治疗组,(ITG),HI-5,结果,p=0.75,p=0.42,p=0.62,死亡率,(%),HI-5,结果,死亡率,HI-5,研究的意义,糖尿病急性心肌梗死患者将血糖控制在,144mg/dL(8.0mmol/L),是必要的。,Summary and Recommendation,Whether control of,glycemia,is sufficient to reduce morbidity and mortality are not proven at this time,It would seem prudent to attempt to maintain glucose10mmol/L and possibly 7.8mmol/L,U-shaped relation suggests that hypoglycemia should be strictly avoided,胰岛素使用方案,Yale University,注 意,1.,该胰岛素使用草案实用于所有高血糖的,ICU,成年患者，而并不是单纯为糖尿病急症制定，如，糖尿病酮症酸中毒（,DKA,）、高血糖高渗综合征（,HHS,）。一旦考虑为糖尿病急症或血糖大于等于,500 mg/,dL,，应该咨询医生的意见进行特殊处理。,2.,如果患者对胰岛素输注的反应异常或与预期不同，或者发生任何指南没有说明的情况，应该及时通知主诊医生。任何输注胰岛素的患者都应该严密检测电介质情况，尤其是血钾的情况。,1.,胰岛素输注：,1U,常规人胰岛素,/ 1,mL,生理盐水通过微泵静脉输入。,2.,起始：在开始胰岛素输注前，经静脉输液管推注,20,mL,胰岛素输注液以饱和输液管上的胰岛素吸附位点。,3.,阈值,：对于任何重症患者，如果血糖持续大于或等于,140 mg/,dL,，应该静脉输注胰岛素；如果血糖大于,120 mg/,dL,，可以考虑用。,4.,目标血糖水平：,90-120 mg/,dL,5.,首剂和起始胰岛素输注速度：如果初始血糖大于或等于,150 mg/,dL,，则将血糖值除以,70,，取近似值，即为首剂及起始胰岛素输注速度；如果初始血糖小于,150 mg/,dL,，同样将血糖值除以,70,取近似值，但不用首剂。,举例,：,1.,初始血糖,335 mg/,dL,，,335/70 = 4.78,，取近似值,5,，则首剂为,5 U,静脉推注，起始胰岛素速度为,5 U/hr,。,2.,起始血糖,=148 mg/,dL, 148/70 = 2.11,取近似值,2,，不用首剂，起始胰岛素速度为,2 U/hr,。,初始胰岛素使用,血糖监测,1.,每小时测一次血糖直至血糖稳定，即连续,3,次测得血糖在目标值范围内。在低血压的患者，毛细血管血糖（指尖血糖）可能不准确，应该通过静脉留置管采血。,2.,然后每,2,小时测一次血糖，一旦血糖稳定,12,24,小时以后，如果满足以下条件，可以每隔,3,4,小时测一次血糖。,a.,临床症状没有明显变化并且,b.,营养摄入没有明显改变,3.,如下有以下任何一种情况发生，应该考虑短期恢复每小时一次的血糖检测，直至血糖再次稳定：,a,.,任何胰岛素输注速度的改变，比如血糖超出目标值时调整胰岛素用量。,b.,临床情况有明显改变,c.,开始或终止升压药或激素治疗,d.,开始或终止透析或,CVVH,（持续静脉静脉血液透析滤过）治疗,e.,开始或终止营养支持治疗或调整其速度。营养支持包括完全肠外营养、部分肠外营养及鼻饲等。,调整胰岛素输注的速度,如果血糖小于,50 mg/,dL,：,停止胰岛素输注,静脉注射,25,克,50%,的葡萄糖，每,10,15,分钟后复测一次血糖。,当血糖大于或等于,90 mg/,dL,时，再观察,1,小时，然后复测血糖，如果血糖仍然大于等于,90 mg/,dL,，从新开始胰岛素输注，不过，速度减为最近胰岛素输注速度的,50,。,如果血糖在,50-69 mg/,dL,之间：,停止胰岛素输注,如果有低血糖症状，或无法评估有无低血糖症状，静脉注射,25,克,50%,的葡萄糖，每,15,分钟后复测一次血糖。,如果没有低血糖症状，可以静脉注射,12.5,克,50%,的葡萄糖或者口服,8,盎司,果汁，每,15,30,分钟后复测一次血糖。,当血糖大于或等于,90 mg/,dL,时，再观察,1,小时，然后复测血糖，如果血糖仍然大于或等于,90 mg/,dL,，按最近速度的,75%,重新输注胰岛素。,调整胰岛素输注的速度,如果血糖大于或等于,70 mg/,dL,:,第一步,按下述表格确定目前血糖所处的水平：,血糖,70-89 mg/,dL,血糖,90-119 mg/,dL,血糖,120-179 mg/,dL,血糖大于等于,180 mg/,dL,第二步,根据目前血糖及前一次测定的血糖计算出血糖的改变速度，然后根据目前血糖及血糖变化的速度在下表中找到相应的方格，方格同行最右边即目前胰岛素的调整方案。,注意：,如果前一次血糖是在,2,4,小时之前测得的，那么应该计算每小时的血糖变化率。例如，下午,2,点钟测的血糖是,150 mg/,dL,，现在下午,4,点钟测得的血糖是,120 mg/,dL,，,2,小时总的血糖变化为,-30 mg/,dL,，然而每小时的血糖变化却是,-30 mg/dL,2,-15 mg/,dL,/hr,。,调整胰岛素输注的速度,*注释：停止胰岛素输注，每,15,30,分钟复测一次血糖，当血糖大于或等于,90 mg/,dL,时，按最近胰岛素输注速度的,75,重新输注胰岛素。,调整胰岛素输注的速度,*注释：根据具体的临床情况，胰岛素输注速度一般为,2-10 U/hr,。很少超过,20 U/hr,，如果确实需要这么大量的胰岛素，应该通知主诊医生，寻找其他可能原因，包括技术故障，例如胰岛素输注液配置错误等。,第三步,胰岛素输注速度的改变，即上述表格所示,是根据目前胰岛素输注速度确定的，具体如下表：,THANK YOU !,