胰岛素的精细调节李学军

糖尿病患者的胰岛素治疗,李学军厦门市糖尿病研究所厦门大学附属第一医院,李学军厦门市糖尿病研究所厦大附一内分泌糖尿病科厦门市内分泌代谢病临床医学中心,糖尿病患者最大的悲剧不是罹患糖尿病，而是没有控制好糖尿病。,如果我们改变不了结局，我们应该努力改变进程。,最有效的控糖手段-“五驾马车”,教 育,运 动,饮 食,监 测,药 物,为什么要使用胰岛素？,2型糖尿病是一种进展性的疾病,Slow decline phase：1.7%/year,Rapid decline phase: 18.2%/year,适用对象基于胰岛B细胞功能,时间 (年),诊断,胰岛素补充治疗,胰岛素替代治疗,胰岛素强化治疗,胰岛素,优势：降糖疗效强局限低血糖体重增加皮下注射，使用不便,如何正确使用胰岛素？,胰岛素的种类,速效胰岛素Aspart(诺和锐)、Lispro(优泌乐)短效胰岛素Regular(普通胰岛素)中长效胰岛素NPH、Lente、Ultralente、Glargine(来得时),胰岛素制剂的持续改进,12,非糖尿病者血糖及胰岛素的变化,9.0,6.0,3.0,0,7,8,9,10,11,12,1,2,3,4,5,6,7,8,9,Insulin,Glucose,a.m.,p.m.,Breakfast,Lunch,Supper,75,50,25,0,Basal insulin,Basal glucose,Insulin(U/mL),Glucose(mmo/L),Time of Day,13,正常人的血糖变化曲线,Blood Glucose (mmol/L),10- 8- 6- 4- 2- 0,8am noon 6pm 2am 4am 8am,Time,www.diabetesclinic.ca,Continuous Infusion,Blood Glucose (mmol/L),8am noon 6pm 2am 4am 8am,Time,10- 8- 6- 4- 2- 0,10/9020/8030/7040/6050/50,Post- prandial hyperglycemia,Pre-prandial hyperglycemia,相对方便 不同的预混比例 (25/75，30/70，50/50). 常见午餐后高血糖.,Cause: Lack of insulin Lunch effect afternoon snacksEffect: Pre-meal hyperglycemia HbA1c by 1.7%,Treat by adding regular dose pre-lunch,Treat by adding regular dose pre-meals and small one before sleep,HypoglycemiaWindowCause: NPH evening dose ? Late sleep Effect: Somogyi effect,Week end or night shift work Problem,胰岛素可能的使用方法,Many different potential regimens!Oral + hs insulin (basal)Oral + AM insulin (basal)Pre-mixed insulin with breakfast and supperShort-acting with meals + bedtime basalPre-mixed with breakfast and supper + R/H with lunch.NPH with breakfast and supper + R/H with breakfast and lunch and supper.Pre-mixed insulin with breakfast or lunch or supperPre-mixed insulin with breakfast + R/H with supperR/H insulin with breakfast and lunch and supper,如何精细调节胰岛素的用量？,确定血糖控制目标,为每个病人确定其最适宜的血糖控制目标。成年病人的一般控制目标： 餐前：4.4-6.1mmol/L；餐后2小时：5.0mmol/L若反复出现低血糖，适当提高控制目标： 餐前：5.6-8.9mmol/L若怀孕，则应适当减低目标血糖值：餐后 6.7mmol/L注意餐前后两次血糖的差值 目标血糖 降低 ICR,11.2,I:C 1:15,3:00,6.8,7:00,60 gms,5.0 u,9:15,要确定是否正确计算碳水化合物系数,尝试 I:C 1:12,确认/调整碳水化合物系数（ICR）,5.5,6.9,比较餐前和餐后2hr血糖,Basal Rate: 0:00 0.5 u/hr 3 :00 0.7 u/hr 7 :00 0.6 u/hr,餐后血糖 目标血糖增加 ICR,ICR: 1:15,3:00,6.7,7:00,5.5,60 gms,3.3 u,9:15,确认/调整碳水化合物系数（ICR）,比较餐前和餐后2hr血糖,Basal Rate: 0:00 0.5 u/hr 3 :00 0.7 u/hr 7 :00 0.6 u/hr,ICR: 1:18,6.9,确定ICR ，需要比较: 餐前血糖与餐后2小时血糖在开始调整阶段，应保持进食低脂肪餐和碳水化合物含量较为固定的食物ICR 估算正确的表现:血糖在餐后2小时没有显著的升高或降低：不超过2.8 3.9mmol/L,* 请牢记，早，中，晚餐的ICR可能会有所不同,确认/调整碳水化合物系数,当患者纠正他的高血糖时，应在2hr内进行血糖监测，以确定血糖是否达标,75 gm,+1.8 u,6.9,(10.4 5.6) 18 = 1.8 u 50,9.3 u,当前BG - 目标 BG (100) = # UISF (50),(13.9 5.6)18 50 = 3.0 units,补充大剂量,Basal Rate: 0:00 0.5 u/hr 3 :00 0.7 u/hr 9 :00 0.5 u/hr,ICR: 1:10ISF: 50,胰岛素敏感系数,确定ISF，需要对比: 输注补充大剂量前的血糖与输注补充大剂量后的血糖当符合下列条件时，ISF已被正确调整 :调整后2 hr血糖不超过目标值(5.6-6.7mmol/L) 1.7mmol/L以上 3小时内再测一次血糖以确认血糖在目标范围内,补充大剂量的计算：确定胰岛素敏感系数（ISF）,影响血糖控制的非胰岛素因素举例,注射部位的选择,把好教育关；时常留心注射部位；血糖不随胰岛素量的变化而变化。,预混胰岛素是否混匀？,在使用之前，应将胰岛素水平滚动和上下翻动各10次，使 瓶内药液充分混匀，直至胰岛素转变成均匀的云雾状白色 液体。比例改变的影响将一直持续至药量用完。,King L. Subcutaneous insulin injection technique. Nurs Stand. 2003;17:45-52.Jehle PM, Micheler C, Jehle DR, Breitig D, Boehm BO. Inadequate suspension of neutral protamine Hagendorn (NPH) insulin in pens. Lancet 1999;354:1604-7.Brown A, Steel JM, Duncan C, Duncun A, McBain AM. An assessment of the adequacy of suspension of insulin in pen injectors. Diabet Med 2004;21:604-608.Nath C. Mixing insulin: shake, rattle or roll? Nursing 2002;32:10.Springs MH. Shake, rattle, or roll?.Challenging traditional insulin injection practices Am J Nurs 1999; 99: 14.,注射时间的灵活运用,以患者的血糖变化谱为基础；不要拘泥于是否餐前；并非总是提前半小时或10分钟。,注射部位还应考虑胰岛素在不同部位的吸收差异,不同注射部位胰岛素吸收不同（分钟）： 研究显示，50%胰岛素吸收所需要的时间腹部最快，手臂中等，大腿和臀部较慢1,1.The American Journal of Nursing, Vol. 98, No.7, pp. 55+57,Clauson PG, Linde B. Absorption of rapid-acting insulin in obese and nonobese NIDDM patients. Diabetes Care 1995;18:986-91.Jamal R, Ross SA, Parkes JL, Pardo S, Ginsberg BH. Role of injection technique in use of insulin pens: prospective evaluation of a 31-gauge, 8mm insulin pen needle. Endocr Pract 1999;5:245-50.Birkebaek N, Solvig J, Hansen B, Jorgensen C, Smedegaard J, Christiansen J. A 4mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults. Diabetes Care. 2008 Sep;22(9): e65. Gibney MA, Arce CH, Byron KJ, Hirsch LJ. Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections: Implications for needle length recommendations. Curr MedRes Opin 2010;26:1519-30.Hirsch L, Klaff L, Bailey T, Gibney M, Albanese J, Qu S, et al. Comparative glycemic control, safety and patient ratings for a new 4 mm32G insulin pen needle in adults with diabetes. Curr Med Res Opin 2010;26:1531-41.Kreugel G, Keers JC, Jongbloed A, Verweij-Gjaltema AH, Wolffenbuttel BHR. The influence of needle length on glycemic control and patient preference in obese diabetic patients. Diabetes 2009;58:A117.Kreugel G, Beijer HJM, Kerstens MN, ter Maaten JC, Sluiter WJ, Boot BS. Influence of needle size for SC insulin administration on metabolic control and patient acceptance. Europ Diab Nursing 2007;4:1-5.Van Doorn LG, Alberda A, Lytzen L. Insulin leakage and pain perception with NovoFine 6 mm and NovoFine 12 mm needle lengths in patients with type 1 or type 2 diabetes. Diabet Med 1998;1:S50.Solvig J, Christiansen JS, Hansen B, Lytzen L. Localisation of potential insulin deposition in normal weight and obese patients with diabetes using Novofine 6 mm and Novofine 12 mm needles. Meeting Federation European Nurses in Diabetes, Jerusalem, Israel, 2000 (Abstract).,留心进针的角度,使