(翻译)2023AAGBI糖尿病患者围手术期管理

1、GuidelinesPeri-operative management of the surgical patient with diabetes2023Association of Anaesthetists of Great Britain and Ireland2023AAGBI糖尿病患者围手术期管理英国和爱尔兰麻醉医师协会Membership of the Working Party: P. Barker, P. E. Creasey, K. Dhatariya,1 N. Levy, A. Lipp,2M. H. Nathanson (Chair), N. Penfold,3 B. W

2、atson and T. Woodcock1 Joint British Diabetes Societies Inpatient Care Group2 British Association of Day Surgery3 Royal College of AnaesthetistsSummaryDiabetes affects 1015% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and

3、length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c 69 mmol.mol1); deciding if the patient can be managed by simple manipulation of pre-existing treatment duringa shor

4、t starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with

5、poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurateand well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guidelin

6、e is to provide detailed guidance on the peri-operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.摘要糖尿病影响着近10% 15% 的手术患者，并且，接受外科手术的糖尿病患者的手术并发症发生率、死亡率和住院天数都相对较高。现代的针对伴有糖尿病的手术患者的管理重点是：通过术前评估和对糖尿病病情的

7、强化管理糖化血红蛋白 69 mmol.mol-1；如果患者可以简单地采用之前既有的调整方案加之一定的饮食控制就能管理好血糖水平，就不要采取可调节的胰岛素静脉输注；当后者是唯一选择需要使用时要注意平安性，例如急诊患者、手术后预期不能马上恢复正常饮食的患者、糖尿病控制很差的患者等。另外，医疗保健专业人员之间以及和患者之间的沟通准确是当务之急，整个过程都需要沟通顺畅。大多数糖尿病患者都有多年的对自己血糖的管理经验了，本指南的目的是对糖尿病患者围手术期处理提供详细的指导，这对麻醉师很有特殊的意义，并且确保现行指南的一致性。IntroductionThe demographics describing

8、the dramatic increase in the number of patients with diabetes are well known. Patients with diabetes require surgical procedures more frequently and have longer hospital stays than those without the condition 2. The presence of diabetes or hyperglycaemia in surgical patients has been shown to lead t

9、o increased morbidity and mortality, with perioperative mortality rates up to 50% greater than the non-diabetic population 2. The reasons for these adverse outcomes are multifactorial, but include: failureto identify patients with diabetes or hyperglycaemia 3, 4; multiple co-morbidities including mi

10、crovascular and macrovascular complications 5; complex polypharmacy and insulin prescribing errors 6; increased peri-operative and postoperative infections 2, 7, 8; associated hypoglycaemia and hyperglycaemia 2; a lack of, or inadequate, institutional guidelines for management of inpatient diabetes

11、or hyperglycaemia 2, 9; and inadequateknowledge of diabetes and hyperglycaemia management amongst staff delivering care 10.Anaesthetists and other peri-operative care providers should be knowledgeable and skilled in the care of patients with diabetes. Management of diabetes is a vital element in the

12、 management of surgical patients with diabetes. It is not good enough for the diabetic care to be a secondary, or sometimes forgotten, element of the peri-operative care package.指南简介众所周知流行病学调查显示糖尿病患者的数量在急剧增加。糖尿病患者需要外科手术更频繁，并有更长的住院时间。相对于非糖尿患者群，患有糖尿病或高血糖的外科患者相应的发病率和死亡率会增加，比起非糖尿病患者，围手术期死亡率增加 50%。导致上述不良

13、结果的原因是多方面的，包括：未能确定患者患有糖尿病或高血糖；包括微血管和大血管并发症的多种疾病；多重用药的复杂性和胰岛素处方错误；围手术期和术后感染的增加；伴有低血糖或高血糖；对糖尿病或高血糖住院管理制度知识的缺乏；对于糖尿病和高血糖患者管理知识匮乏尤其是在护理方面。麻醉师和围手术期护理人员对于护理糖尿病患者应该具有详尽的知识和熟练的技能。对于伴有糖尿病的外壳患者的管理中糖尿病护理是至关重要的环节，在围手术期的护理中是第一位的。Previous guidelinesIn April 2023 NHS Diabetes (now part of NHS Improving Quality) pu

14、blished a document: NHS Diabetes Guideline for the Peri-operative Management of the Adult Patient with Diabetes, in association with the Joint British Diabetes Societies (JBDS) 1 (an almost identical version, Management of Adults with Diabetes Undergoing Surgery and Elective Procedures: ImprovingSta

15、ndards, is available at .uk/JBDS/JBDS.htm). This comprehensive guideline provided both background information and advice to clinicians caring for patients with diabetes. Some of the recommendations in that document were due for review in the light of new evidence and, in addit

16、ion, it was felt that anaesthetists and other practitioners caring for patients with diabetes in the peri-operative period needed shorter, practical advice. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) offered to co-author this shortened guideline, in collaboration with coll

17、eagues involved with the 2023 document. The previous 2023 NHS Diabetes guidelines will also be updated in 2023.先前的指南在2023年4月NHS和JBDS发表了一版成年糖尿病患者围手术期管理指南。这版详尽的指南提供了背景知识以及对于糖尿病患者护理的建议。这些建议很多出自循证医学证据，并且说明，麻醉师和临床医生对于糖尿病患者的围手术护理需要更精简贴近实际的建议。结合2023版的这版指南，AAGBI出版了这版更精简的指南。之前的2023NHS糖尿病指南在2023也会更新。The risks

18、 of poor diabetic controlStudies have shown that high pre-operative and perioperative glucose and glycated haemoglobin (HbA1c) levels are associated with poor surgical outcomes. These findings have been seen in both elective and emergency surgery including spinal 11, vascular 12, colorectal 13, card

19、iac 14, 15, trauma 16, breast17, orthopaedic 18, neurosurgical, and hepatobiliary surgery 19, 20. One study showed that the adverse outcomes include a greater than 50% increase in mortality,a 2.4-fold increase in the incidence of postoperative respiratory infections, a doubling of surgical site infe

20、ctions, a threefold increase in postoperative urinary tract infections, a doubling in the incidence of myocardial infarction, and an almost twofold increase in acute kidney injury 2. Paradoxically, there are some data to show that the outcomes of patients with diabetes maynot be different from, or m

21、ay indeed be better than, those without diabetes if the diagnosis is known before surgery 21. The reasons for this are unknown, but may be due to increased vigilance surrounding glucose control for those with a diagnosis of diabetes.糖尿病控制不佳的风险研究结果说明围手术期和手术期间的高血糖、高糖化血红蛋白水平与患者术后预后不佳关系密切，这种预后不佳无论是择期手术还

22、是急诊手术均有表达，这些手术包括脊髓、血管、结肠直肠、心脏、创伤、乳腺、整形、神外以及肝胆手术等。一项研究显示这些不良结局包括：死亡率增加50%、术后呼吸道感染增加2.4倍、手术部位感染加倍、尿道感染增加三倍、心肌梗死的发生率加倍，急性肾损伤几乎增加两倍。矛盾的是，也有一些数据说明术前诊断明确的伴有糖尿病的患者和普通患者的预后没有差异，甚至更好。但是这是什么原因还不得而知，也许是因为患者之前已明确诊断为糖尿病，对血糖的管理有更为积极的控制。Referral from primary care and planning surgery 从初级保健到方案手术的转诊The aim is to ens

23、ure that diabetes is as well controlled as possible before elective surgery and to avoid delays to surgery due to poor control. The Working Party supports the consensus advice published in the 2023 NHS Diabetes guideline that the HbA1c should be 69 mmol.mol1 (8.5%) for elective cases 1, andthat elec

24、tive surgery should be delayed if it is 69 mmol.mol1, while control is improved. Changesto diabetes management can be made concurrently withreferral to ensure the patients diabetes is as well controlled as possible at the time of surgery. Elective surgery in patients with diabetes should be planned

25、with the aim of minimising disruption to their self-management.其目的是确保糖尿病在择期手术前尽可能地控制良好，防止因为血糖控制不佳而手术延期。遵循2023 版的 NHS 糖尿病指南，择期手术情况下 HbA1c 应 69 mmol.mol-18.5%，当HbA1c 69 mmol-1时，手术应延迟到血糖控制有所改善的时候。糖尿病管理策略可以适时改变以确保手术期患者的糖尿病可以尽可能地控制到最好。伴有糖尿病的手术患者的择期手术方案应该尽可能地把对患者自我管理的破坏降到最低。 Recommendation: Glycaemic cont

26、rol should bechecked at the time of referral for surgery. Information about duration, type of diabetes, current treatment and complications should be made available to the secondary care team.建议：转诊手术时应检查血糖控制水平、病程、类型、现有治疗方案和并发症。Surgical outpatient clinicThe adequacy of diabetes control should be asse

27、ssed again at the time of listing for surgery, ideally with a recorded HbA1c 69 mmol.mol1); and most patients with diabetes requiring emergency surgery. Variable-rate intravenous insulin infusions should be administered and monitored by appropriately experienced and qualified staff. An example of a

28、VRIII regimen is provided in Appendix 1.可调节的静脉胰岛素输注VRIII的应用可调节的静脉胰岛素输注VRIII对于以下人群是首选：需要节食至少一餐的患者；没有胰岛素注射史的 I 型糖尿病患者；糖尿病控制不佳定义为糖化血红蛋白 69 mmol.mol-1；需急诊外科手术的多数糖尿病患者。可调节的静脉胰岛素输注VRIII应用和监测应该由有经验的专业的医护人员进行。VRIII规那么的示范见附件1.Intra-operative care and monitoring术中看护与监测The aim of intra-operative care is to mai

29、ntain good glycaemic control and normal electrolyte concentrations,while optimising cardiovascular function and renal perfusion. If possible, multimodal analgesia should be used along with appropriate anti-emetic prophylaxis,to enable an early return to a normal dietand the patients usual diabetes r

30、egimen.术中看护与监测的目的是维持良好的血糖水平和正常的电解质浓度，同时优化心血管功能和肾脏灌注。如果可能的话，可以将多种模式镇痛与适当的抗呕吐预防机制一起进行，使患者早日恢复正常的饮食规律和常规糖尿病治疗。 Recommendation: An intra-operative CBG range of 610 mmol.l1 should be aimed for (an upper limit of 12 mmol.l1 may be tolerated at times, e.g. if the patient has poorly controlled diabetes and

31、is being managed by a modification of his/her normal medication without a VRIII). It should be understood by all staff that a CBG within the range of610 mmol.l1 is acceptable and that there is no requirment for a CBG of 6 mmol.l1 to be the target.The CBG should be checked before induction of anaesth

32、esia and monitored regularly during the procedure (at least hourly, or more frequently if the results are outside the target range). The CBG, insulin infusion rate and substrate infusion should be recorded on the anaesthetic record. Some charts use colour-coded areas to highlight abnormalresults req

33、uiring further intervention or a change of treatment (see Appendix 2).*提示：术中血糖应控制在6-10mmol.l-1 (特殊情况下最高控制在12mmol.l-1 例如：血糖控制较差没有接受VRIII治疗，正在调整治疗方案的糖尿病患者)医护人员需要明确血糖范围在6-10mmol.l-1 都是可以接受的，没有必要以控制在6 mmol.l-1 为目标。血糖水平应在麻醉前检查并且在术中不断监测至少每小时一次，如果血糖超出目标范围要增加监测频次。血糖、胰岛素注射速率和基质输入需要记录在麻醉记录上。一些图标需要用颜色区分标示不正常的数

34、值以便于后续调整或改变治疗方案见附件2Management of intra-operative hyperglycaemia and hypoglycaemiaIf the CBG exceeds 12 mmol.l1 and insulin has been omitted, capillary blood ketone levels should be measured if possible (point-of-care devices are available). If the capillary blood ketones are 3 mmol.l1 or there is si

35、gnificant ketonuria ( 2+ on urine sticks) the patient should be treated as having diabetic ketoacidoketoacidosis(DKA). Diabetic ketoacidosis is a triad of ketonaemia 3.0 mmol.l1, blood glucose 11.0 mmol.l1,and bicarbonate 15.0 mmol.l1 or venous pH 7.3.Diabetic ketoacidosis is a medical emergency and

36、 specialisthelp should be obtained from the diabetes team.If DKA is not present, the high blood glucose should be corrected using subcutaneous insulin (see below) or by altering the rate of the VRIII (if in use).If two subcutaneous insulin doses do not work, a VRIII should be started.术中低血糖和高血糖的管理如果未

37、使用胰岛素血糖超过12mmol.l-1 需检测血酮水平可用床旁诊断如果血酮大于3mmol.l-1 或者有明显的酮尿大于+,需要视为糖尿病酮症酸中毒处理。血酮大于3mmol.l-1血糖超过11mmol.l-1 电解质-1 或者PH7.3即可诊断。糖尿病酮症酸中毒是急性并发症需要糖尿病专业人员处理。如果没有发生酮症，需要采取皮下胰岛素注射降低血糖见下文或者改变VRIII输注速率已采用的情况下。如果两次皮下胰岛素注射后没有起效，需要启用VRIII.Treatment of hyperglycaemia in a patient with type-1 diabetesSubcutaneous rap

38、id-acting insulin (such as Novorapid, Humalog or Apidra) should be given (up toa maximum of 6 IU), using a specific insulin syringe,assuming that 1 IU will drop the CBG by 3 mmol.l1.Death or severe harm as a result of maladministration of insulin, including failure to use the specific insulin syring

39、e, is a Never Event. If the patient is awake, it is important to ensure that the patient is content with proposed dose (patients may react differently to subcutaneous rapid-acting insulin). The CBG should be checked hourly and a second dose considered onlyafter 2 h.1型糖尿病患者高血糖处理假设一单位剂量降低3mmol.l-1 血糖，

40、使用速效胰岛素门冬胰岛素、赖脯胰岛素或Apidra配合注射装置注射最大6个单位剂量胰岛素的不标准使用会引发死亡和很多严重的伤害是必须要防止发生的，这其中包括不当使用注射装置。如果病人是清醒的，与病人确认注射剂量是非常重要的病人对速效胰岛素的注射有不同的反响。血糖水平需要每小时监测，第二次注射至少在两小时之后。Treatment of hyperglycaemia in a patient with type-2 diabetesSubcutaneous rapid-acting insulin 0.1 IU.kg1 should be given (up to a maximum of 6 I

41、U), using a specific insulin syringe. The CBG should be checked hourly and a second dose considered only after 2 h. A VRIII should be considered if the patient remains hyperglycaemic.2型糖尿病患者高血糖处理使用速效胰岛素0.1IU/配合注射装置注射最大6个单位剂量血糖水平需要每小时监测，第二次注射至少在两小时之后。如果高血糖持续没有改善，需要启用VRIII.Treatment of intra-operative

42、 hypoglycaemiaFor a CBG 4.06.0 mmol.l1, 50 ml glucose 20% (10 g) should be given intravenously; for hypoglycaemia 4.0 mmol.l1 a dose of 100 ml (20 g) should be given.术中低血糖处理如果血糖在4-6mmol.l-1 ，静脉注射50ml 20%葡萄糖10g如果血糖 4.0mmol.l-1 ，剂量应为100ml20gFluid management体液管理There is a limited evidence base for the

43、recommendation of optimal fluid management of the adult diabetic patient undergoing surgery. It is now recognised that Hartmanns solution is safe to administer to patients with diabetes and does not contribute to clinically significant hyperglycaemia 23.成人糖尿病患者接受手术期间只有理论根底有限的最正确体液管理的建议。哈特曼氏溶液认为是较平安的

44、对于糖尿病患者的平安管理，但对于临床上的显著高血糖效果较不明显23。Fluid management for patients requiring a VRIIIThe aim is to provide glucose as a substrate to prevent proteolysis, lipolysis and ketogenesis, as well asto optimise intravascular volume status and maintain plasma electrolytes within the normal range. It isimportant

45、to avoid iatrogenic hyponatraemia from the administration of hypotonic solutions. Glucose 5% solution should be avoided. Use of glucose 4% in 0.18% saline can be associated with hyponatraemia.需要VRIII治疗的病人体液管理其目的是提供葡萄糖以防止蛋白质与脂肪分解，发生酮症，同时也是保持血管内体积良好和维持机体电解质正常平衡。防止低渗溶液引起的低钠血症非常重要。5%的葡萄糖溶液不可以采用。4%葡萄糖的0.

46、18%生理盐水也可能引起低钠血症。The substrate solution to be used should be based on the patients current electrolyte concentrations.While there is no clear evidence that one type of balanced crystalloid fluid is better than another, half-strength normal saline combined with glucose is, theoretically,a reasonable

47、compromise to achieve these aims. Thus, the initialfluid should be glucose 5% in saline 0.45% pre-mixed with either potassium chloride0.15% (20 mmol.l_1) or potassium chloride 0.3%(40 mmol.l_1), depending on the presence of hypokalaemia( 3.5 mmol.l_1).基质溶液应用应以病人目前的体液情况为根底。如果没有明确的证明一种晶体液优于另一种，理论上，半强度

48、的混合葡萄糖的生理盐水是最正确的解决方案。因此，最初应采取5%葡萄糖的0.45%的生理盐水预混0.15%20 mmol.l-1 或0.3%40 mmol.l-1 氯化钾，取决于病人目前的血钾情况 24 h), a VRIII should be considered and glucose 5% in saline 0.45% with pre-mixed potassium chloride given as above.不需要VRIII治疗的病人体液管理除非低血糖否那么不采用含有葡萄糖的溶液。防止高氯血症代谢性酸中毒非常重要；哈特曼氏溶液有利于改善血管内体积。如果病人需要术后持续输液( 2

49、4 h),需要考虑VRIII与5%葡萄糖的0.45%生理盐水预混0.15%氯化钾补液。Returning to normal (pre-operative) medication and diet回归正常术前的治疗和饮食The postoperative blood glucose management plan,and any alterations to existing medications, should be clearly communicated to ward staff. Patients with diabetes should be involved in planni

50、ng their postoperative care. If subcutaneous insulin is required in insulin-nave patients, or the type of insulin or the time it is to be given is to change, the specialist diabetes team should be contacted for advice.应清楚地传达关于术后血糖管理方案、对现有药物的任何改变给病房工作人员。糖尿病患者应参与术后护理的规划。如果单纯性胰岛素患者需要皮下胰岛素，胰岛素的注射时间或类型需要

51、改变，糖尿病的专家团队应考虑病人的建议。Transferring from a VRIII back to oral treatment or subcutaneous insulinIf the patient has type-1 diabetes and a VRIII has been used, it must be continued for 3060 min after the patient has had their subcutaneous insulin (see below).Premature discontinuation is associated with ia

52、trogenic DKA.从VRIII转变为口服药或皮下注射胰岛素治疗如果1型糖尿病患者已使用VRIII，皮下注射胰岛素后需继续维持VRIII30-60min见下过早的中断易引起酮症。Restarting oral hypoglycaemic medicationOral hypoglycaemic agents should be recommenced at pre-operative doses once the patient is ready to eat and drink; withholding or reduction in sulphonylureas may be req

53、uired if the food intake is likely to be reduced. Metformin should only be restarted if the estimated glomerular filtration rate exceeds 50 ml.min1.1.73 m2 25.重新开始口服降糖药治疗当病人可以开始正常饮食时可以考虑重新开始按术前剂量进行口服降糖药治疗；如果饮食减少应该防止或减少磺脲类药物治疗。只有估计肾小球滤过率高于50ml/min1.73/m2时考虑重新开始双胍类治疗25.Restarting subcutaneous insulin

54、for patients already established on insulinConversion to subcutaneous insulin should commence once the patient is able to eat and drink without nausea or vomiting. The pre-surgical regimen should be restarted, but may require adjustment because the insulin requirement may change as a result of posto

55、perative stress, infection or altered food intake. The diabetes specialist team should be consulted if the blood glucose levels are outside the acceptable range (612 mmol.l1) or if a change in diabetes management is required.已使用胰岛素治疗的患者恢复皮下胰岛素治疗当病人可以开始正常饮食并且没有恶心呕吐时可以考虑重新开始皮下胰岛素治疗。因为术后的压力、感染或者饮食改变可能对

56、胰岛素用量有所影响，所以需要调节剂量重新开始胰岛素治疗。如重新口服或皮下注射胰岛素、重新进行口服降糖药物、为患者持续皮下胰岛素输注等。糖尿病患者成功治疗的关键就是恢复正常饮食习惯。如果血糖不在可接受的范围6-12mmol.l-1之外，糖尿病专家需要商量考虑是否更改糖尿病管理方案。The transition from intravenous to subcutaneous insulin should take place when the next meal-related subcutaneous insulin dose is due, for example with breakfas

57、t or lunch.静脉到皮下的转变应该在下一餐胰岛素皮下剂量确定的时候进行过渡，比方早饭或者午饭时。For the patient on basal and bolus insulinThere should be an overlap between the end of the VRIII and the first injection of subcutaneous insulin,which should be given with a meal and the intravenous insulin and fluids discontinued 30-60 min later.

58、根底加餐时胰岛素治疗的患者VRIII结束的时候胰岛素作用时间可能和第一次根底胰岛素有重叠，应该在速效胰岛素与液体终止后的30-60min，并在餐时注射根底胰岛素。If the patient was previously on a long-acting insulin analogue such as Lantus, Levemir or Tresbia, this should have been continued and thus the only action should be to restart his/her usual rapid-acting insulin at the

59、 next meal as outlined above. If the basal insulin was stopped, the insulin infusion should be continued until a background insulin has been given.如果病人之前使用长效胰岛素类似物比方甘精、地特和Tresbia，可以继续使用只需要在下一餐时按需要重新启用平常的速效胰岛素。如果根底胰岛素已经停止，胰岛素输注需要继续直到启用根底胰岛素为止。For the patient on a twice-daily, fixed-mix regimenThe ins

60、ulin should be re-introduced before breakfast or before the evening meal, and not at any other time. The VRIII should be maintained for 30-60 min after the subcutaneous insulin has been given.两针预混治疗的患者应该在早餐前或者晚餐前重新启用，而不是其他任何时间。皮下注射胰岛素后需继续维持VRIII30-60min。For the patient on a continuous subcutaneous i