(翻译)2015AAGBI糖尿病患者围手术期管理

(翻译)2015AAGBI糖尿病患者围手术期管理LtDGuidelinesPeri-operativemanagementofthesurgicalpatientwithdiabetes2015AssociationofAnaesthetistsofGreatBritainandIreland2015AAGBI糖尿病患者围手术期管理英国和爱尔兰麻醉医师协会MembershipoftheWorkingParty:P.Barker,P.E.Creasey,K.Dhatariya,1N.Levy,A.Lipp,2M.H.Nathanson(Chair),N.Penfold,3B.WatsonandT.Woodcock1JointBritishDiabetesSocietiesInpatientCareGroup2BritishAssociationofDaySurgery3RoyalCollegeofAnaesthetistsSummaryDiabetesaffects10–15%ofthesurgicalpopulationandpatientswithdiabetesundergoingsurgeryhavegreatercomplicationrates,mortalityratesand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。IntroductionThedemographicsdescribingthedramaticincreaseinthenumberofpatientswithdiabetesarewellknown.Patientswithdiabetesrequiresurgicalproceduresmorefrequentlyandhavelongerhospitalstaysthanthosewithoutthecondition[2].Thepresenceofdiabetesorhyperglycaemiainsurgicalpatientshasbeenshowntoleadtoincreasedmorbidityandmortality,withperioperativemortalityratesupto50%greaterthanthenon-diabeticpopulation[2].Thereasonsfortheseadverseoutcomesaremultifactorial,butinclude:failuretoidentifypatientswithdiabetesorhyperglycaemia[3,4];multipleco-morbiditiesincludingmicrovascularandmacrovascularcomplications[5];complexpolypharmacyandinsulinprescribingerrors[6];increasedperi-operativeandpostoperativeinfections[2,7,8];associatedhypoglycaemiaandhyperglycaemia[2];alackof,orinadequate,institutionalguidelinesformanagementofinpatientdiabetesorhyperglycaemia[2,9];andinadequateknowledgeofdiabetesandhyperglycaemiamanagementamongststaffdeliveringcare[10].Anaesthetistsandotherperi-operativecareprovidersshouldbeknowledgeableandskilledinthecareofpatientswithdiabetes.Managementofdiabetesisavitalelementinthemanagementofsurgicalpatientswithdiabetes.Itisnotgoodenoughforthediabeticcaretobeasecondary,orsometimesforgotten,elementoftheperi-operativecarepackage.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。PreviousguidelinesInApril2011NHSDiabetes(nowpartofNHSImprovingQuality)publishedadocument:NHSDiabetesGuidelineforthePeri-operativeManagementoftheAdultPatientwithDiabetes,inassociationwiththeJointBritishDiabetesSocieties(JBDS)[1](analmostidenticalversion,ManagementofAdultswithDiabetesUndergoingSurgeryandElectiveProcedures:ImprovingStandards,isavailableat.uk/JBDS/JBDS.htm).Thiscomprehensiveguidelineprovidedbothbackgroundinformationandadvicetoclinicianscaringforpatientswithdiabetes.Someoftherecommendationsinthatdocumentweredueforreviewinthelightofnewevidenceand,inaddition,itwasfeltthatanaesthetistsandotherpractitionerscaringforpatientswithdiabetesintheperi-operativeperiodneededshorter,practicaladvice.TheAssociationofAnaesthetistsofGreatBritainandIreland(AAGBI)offeredtoco-authorthisshortenedguideline,incollaborationwithcolleaguesinvolvedwiththe2011document.Theprevious2011NHSDiabetesguidelineswillalsobeupdatedin2015.先前的指南在2011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，并且表明，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2011版的这版指南，AAGBI出版了这版更精简的指南。之前的2011NHS糖尿病指南在2015也会更新。TherisksofpoordiabeticcontrolStudieshaveshownthathighpre-operativeandperioperativeglucoseandglycatedhaemoglobin(HbA1c)levelsareassociatedwithpoorsurgicaloutcomes.Thesefindingshavebeenseeninbothelectiveandemergencysurgeryincludingspinal[11],vascular[12],colorectal[13],cardiac[14,15],trauma[16],breast[17],orthopaedic[18],neurosurgical,andhepatobiliarysurgery[19,20].Onestudyshowedthattheadverseoutcomesincludeagreaterthan50%increaseinmortality,a2.4-foldincreaseintheincidenceofpostoperativerespiratoryinfections,adoublingofsurgicalsiteinfections,athreefoldincreaseinpostoperativeurinarytractinfections,adoublingintheincidenceofmyocardialinfarction,andanalmosttwofoldincreaseinacutekidneyinjury[2].Paradoxically,therearesomedatatoshowthattheoutcomesofpatientswithdiabetesmaynotbedifferentfrom,ormayindeedbebetterthan,thosewithoutdiabetesifthediagnosisisknownbeforesurgery[21].Thereasonsforthisareunknown,butmaybeduetoincreasedvigilancesurroundingglucosecontrolforthosewithadiagnosisofdiabetes.糖尿病控制不佳的风险研究结果表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是急诊手术均有体现，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，也有一些数据表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别，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。Referralfromprimarycareandplanningsurgery从初级保健到计划手术的转诊Theaimistoensurethatdiabetesisaswellcontrolledaspossiblebeforeelectivesurgeryandtoavoiddelaystosurgeryduetopoorcontrol.TheWorkingPartysupportstheconsensusadvicepublishedinthe2011NHSDiabetesguidelinethattheHbA1cshouldbe<69mmol.mol1(8.5%)forelectivecases[1],andthatelectivesurgeryshouldbedelayedifitis≥69mmol.mol1,whilecontrolisimproved.Changestodiabetesmanagementcanbemadeconcurrentlywithreferraltoensurethepatient’sdiabetesisaswellcontrolledaspossibleatthetimeofsurgery.Electivesurgeryinpatientswithdiabetesshouldbeplannedwiththeaimofminimisingdisruptiontotheirself-management.其目的是确保糖尿病在择期手术前尽可能地控制良好，避免因为血糖控制不佳而手术延期。遵循2011版的NHS糖尿病指南，择期手术情况下HbA1c应＜69mmol.mol-1（8.5%），当HbA1c≥69mmol-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计划应该尽可能地把对患者自我管理的破坏降到最低。•Recommendation:Glycaemiccontrolshouldbecheckedatthetimeofreferralforsurgery.Informationaboutduration,typeofdiabetes,currenttreatmentandcomplicationsshouldbemadeavailabletothesecondarycareteam.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。SurgicaloutpatientclinicTheadequacyofdiabetescontrolshouldbeassessedagainatthetimeoflistingforsurgery,ideallywitharecordedHbA1c<69mmol.mol1inthepreviousthreemonths.Ifitis≥69mmol.mol1,electivesurgeryshouldbedelayedwhilecontrolisimproved.Inasmallnumberofcasesitmaynotbepossibletoimprovediabeticcontrolpre-operatively,particularlyifthereasonforsurgery,suchaschronicinfection,iscontributingtopoorcontrol,orifsurgeryissemi-urgent.Inthesecircumstances,itmaybeacceptabletoproceedwithsurgeryafterexplanationtothepatientoftheincreasedrisks.Patientsshouldbemanagedasadaycaseiftheprocedureissuitableandthepatientfulfilsthecriteriaforday-casesurgerymanagement.Well-controlleddiabetesshouldnotbeacontra-indicationtoday-casesurgery.外科门诊病人手术期间应对患者血糖控制水平进行充分的评估，理想状态是术前三个月HbA1c控制在＜69mmol.mol-1（8.5%）当HbA1c≥69mmol-1时，手术应延迟到血糖控制有所改善的时候。有一小部分的情况患者的血糖可能在术前难以控制，特别是需要手术的病因本身就引起血糖控制不佳，如慢性感染；或者手术比较紧急。这种情况下，需要和病人沟通解释因此带来的风险，患者接受，可以进行手术。在程序适宜的情况下管理病人以满足日间手术的标准。糖尿病的良好控制不应该是日间手术的禁忌。Patientswithpoorlycontrolleddiabetesatthetimeofsurgerywillneedclosemonitoringandmayneedtostartavariable-rateintravenousinsulininfusion(VRIII).•Recommendation:Patientswithdiabetesshouldbeidentifiedearlyinthepre-operativepathway.无法很好控制血糖的糖尿病患者在手术期间需要严密的监测及采用可调节的静脉胰岛素输注（VRIII）提示：伴有糖尿病的患者应在手术前应进行提前鉴定Pre-operativeassessment术前评估Appropriateandearlypre-operativeassessmentshouldbearranged.Apre-operativeassessmentnursemayundertaketheassessmentwithsupportfromeitherananaesthetistoradiabetesspecialistnurse.Itshouldoccursufficientlyinadvanceoftheplannedsurgerytoensureoptimisationofglycaemiccontrolbeforethedateofproposedsurgery.Theaimistoensurethatallrelevantinvestigationsareavailableandcheckedinadvanceoftheplannedsurgery,thatthepatientunderstandshowtomanagehis/herdiabetesintheperi-operativeperiod,andthattheperiodofpre-operativefastingisminimised.应安排适当的或早期的术前评估。进行术前评估护士可能需要来自麻醉师或糖尿病专科护士的支持。术前评估应在计划手术之前以确保手术日期前血糖得到控制优化。术前评估的目的是：在计划手术前确保获得所有相关检查以及进一步的检查；使患者了解在围手术期如何管理他/她的糖尿病；减少术前禁食时间。•Recommendation:Testsshouldbeorderedtoassessco-morbiditiesinlinewithNationalInstituteforHealthandCareExcellence(NICE)guidanceonpre-operativetesting[22].ThisshouldincludeureaandelectrolytesandECGforallpatientswithdiabetes;however,arandombloodglucosemeasurementisnotindicated.建议：检查遵循NICE指南，应该包括尿检、糖尿病患者电解质及心电图检查；然而，随机血糖测量未注明。Planningadmission(includingdaysurgery)Theaimistominimisethefastingperiod,ensurenormoglycaemia(capillarybloodglucose(CBG)6–10mmol.l1)andminimiseasfaraspossibledisruptiontothepatient’susualroutine.Ideally,thepatientshouldbebookedfirstontheoperatinglisttominimizetheperiodoffasting.Ifthefastingperiodisexpectedtobelimitedtoonemissedmeal,thepatientcanbemanagedbymodificationofhis/herusualdiabetesmedication(seebelow).Patientsshouldbeprovidedwithwritteninstructionsfromthepre-operativeassessmentteamaboutmanagementoftheirdiabetesmedicationonthedayofsurgery,themanagementofhypo-orhyperglycaemiaintheperi-operativeperiod,andthelikelyeffectsofsurgeryontheirdiabetescontrol.Patientsshouldbeadvisedtocarryaformofglucosethattheycantakeincaseofsymptomsofhypoglycaemiathatwillnotcausesurgerytobecancelled,forexampleaclear,sugar-containingdrink(glucosetabletsmaybeusedinstead,butsomeanaesthetistsmayfeeltheyshouldnotbetakenwithin6hofthestartofanaesthesia).Patientsshouldbewarnedthattheirbloodglucosecontrolmaybeerraticforafewdaysaftertheprocedure.术前管理（包括日间手术）其目的是尽可能地缩短周期，确保血糖正常（6-10mmol.l-1）尽可能少地打乱患者的日常护理。理论上，患者应列入手术队列计划以尽可能减少禁食期。如果禁食期需要限制患者一次进餐，需要相应调整他/她日常的用药。术前评估团队需要对病人的手术期间用药管理、围手术期间的高血糖或者低血糖以及手术可能对糖尿病控制带来影响的可能因素给予指导，应该给患者列一个可摄入糖的列表，以预防万一出现的低血糖带来手术取消，举个例子详加说明，比如含糖饮料（或者糖块也可以，但是麻醉师要求麻醉前六小时不能摄入）患者应该被警告在术后可能有几天的血糖波动。•Recommendation:Whenpossible,admissionshouldbeplannedforthedayofsurgery,withboththepatientandthewardstaffawareoftheplannedperi-operativediabetescare,includingaplantomanagehypo-andhyperglycaemia.Surgeryshouldbescheduledatthestartofthetheatrelisttominimisedisruptiontothepatient’sglycaemiccontrol.*建议：只有当患者和医护人员确定了糖尿病围手术期护理方案，包括低血糖高血糖管理，才能准入手术。手术应尽早确定日程以尽可能少的打乱患者控糖。Managementofexistingtherapy既有治疗的管理Withappropriateguidance,patientswithdiabetesshouldbeallowedtoretaincontrolandpossessionof,andcontinuetoself-administer,theirmedication.Manypatientswillhaveseveralyears’experienceandbeexpertinself-medication.在适当的指引下，应允许糖尿病患者进行自我药物管理。许多患者会有数年的经验并已成为自我药物管理的专家。Theaimistoavoidhypo-orhyperglycaemiaduringtheperiodoffastingandthetimeduringandaftertheprocedure,untilthepatientiseatinganddrinkingnormally.Inpeoplewhoarelikelytomissonemealonly,thiscanoftenbeachievedbymanipulatingthepatient’snormalmedicationusingtheguidanceprovidedinTables1and2.其目的是在禁食期及手术中和手术后防止高血糖或者低血糖的发生直到患者可以正常饮食为止。如果患者需要一餐的禁食，可以根据表格1和表格2对患者的用药进行调整。Glycaemiccontrolinpatientswithdiabetesisabalancebetweentheircarbohydrateintakeandutilization(forexample,exercise).Italsodependsonwhatmedicationtheytakeandhowthosemedicationswork.Someagents(e.g.sulphonylureas,meglitinides,insulinandtosomeextent,thiazolidinediones)actbyloweringglucoseconcentrations,anddosesneedtobemodifiedortheagentsstoppedduringperiodsofstarvation.Othersworkbypreventingglucoselevelsfromrising(e.g.metformin,glucagon-likepeptide-1analogues,dipeptidylpeptidase-4inhibitors);thesedrugsmaybecontinuedwithouttheriskofhypoglycaemia.Thetimeofdayandtheexpecteddurationoftheoperationneedtobeconsidered,aswillwhetheraVRIIIwillbeneeded.PatientswithcontinuoussubcutaneousinsulininfusionsonlymissingonemealshouldbeadvisedtomaintaintheirCBGat6–10mmol.l1.Iflongerperiodsofstarvationarepredicted,aVRIIIshouldbeusedandspecialistadvicesought.糖尿病人血糖的管理就是平衡他们碳水化合物的摄入和利用（比如运动）也取决于他们使用什么药物和药物如何作用。一些降糖药物可以降低血糖浓度在禁食期间需要调整剂量甚至停药（如胰岛素和磺脲类、格列奈类、噻唑烷二酮类药物）其他降糖药物作用是防止血糖升高（双胍类、GLP-1、DPP-4）这些药物没有低血糖风险下可以继续使用。是否需要VRIII需要考虑手术时间和手术持续时间。有一餐禁食的持续皮下注射胰岛素患者需要告知其血糖需维持在6-10mmol.l-1如果预计需要长时间禁食，应该听从专业意见启用VRIII。Tables1and2havebeendesignedtotakeallofthesefactorsintoconsideration.Theyareapragmaticapproachtothepre-operativemanagementofalltheavailableclassesofagentusedtomanagediabetes.表格1和表格2设计考虑了所有因素，对于各种类型的糖尿病围手术期护理都给出了实际的临床管理办法。（具体参见原文）Useofavariable-rateintravenousinsulininfusionVariable-rateintravenousinsulininfusionsarepreferredin:patientswhowillmissmorethanonemeal;thosewithtype-1diabetesundergoingsurgerywhohavenotreceivedbackgroundinsulin;thosewithpoorlycontrolleddiabetes(definedasaHbA1c>69mmol.mol1);andmostpatientswithdiabetesrequiringemergencysurgery.Variable-rateintravenousinsulininfusionsshouldbeadministeredandmonitoredbyappropriatelyexperiencedandqualifiedstaff.AnexampleofaVRIIIregimenisprovidedinAppendix1.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＞69mmol.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规则的示范见附件1.Intra-operativecareandmonitoring术中看护与监测Theaimofintra-operativecareistomaintaingoodglycaemiccontrolandnormalelectrolyteconcentrations,whileoptimisingcardiovascularfunctionandrenalperfusion.Ifpossible,multimodalanalgesiashouldbeusedalongwithappropriateanti-emeticprophylaxis,toenableanearlyreturntoanormaldietandthepatient’susualdiabetesregimen.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:Anintra-operativeCBGrangeof6–10mmol.l1shouldbeaimedfor(anupperlimitof12mmol.l1maybetoleratedattimes,e.g.ifthepatienthaspoorlycontrolleddiabetesandisbeingmanagedbyamodificationofhis/hernormalmedicationwithoutaVRIII).ItshouldbeunderstoodbyallstaffthataCBGwithintherangeof6–10mmol.l1isacceptableandthatthereisnorequirmentforaCBGof6mmol.l1tobethetarget.TheCBGshouldbecheckedbeforeinductionofanaesthesiaandmonitoredregularlyduringtheprocedure(atleasthourly,ormorefrequentlyiftheresultsareoutsidethetargetrange).TheCBG,insulininfusionrateandsubstrateinfusionshouldberecordedontheanaestheticrecord.Somechartsusecolour-codedareastohighlightabnormalresultsrequiringfurtherinterventionorachangeoftreatment(seeAppendix2).*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6mmol.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值以便于后续调整或改变治疗方案（见附件2）Managementofintra-operativehyperglycaemiaandhypoglycaemiaIftheCBGexceeds12mmol.l1andinsulinhasbeenomitted,capillarybloodketonelevelsshouldbemeasuredifpossible(point-of-caredevicesareavailable).Ifthecapillarybloodketonesare>3mmol.l1orthereissignificantketonuria(>2+onurinesticks)thepatientshouldbetreatedashavingdiabeticketoacidoketoacidosis(DKA).Diabeticketoacidosisisatriadofketonaemia>3.0mmol.l1,bloodglucose>11.0mmol.l1,andbicarbonate<15.0mmol.l1orvenouspH<7.3.Diabeticketoacidosisisamedicalemergencyandspecialisthelpshouldbeobtainedfromthediabetesteam.IfDKAisnotpresent,thehighbloodglucoseshouldbecorrectedusingsubcutaneousinsulin(seebelow)orbyalteringtherateoftheVRIII(ifinuse).Iftwosubcutaneousinsulindosesdonotwork,aVRIIIshouldbestarted.术中低血糖和高血糖的管理如果未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<15.0mmol.l-1或者PH<7.3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.Treatmentofhyperglycaemiainapatientwithtype-1diabetesSubcutaneousrapid-actinginsulin(suchasNovorapid,HumalogorApidra)shouldbegiven(uptoamaximumof6IU),usingaspecificinsulinsyringe,assumingthat1IUwilldroptheCBGby3mmol.l1.Deathorsevereharmasaresultofmaladministrationofinsulin,includingfailuretousethespecificinsulinsyringe,isa‘NeverEvent’.Ifthepatientisawake,itisimportanttoensurethatthepatientiscontentwithproposeddose(patientsmayreactdifferentlytosubcutaneousrapid-actinginsulin).TheCBGshouldbecheckedhourlyandaseconddoseconsideredonlyafter2h.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，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）胰岛素的不规范使用会引发死亡和很多严重的伤害是必须要避免发生的，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应）。血糖水平需要每小时监测，第二次注射至少在两小时之后。Treatmentofhyperglycaemiainapatientwithtype-2diabetesSubcutaneousrapid-actinginsulin0.1IU.kg1shouldbegiven(uptoamaximumof6IU),usingaspecificinsulinsyringe.TheCBGshouldbecheckedhourlyandaseconddoseconsideredonlyafter2h.AVRIIIshouldbeconsideredifthepatientremainshyperglycaemic.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.Treatmentofintra-operativehypoglycaemiaForaCBG4.0–6.0mmol.l1,50mlglucose20%(10g)shouldbegivenintravenously;forhypoglycaemia<4.0mmol.l1adoseof100ml(20g)shouldbegiven.术中低血糖处理如果血糖在4-6mmol.l-1，静脉注射50ml20%葡萄糖（10g）如果血糖<4.0mmol.l-1，剂量应为100ml（20g）Fluidmanagement体液管理Thereisalimitedevidencebasefortherecommendationofoptimalfluidmanagementoftheadultdiabeticpatientundergoingsurgery.ItisnowrecognisedthatHartmann’ssolutionissafetoadministertopatientswithdiabetesanddoesnotcontributetoclinicallysignificanthyperglycaemia[23].成人糖尿病患者接受手术期间只有理论基础有限的最佳体液管理的建议。

哈特曼氏溶液认为是较安全的对于糖尿病患者的安全管理，但对于临床上的显著高血糖效果较不明显[23]。FluidmanagementforpatientsrequiringaVRIIITheaimistoprovideglucoseasasubstratetopreventproteolysis,lipolysisandketogenesis,aswellastooptimiseintravascularvolumestatusandmaintainplasmaelectrolyteswithinthenormalrange.Itisimportanttoavoidiatrogenichyponatraemiafromtheadministrationofhypotonicsolutions.Glucose5%solutionshouldbeavoided.Useofglucose4%in0.18%salinecanbeassociatedwithhyponatraemia.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。避免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0.18%生理盐水也可能引起低钠血症。Thesubstratesolutiontobeusedshouldbebasedonthepatient’scurrentelectrolyteconcentrations.Whilethereisnoclearevidencethatonetypeofbalancedcrystalloidfluidisbetterthananother,half-strength‘normal’salinecombinedwithglucoseis,theoretically,areasonablecompromisetoachievetheseaims.Thus,theinitialfluidshouldbeglucose5%insaline0.45%pre-mixedwitheitherpotassiumchloride0.15%(20mmol.l_1)orpotassiumchloride0.3%(40mmol.l_1),dependingonthepresenceofhypokalaemia(<3.5mmol.l_1).基质溶液应用应以病人目前的体液情况为基础。如果没有明确的证明一种晶体液优于另一种，理论上，半强度的混合葡萄糖的生理盐水是最佳的解决方案。因此，最初应采取5%葡萄糖的0.45%的生理盐水预混0.15%（20mmol.l-1）或0.3%（40mmol.l-1）氯化钾，取决于病人目前的血钾情况（<3.5mmol.l-1）TheWorkingPartyrecognisesthatthesefluidsmaynotbeavailableinallinstitutions.Itisourviewthattheyshouldbemadeavailableinallareaswherepatientswithdiabeteswillbemanaged.(Hospitalscaringforchildrenwillusuallyhavethesesolutionsalreadyavailableforgeneralpaediatricuse).共识认为补液并不一定适用于所有情况。我们认为在糖尿病人管理治疗的各个领域都应该需要借鉴（普通儿科的儿童的医院护理将要把此纳入常规应用）Fluidshouldbeadministeredattheratethatisappropriateforthepatient’susualmaintenancerequirements–usually25–50ml.kg_1.day_1(approximately83ml.h_1fora70-kgpatient)[24].补液速率需要根据病人平时所需情况-一般是25-50ml/kg/天（大约70kg的病人83ml/h）[24].Veryoccasionally,thepatientmaydevelophyponatraemiawithoutsignsoffluidoverload.Inthesecircumstances,itisacceptabletoprescribeoneofthefollowingsolutionsasthesubstratesolution:glucose5%insaline0.9%withpre-mixedpotassiumchloride0.15%(20mmol.l_1);orglucose5%insaline0.9%withpremixedpotassiumchloride0.3%(40mmol.l_1).(Again,hospitalscaringforchildrenwillusuallyhavethesesolutionsavailable).偶尔，没有液体过量的信号下病人会发生低钠血症。在这种情况下，以下的解决方案可作为基质溶液：5%葡萄糖的0.9%生理盐水预混0.15%氯化钾（20mmol.l-1）或者5%葡萄糖的0.9%生理盐水预混0.3%氯化钾（40mmol.l-1）（再次强调，普通儿科的儿童的医院护理将要把此纳入常规应用）AdditionalHartmann’ssolutionoranotherbalancedisotoniccrystalloidsolutionshouldbeusedtooptimiseintravascularvolumestatus.

另外哈特曼氏溶液或者其他的等渗晶体液可以用于改善血管内体积。FluidmanagementforpatientsnotrequiringaVRIIITheaimistoavoidglucose-containingsolutionsunlessthebloodglucoseislow.Itisimportanttoavoidhyperchloraemicmetabolicacidosis;Hartmann’ssolutionshouldbeadministeredtooptimisetheintravascularvolumestatus.Ifthepatientrequiresprolongedpostoperativefluids(>24h),aVRIIIshouldbeconsideredandglucose5%insaline0.45%withpre-mixedpotassiumchloridegivenasabove.不需要VRIII治疗的病人体液管理除非低血糖否则不采用含有葡萄糖的溶液。避免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(>24h),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。Returningto‘normal’(pre-operative)medicationanddiet回归正常（术前）的治疗和饮食Thepostoperativebloodglucosemanagementplan,andanyalterationstoexistingmedications,shouldbeclearlycommunicatedtowardstaff.Patientswithdiabetesshouldbeinvolvedinplanningtheirpostoperativecare.Ifsubcutaneousinsulinisrequiredininsulin-naıvepatients,orthetypeofinsulinorthetimeitistobegivenistochange,thespecialistdiabetesteamshouldbecontactedforadvice.应清楚地传达关于术后血糖管理计划、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改变，糖尿病的专家团队应考虑病人的建议。TransferringfromaVRIIIbacktooraltreatmentorsubcutaneousinsulinIfthepatienthastype-1diabetesandaVRIIIhasbeenused,itmustbecontinuedfor30–60minafterthepatienthashadtheirsubcutaneousinsulin(seebelow).PrematurediscontinuationisassociatedwithiatrogenicDKA.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。RestartingoralhypoglycaemicmedicationOralhypoglycaemicagentsshouldberecommencedatpre-operativedosesoncethepatientisreadytoeatanddrink;withholdingorreductioninsulphonylureasmayberequiredifthefoodintakeislikelytobereduced.Metforminshouldonlyberestartediftheestimatedglomerularfiltrationrateexceeds50ml.min1.1.73m2[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；如果饮食减少应该避免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].RestartingsubcutaneousinsulinforpatientsalreadyestablishedoninsulinConversiontosubcutaneousinsulinshouldcommenceoncethepatientisabletoeatanddrinkwithoutnauseaorvomiting.Thepre-surgicalregimenshouldberestarted,butmayrequireadjustmentbecausetheinsulinrequirementmaychangeasaresultofpostoperativestress,infectionoralteredfoodintake.Thediabetesspecialistteamshouldbeconsultedifthebloodglucoselevelsareoutsidetheacceptablerange(6–12mmol.l1)orifachangeindiabetesmanagementisrequired.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。Thetransitionfromintravenoustosubcutaneousinsulinshouldtakeplacewhenthenextmeal-relatedsubcutaneousinsulindoseisdue,forexamplewithbreakfastorlunch.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，比如早饭或者午饭时。ForthepatientonbasalandbolusinsulinThereshouldbeanoverlapbetweentheendoftheVRIIIandthefirstinjectionofsubcutaneousinsulin,whichshouldbegivenwithamealandtheintravenousinsulinandfluidsdiscontinued30-60minlater.基础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基础胰岛素有重叠，应该在速效胰岛素与液体终止后的30-60min，并在餐时注射基础胰岛素。Ifthepatientwaspreviouslyonalong-actinginsulinanaloguesuchasLantus,LevemirorTresbia,thisshouldhavebeencontinuedandthustheonlyactionshouldbetorestarthis/herusualrapid-actinginsulinatthenextmealasoutlinedabove.Ifthebasalinsulinwasstopped,theinsulininfusionshouldbecontinueduntilabackgroundinsulinhasbeengiven.如果病人之前使用长效胰岛素类似物比如甘精、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。如果基础胰岛素已经停止，胰岛素输注需要继续直到启用基础胰岛素为止。Forthepatientonatwice-daily,fixed-mixregimenTheinsulinshouldbere-introducedbeforebreakfastorbeforetheeveningmeal,andnotatanyothertime.TheVRIIIshouldbemaintainedfor30-60minafterthesubcutaneousinsulinhasbeengiven.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。ForthepatientonacontinuoussubcutaneousinsulininfusionThesubcutaneousinsulininfusionshouldberecommencedatthepatient’snormalbasalrate;theVRIIIshouldbecontinueduntilthenextmealbolushasbeengiven.Thesubcutaneousinsulininfusionsshouldnotbere-startedatbedtime.持续皮下胰岛素输注的患者按找病人正常的基础胰岛素输注速率重新启用持续皮下胰岛素输注；VRIII应该保持到直到下一个餐时大剂量启用为止。不要在就寝时间重新启用持续皮下胰岛素输注。ResumptionofnormaldietThekeytosuccessfulmanagementofthesurgicalpatientwithdiabetesisresumptionofhis/herusualdiet.Thisallowsresumptionofnormaldiabetesmedication.Hospitaldischargeisonlyfeasibleoncethepatienthasresumedeatinganddrinking.重新开始正常饮食伴有糖尿病手术患者成功管理的关键就是恢复正常饮食习惯。只有恢复饮食才能恢复药物治疗。重新开始正常饮食治疗手段才是可行的。Otheranaestheticconsiderations其他麻醉考虑