糖尿病患者麻醉

糖尿病患者手術(shù)麻醉,病例概況,女性，62歲，腹痛3日，擬診上消化道穿孔行剖腹探查術(shù)身高158cm，體重85kg，神志淡漠，T39.5高血壓病史16年，口服伊諾普利、尼群地平控制血壓，平素140/80，入院95/55糖尿病病史8年，口服二甲雙胍，血糖控制在6-8mmol/L，入院時(shí)血糖26.3，尿酮體+高血脂，他汀類控制，效果佳ECG竇性心動過速（135bpm），ST-T改變,糖尿?。―M）診斷和分型,The spectrum from normal glucose tolerance to diabetes in type 1 DM, type 2 DM, other specific types of diabetes, and gestational DM is shown from left to right. In most types of DM, the individual traverses from normal glucose tolerance to impaired glucose tolerance to overt diabetes. Arrows indicate that changes in glucose tolerance may be bi-directional in some types of diabetes. For example, individuals with type 2 DM may return to the impaired glucose tolerance category with weight loss; in gestational DM diabetes may revert to impaired glucose tolerance or even normal glucose tolerance after delivery. The fasting plasma glucose (FPG) and 2-h plasma glucose (PG), after a glucose challenge for the different categories of glucose tolerance, are shown at the lower part of the figure. These values do not apply to the diagnosis of gestational DM. Some types of DM may or may not require insulin for survival, hence the dotted line.,分型主要根據(jù)病因，而非根據(jù)發(fā)病年齡和治療方法。1型病因是胰島細(xì)胞衰竭和胰島素缺乏；2型病因包括胰島素缺乏、胰島素抵抗和糖異生增加,糖尿?。―M）流行病學(xué),糖尿病（DM）流行病學(xué),DM發(fā)病率大幅增高老齡化、肥胖、不運(yùn)動慢性炎癥，導(dǎo)致葡萄糖耐量異常的治療，遺傳背景,糖尿?。―M）流行病學(xué),糖尿病影響圍手術(shù)期的并發(fā)癥和死亡率2779名DM患者行CABG手術(shù)，與正常人群相比，DM患者ICU和住院時(shí)間延長正性肌力藥、輸血、透析腎衰、中風(fēng)、縱隔炎、傷口感染30日死亡率2.6%1.6%5年累積生存率84.4%91.3%,糖尿?。―M）流行病學(xué),許多2型DM直至手術(shù)時(shí)才發(fā)現(xiàn)DM7310名，CABG,何時(shí)發(fā)現(xiàn)并開始治療DM非常重要,DM相關(guān)并發(fā)癥 強(qiáng)直性關(guān)節(jié)綜合征,多見于青少年起病的DM患者關(guān)節(jié)僵硬，身材矮小，皮膚呈蠟樣緊張膠原組織糖基化是可能原因開始于第5指掌指關(guān)節(jié)和近指關(guān)節(jié)，可以侵犯包括頸椎和胸椎在內(nèi)的大關(guān)節(jié)對于肥胖患者糖尿病是其困難插管的預(yù)測因子,DM相關(guān)并發(fā)癥 心血管疾病,DM患者圍手術(shù)期心血管并發(fā)癥和死亡率增高2-3倍心血管病變占DM患者死亡原因的80%高血壓、冠狀動脈疾病、周圍動脈疾病、收縮性或舒張性心功能異常、心衰大多數(shù)65歲的DM患者存在有/無癥狀冠狀動脈疾病，更多發(fā)生無癥狀心肌缺血，有自主神經(jīng)病變者應(yīng)提高警惕DM性心肌病使心室舒張受限，左室充盈壓增高，導(dǎo)致心衰,DM相關(guān)并發(fā)癥 心血管疾病,DM患者高血壓發(fā)生率高于非DM患者，且隨DM時(shí)間延長而增加，與DM腎病的進(jìn)展緊密相關(guān)。2型DM患者血壓控制可能比長期的血糖控制更重要，推薦的血壓130/80。ACEI或-blocker可降低DM大血管病變相關(guān)的死亡率。,DM相關(guān)并發(fā)癥 微血管病變,糖尿病視網(wǎng)膜病變,DM相關(guān)并發(fā)癥 微血管病變,糖尿病視網(wǎng)膜病變,Diabetic retinopathy results in scattered hemorrhages, yellow exudates, and neovascularization. This patient has neovascular vessels proliferating from the optic disc, requiring urgent pan retinal laser photocoagulation.,DM相關(guān)并發(fā)癥 微血管病變,糖尿病視網(wǎng)膜病變視網(wǎng)膜循環(huán)是腦循環(huán)的預(yù)測因子術(shù)前存在視網(wǎng)膜微血管病變嚴(yán)重提示手術(shù)后腦功能障礙和死亡率風(fēng)險(xiǎn)增加,DM相關(guān)并發(fā)癥 微血管病變,糖尿病腎病,Time course of development of diabetic nephropathy. The relationship of time from onset of diabetes, the glomerular filtration rate (GFR), and the serum creatinine are shown. (Adapted from RA DeFranzo, in Therapy for Diabetes Mellitus and Related Disorders, 3d ed. American Diabetes Association, Alexandria, VA, 1998.),DM相關(guān)并發(fā)癥 神經(jīng)病變,周圍神經(jīng)痛 靜息痛、夜間痛、下肢多見感覺異常自主神經(jīng)包括膽堿能、去甲腎上腺素能、肽能（如胰多肽、P物質(zhì)等）心血管系統(tǒng)：靜息性心動過速，體位性低血壓，甚至猝死胃輕癱、膀胱排空異常上肢多汗，下肢無汗（下肢皮膚干裂，潰瘍風(fēng)險(xiǎn)增加）激素釋放的反調(diào)控機(jī)制減弱，導(dǎo)致不能感知低血糖,DM急性并發(fā)癥 酮癥酸中毒,DM急性并發(fā)癥 酮癥酸中毒,Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis).Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH 7.00 or unconscious.Assess: Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate); Acid-base statuspH, HCO3-, PCO2, b-hydroxybutyrate; Renal function (creatinine, urine output)Replace fluids: 23 L of 0.9% saline over first 13 h (1015 mL/kg per hour); subsequently, 0.45% saline at 150300 mL/h; change to 5% glucose and 0.45% saline at 100200 mL/h when plasma glucose reaches 250 mg/dL (14 mmol/L).Administer short-acting insulin: IV (0.1 units/kg) or IM (0.3 units/kg), then 0.1 units/kg per hour by continuous IV infusion; increase 2- to 3-fold if no response by 24 h. If initial serum potassium is 3.3 mmol/L.Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, ECG).Measure capillary glucose every 12 h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h.Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 14 h.Replace K+: 10 meq/h when plasma K+ 5.5 meq/L, ECG normal, urine flow and normal creatinine documented; administer 4080 meq/h when plasma K+ 3.5 meq/L or if bicarbonate is given.Continue above until patient is stable, glucose goal is 150250 mg/dL, and acidosis is resolved. Insulin infusion may be decreased to 0.050.1 units/kg per hour.Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and subcutaneous insulin injection.,治療,DM急性并發(fā)癥 高血糖性高滲性昏迷,多見于成年2型糖尿病多尿、體重下降、進(jìn)食減少數(shù)周精神錯(cuò)亂、嗜睡或昏迷嚴(yán)重的脫水、高滲、低血壓和心動過速無DKA特有的惡心、嘔吐、腹痛及Kussmaul呼吸多由嚴(yán)重的合并癥誘發(fā)，如心梗、腦梗、膿毒癥、肺炎或其他嚴(yán)重感染,臨床特點(diǎn),DM急性并發(fā)癥 高血糖性高滲性昏迷,DM的治療,DM的治療,aAs recommended by the ADA; Goals should be developed for each patient. Goals may be different for certain patient populations. bA1C is primary goal. cWhile the ADA recommends an A1C 7.0% in general, in the individual patient it recommends an . . . A1C as close to normal (6.0%) as possible without significant hypoglycemia. . . . Normal range for A1C4.06.0 (DCCT-based assay). dOne-two hours after beginning of a meal. eIn patients with reduced GFR and macroalbuminuria, the goal is 125/75. fIn decreasing order of priority. gFor women, some suggest a goal that is 0.25 mmol/L (10 mg/dL) higher. Source: Adapted from American Diabetes Association, 2007.,DM的治療,胰島素分泌刺激劑如磺脲類，通過作用于細(xì)胞的ATP敏感性鉀通道促進(jìn)胰島素釋放雙胍類如二甲雙胍，抑制肝糖異生并增加外周組織糖利用，但可導(dǎo)致乳酸酸中毒糖苷酶抑制劑如米格列醇，延緩葡萄糖吸收而降低餐后高血糖噻唑烷二酮類如匹格列酮，與脂肪細(xì)胞細(xì)胞核內(nèi)受體結(jié)合來降低胰島素抵抗,本例患者如何評估,女性，62歲，腹痛3日，擬診上消化道穿孔行剖腹探查術(shù)身高158cm，體重85kg，神志淡漠，T39.5高血壓病史16年，口服伊諾普利、尼群地平控制血壓，平素140/80，入院95/55糖尿病病史8年，口服二甲雙胍，血糖控制在6-8mmol/L，入院時(shí)血糖26.3，尿酮體+高血脂，他汀類控制，效果佳ECG竇性心動過速（135bpm），ST-T改變,術(shù)前評估,是否確診？是否可爭取時(shí)間內(nèi)科治療？膈下游離氣體、急腹癥腹痛3日，未禁食，估計(jì)腹腔感染嚴(yán)重,爭取時(shí)間，盡快完善術(shù)前準(zhǔn)備，同時(shí)盡早開始內(nèi)科治療，處理酮癥,術(shù)前評估,術(shù)前還需哪些檢查？,動脈血?dú)怆娊赓|(zhì)肝腎功能,K+ 3.2，Na+ 136，Cl- 99，HCO3 9，pH 7.05，CO2 33，肌酐、尿素氮稍升高 ，白蛋白 28,術(shù)前評估,術(shù)前內(nèi)科治療水化胰島素糾酸電解質(zhì),術(shù)中管理,麻醉和手術(shù)對葡萄糖代謝的影響七氟烷和異氟烷對葡萄糖耐量的損害程度相同，與手術(shù)刺激無關(guān)手術(shù)可產(chǎn)生應(yīng)激反應(yīng)，使機(jī)體處于分解代謝狀態(tài)，改變程度與手術(shù)大小有關(guān)硬膜外麻醉可減少應(yīng)激反應(yīng)激素的釋放而對血糖影響小,術(shù)中管理,麻醉方法的選擇全麻插管保護(hù)氣道椎管內(nèi)阻滯、神經(jīng)阻滯對機(jī)體代謝影響小,術(shù)中管理,擇期手術(shù)手術(shù)當(dāng)日胰島素的用法反復(fù)測量血糖是關(guān)鍵未使用胰島素的2型DM患者，術(shù)晨不給降糖藥，二甲雙胍術(shù)前24h停藥，一般手術(shù)無需輸注含糖液體，大手術(shù)及術(shù)后幾天不能進(jìn)食者應(yīng)靜脈給予含糖液，并使用胰島素,術(shù)中管理,擇期手術(shù)手術(shù)當(dāng)日胰島素的用法使用胰島素的患者接受大于2h的手術(shù)，同時(shí)輸注葡萄糖和胰島素可能對患者有益。5%的葡萄糖125ml/h或2ml/kg.h，胰島素5U負(fù)荷量，維持的速度為最近測得的血糖（mg/dl）/150（嚴(yán)重感染或應(yīng)激大的手術(shù)100），或者1U/h重要的是密切監(jiān)測血糖和電解質(zhì),術(shù)中管理,本例患者如何監(jiān)測？,術(shù)中管理,如何處理術(shù)中高血糖？血糖超過14mmol/l需靜脈給予胰島素單次劑量胰島素5-10u，成人胰島素一般1u降低血糖0.6mmol/l，或者降低1mmol/l血糖需胰島素1.7u持續(xù)輸注胰島素,術(shù)中管理,如何識別和處理術(shù)中低血糖？全身麻醉下表現(xiàn)為難以解釋的休克和,Neuroglycopenic symptoms of hypoglycemia are the direct result of central nervous system (CNS) glucose deprivation. They include behavioral changes, confusion, fatigue, seizure, loss of consciousness, and, if hypoglycemia is severe and prolonged, death. Neurogenic (or autonomic) symptoms of hypoglycemia are the result of the perception of physiologic changes caused by the CNS-mediated sympathoadrenal discharge triggered by hypoglycemia. They include adrenergic symptoms (mediated largely by norepinephrine released from sympathetic postganglionic neurons but perhaps also by epinephrine released from the adrenal medullae) such as palpitations, tremor, and anxiety. They also include cholinergic symptoms (mediated by acetylcholine released from sympathetic postganglionic neurons) such as sweating, hunger, and paresthesias. Clearly, these are nonspecific symptoms. Their attribution to hypoglycemia requires a corresponding low plasma glucose concentration and their resolution after the glucose level is raised (Whipples triad).Common signs of hypoglycemia include diaphoresis and pallor. Heart rate and systolic blood pressure are typically raised, but these findings may not be prominent. Neuroglycopenic manifestations are often observable. Transient focal neurologic deficits occur occasionally. Permanent neurologic deficits are rare.,術(shù)中管理,如何識別和處理術(shù)中低血糖？全身麻醉下臨床表現(xiàn)被掩蓋，常出現(xiàn)難以解釋的大汗、低血壓、心動過速確診依靠血糖監(jiān)測Oral treatment with glucose tablets or glucose-containing fluids, candy, or food is appropriate if the patient is able and willing to take these. A reason