(翻譯)2015AAGBI糖尿病患者圍手術期管理

(翻譯)2015AAGBI糖尿病患者圍手術期管理LtDGuidelinesPeri-operativemanagementofthesurgicalpatientwithdiabetes2015AssociationofAnaesthetistsofGreatBritainandIreland2015AAGBI糖尿病患者圍手術期管理英國和愛爾蘭麻醉醫(yī)師協(xié)會MembershipoftheWorkingParty:P.Barker,P.E.Creasey,K.Dhatariya,1N.Levy,A.Lipp,2M.H.Nathanson(Chair),N.Penfold,3B.WatsonandT.Woodcock1JointBritishDiabetesSocietiesInpatientCareGroup2BritishAssociationofDaySurgery3RoyalCollegeofAnaesthetistsSummaryDiabetesaffects10–15%ofthesurgicalpopulationandpatientswithdiabetesundergoingsurgeryhavegreatercomplicationrates,mortalityratesand對自己血糖的管理經(jīng)驗了，本指南的目的是對糖尿病患者圍手術期處理提供詳細的指導，這對麻醉師很有特殊的意義，并且確?，F(xiàn)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.指南簡介眾所周知流行病學調查顯示糖尿病患者的數(shù)量在急劇增加。糖尿病患者需要外科手術更頻繁，并有更長的住院時間。相對于非糖尿患者群，患有糖尿病或高血糖的外科患者相應的發(fā)病率和死亡率會增加，比起非糖尿病患者，圍手術期死亡率增加50%。導致上述不良結果的原因是多方面的，包括：未能確定患者患有糖尿病或高血糖；包括微血管和大血管并發(fā)癥的多種疾病；多重用藥的復雜性和胰島素處方錯誤；圍手術期和術后感染的增加；伴有低血糖或高血糖；對糖尿病或高血糖住院管理制度知識的缺乏；對于糖尿病和高血糖患者管理知識匱乏尤其是在護理方面。麻醉師和圍手術期護理人員對于護理糖尿病患者應該具有詳盡的知識和熟練的技能。對于伴有糖尿病的外殼患者的管理中糖尿病護理是至關重要的環(huán)節(jié)，在圍手術期的護理中是第一位的。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發(fā)表了一版成年糖尿病患者圍手術期管理指南。這版詳盡的指南提供了背景知識以及對于糖尿病患者護理的建議。這些建議很多出自循證醫(yī)學證據(jù)，并且表明，麻醉師和臨床醫(yī)生對于糖尿病患者的圍手術護理需要更精簡貼近實際的建議。結合2011版的這版指南，AAGBI出版了這版更精簡的指南。之前的2011NHS糖尿病指南在2015也會更新。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.糖尿病控制不佳的風險研究結果表明圍手術期和手術期間的高血糖、高糖化血紅蛋白水平與患者術后預后不佳關系密切，這種預后不佳無論是擇期手術還是急診手術均有體現(xiàn)，這些手術包括脊髓、血管、結腸直腸、心臟、創(chuàng)傷、乳腺、整形、神外以及肝膽手術等。一項研究顯示這些不良結局包括：死亡率增加50%、術后呼吸道感染增加2.4倍、手術部位感染加倍、尿道感染增加三倍、心肌梗死的發(fā)生率加倍，急性腎損傷幾乎增加兩倍。矛盾的是，也有一些數(shù)據(jù)表明術前診斷明確的伴有糖尿病的患者和普通患者的預后沒有差別，甚至更好。但是這是什么原因還不得而知，也許是因為患者之前已明確診斷為糖尿病，對血糖的管理有更為積極的控制。Referralfromprimarycareandplanningsurgery從初級保健到計劃手術的轉診Theaimistoensurethatdiabetesisaswellcontrolledaspossiblebeforeelectivesurgeryandtoavoiddelaystosurgeryduetopoorcontrol.TheWorkingPartysupportstheconsensusadvicepublishedinthe2011NHSDiabetesguidelinethattheHbA1cshouldbe<69mmol.mol1(8.5%)forelectivecases[1],andthatelectivesurgeryshouldbedelayedifitis≥69mmol.mol1,whilecontrolisimproved.Changestodiabetesmanagementcanbemadeconcurrentlywithreferraltoensurethepatient’sdiabetesisaswellcontrolledaspossibleatthetimeofsurgery.Electivesurgeryinpatientswithdiabetesshouldbeplannedwiththeaimofminimisingdisruptiontotheirself-management.其目的是確保糖尿病在擇期手術前盡可能地控制良好，避免因為血糖控制不佳而手術延期。遵循2011版的NHS糖尿病指南，擇期手術情況下HbA1c應＜69mmol.mol-1（8.5%），當HbA1c≥69mmol-1時，手術應延遲到血糖控制有所改善的時候。糖尿病管理策略可以適時改變以確保手術期患者的糖尿病可以盡可能地控制到最好。伴有糖尿病的手術患者的擇期手術計劃應該盡可能地把對患者自我管理的破壞降到最低。?Recommendation:Glycaemiccontrolshouldbecheckedatthetimeofreferralforsurgery.Informationaboutduration,typeofdiabetes,currenttreatmentandcomplicationsshouldbemadeavailabletothesecondarycareteam.建議：轉診手術時應檢查血糖控制水平、病程、類型、現(xiàn)有治療方案和并發(fā)癥。SurgicaloutpatientclinicTheadequacyofdiabetescontrolshouldbeassessedagainatthetimeoflistingforsurgery,ideallywitharecordedHbA1c<69mmol.mol1inthepreviousthreemonths.Ifitis≥69mmol.mol1,electivesurgeryshouldbedelayedwhilecontrolisimproved.Inasmallnumberofcasesitmaynotbepossibletoimprovediabeticcontrolpre-operatively,particularlyifthereasonforsurgery,suchaschronicinfection,iscontributingtopoorcontrol,orifsurgeryissemi-urgent.Inthesecircumstances,itmaybeacceptabletoproceedwithsurgeryafterexplanationtothepatientoftheincreasedrisks.Patientsshouldbemanagedasadaycaseiftheprocedureissuitableandthepatientfulfilsthecriteriaforday-casesurgerymanagement.Well-controlleddiabetesshouldnotbeacontra-indicationtoday-casesurgery.外科門診病人手術期間應對患者血糖控制水平進行充分的評估，理想狀態(tài)是術前三個月HbA1c控制在＜69mmol.mol-1（8.5%）當HbA1c≥69mmol-1時，手術應延遲到血糖控制有所改善的時候。有一小部分的情況患者的血糖可能在術前難以控制，特別是需要手術的病因本身就引起血糖控制不佳，如慢性感染；或者手術比較緊急。這種情況下，需要和病人溝通解釋因此帶來的風險，患者接受，可以進行手術。在程序適宜的情況下管理病人以滿足日間手術的標準。糖尿病的良好控制不應該是日間手術的禁忌。Patientswithpoorlycontrolleddiabetesatthetimeofsurgerywillneedclosemonitoringandmayneedtostartavariable-rateintravenousinsulininfusion(VRIII).?Recommendation:Patientswithdiabetesshouldbeidentifiedearlyinthepre-operativepathway.無法很好控制血糖的糖尿病患者在手術期間需要嚴密的監(jiān)測及采用可調節(jié)的靜脈胰島素輸注（VRIII）提示：伴有糖尿病的患者應在手術前應進行提前鑒定Pre-operativeassessment術前評估Appropriateandearlypre-operativeassessmentshouldbearranged.Apre-operativeassessmentnursemayundertaketheassessmentwithsupportfromeitherananaesthetistoradiabetesspecialistnurse.Itshouldoccursufficientlyinadvanceoftheplannedsurgerytoensureoptimisationofglycaemiccontrolbeforethedateofproposedsurgery.Theaimistoensurethatallrelevantinvestigationsareavailableandcheckedinadvanceoftheplannedsurgery,thatthepatientunderstandshowtomanagehis/herdiabetesintheperi-operativeperiod,andthattheperiodofpre-operativefastingisminimised.應安排適當?shù)幕蛟缙诘男g前評估。進行術前評估護士可能需要來自麻醉師或糖尿病專科護士的支持。術前評估應在計劃手術之前以確保手術日期前血糖得到控制優(yōu)化。術前評估的目的是：在計劃手術前確保獲得所有相關檢查以及進一步的檢查；使患者了解在圍手術期如何管理他/她的糖尿?。粶p少術前禁食時間。?Recommendation:Testsshouldbeorderedtoassessco-morbiditiesinlinewithNationalInstituteforHealthandCareExcellence(NICE)guidanceonpre-operativetesting[22].ThisshouldincludeureaandelectrolytesandECGforallpatientswithdiabetes;however,arandombloodglucosemeasurementisnotindicated.建議：檢查遵循NICE指南，應該包括尿檢、糖尿病患者電解質及心電圖檢查；然而，隨機血糖測量未注明。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.術前管理（包括日間手術）其目的是盡可能地縮短周期，確保血糖正常（6-10mmol.l-1）盡可能少地打亂患者的日常護理。理論上，患者應列入手術隊列計劃以盡可能減少禁食期。如果禁食期需要限制患者一次進餐，需要相應調整他/她日常的用藥。術前評估團隊需要對病人的手術期間用藥管理、圍手術期間的高血糖或者低血糖以及手術可能對糖尿病控制帶來影響的可能因素給予指導，應該給患者列一個可攝入糖的列表，以預防萬一出現(xiàn)的低血糖帶來手術取消，舉個例子詳加說明，比如含糖飲料（或者糖塊也可以，但是麻醉師要求麻醉前六小時不能攝入）患者應該被警告在術后可能有幾天的血糖波動。?Recommendation:Whenpossible,admissionshouldbeplannedforthedayofsurgery,withboththepatientandthewardstaffawareoftheplannedperi-operativediabetescare,includingaplantomanagehypo-andhyperglycaemia.Surgeryshouldbescheduledatthestartofthetheatrelisttominimisedisruptiontothepatient’sglycaemiccontrol.*建議：只有當患者和醫(yī)護人員確定了糖尿病圍手術期護理方案，包括低血糖高血糖管理，才能準入手術。手術應盡早確定日程以盡可能少的打亂患者控糖。Managementofexistingtherapy既有治療的管理Withappropriateguidance,patientswithdiabetesshouldbeallowedtoretaincontrolandpossessionof,andcontinuetoself-administer,theirmedication.Manypatientswillhaveseveralyears’experienceandbeexpertinself-medication.在適當?shù)闹敢?，應允許糖尿病患者進行自我藥物管理。許多患者會有數(shù)年的經(jīng)驗并已成為自我藥物管理的專家。Theaimistoavoidhypo-orhyperglycaemiaduringtheperiodoffastingandthetimeduringandaftertheprocedure,untilthepatientiseatinganddrinkingnormally.Inpeoplewhoarelikelytomissonemealonly,thiscanoftenbeachievedbymanipulatingthepatient’snormalmedicationusingtheguidanceprovidedinTables1and2.其目的是在禁食期及手術中和手術后防止高血糖或者低血糖的發(fā)生直到患者可以正常飲食為止。如果患者需要一餐的禁食，可以根據(jù)表格1和表格2對患者的用藥進行調整。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們碳水化合物的攝入和利用（比如運動）也取決于他們使用什么藥物和藥物如何作用。一些降糖藥物可以降低血糖濃度在禁食期間需要調整劑量甚至停藥（如胰島素和磺脲類、格列奈類、噻唑烷二酮類藥物）其他降糖藥物作用是防止血糖升高（雙胍類、GLP-1、DPP-4）這些藥物沒有低血糖風險下可以繼續(xù)使用。是否需要VRIII需要考慮手術時間和手術持續(xù)時間。有一餐禁食的持續(xù)皮下注射胰島素患者需要告知其血糖需維持在6-10mmol.l-1如果預計需要長時間禁食，應該聽從專業(yè)意見啟用VRIII。Tables1and2havebeendesignedtotakeallofthesefactorsintoconsideration.Theyareapragmaticapproachtothepre-operativemanagementofalltheavailableclassesofagentusedtomanagediabetes.表格1和表格2設計考慮了所有因素，對于各種類型的糖尿病圍手術期護理都給出了實際的臨床管理辦法。（具體參見原文）Useofavariable-rateintravenousinsulininfusionVariable-rateintravenousinsulininfusionsarepreferredin:patientswhowillmissmorethanonemeal;thosewithtype-1diabetesundergoingsurgerywhohavenotreceivedbackgroundinsulin;thosewithpoorlycontrolleddiabetes(definedasaHbA1c>69mmol.mol1);andmostpatientswithdiabetesrequiringemergencysurgery.Variable-rateintravenousinsulininfusionsshouldbeadministeredandmonitoredbyappropriatelyexperiencedandqualifiedstaff.AnexampleofaVRIIIregimenisprovidedinAppendix1.可調節(jié)的靜脈胰島素輸注（VRIII）的應用可調節(jié)的靜脈胰島素輸注（VRIII）對于以下人群是首選：需要節(jié)食至少一餐的患者；沒有胰島素注射史的I型糖尿病患者；糖尿病控制不佳（定義為糖化血紅蛋白＞69mmol.mol-1）；需急診外科手術的多數(shù)糖尿病患者。可調節(jié)的靜脈胰島素輸注（VRIII）應用和監(jiān)測應該由有經(jīng)驗的專業(yè)的醫(yī)護人員進行。VRIII規(guī)則的示范見附件1.Intra-operativecareandmonitoring術中看護與監(jiān)測Theaimofintra-operativecareistomaintaingoodglycaemiccontrolandnormalelectrolyteconcentrations,whileoptimisingcardiovascularfunctionandrenalperfusion.Ifpossible,multimodalanalgesiashouldbeusedalongwithappropriateanti-emeticprophylaxis,toenableanearlyreturntoanormaldietandthepatient’susualdiabetesregimen.術中看護與監(jiān)測的目的是維持良好的血糖水平和正常的電解質濃度，同時優(yōu)化心血管功能和腎臟灌注。如果可能的話，可以將多種模式鎮(zhèn)痛與適當?shù)目箛I吐預防機制一起進行，使患者早日恢復正常的飲食規(guī)律和常規(guī)糖尿病治療。?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：術中血糖應控制在6-10mmol.l-1(特殊情況下最高控制在12mmol.l-1例如：血糖控制較差沒有接受VRIII治療，正在調整治療方案的糖尿病患者)醫(yī)護人員需要明確血糖范圍在6-10mmol.l-1都是可以接受的，沒有必要以控制在6mmol.l-1為目標。血糖水平應在麻醉前檢查并且在術中不斷監(jiān)測（至少每小時一次，如果血糖超出目標范圍要增加監(jiān)測頻次）。血糖、胰島素注射速率和基質輸入需要記錄在麻醉記錄上。一些圖標需要用顏色區(qū)分標示不正常的數(shù)值以便于后續(xù)調整或改變治療方案（見附件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.術中低血糖和高血糖的管理如果未使用胰島素血糖超過12mmol.l-1需檢測血酮水平（可用床旁診斷）如果血酮大于3mmol.l-1或者有明顯的酮尿（大于++）,需要視為糖尿病酮癥酸中毒處理。血酮大于3mmol.l-1血糖超過11mmol.l-1電解質<15.0mmol.l-1或者PH<7.3即可診斷。糖尿病酮癥酸中毒是急性并發(fā)癥需要糖尿病專業(yè)人員處理。如果沒有發(fā)生酮癥，需要采取皮下胰島素注射降低血糖（見下文）或者改變VRIII輸注速率（已采用的情況下）。如果兩次皮下胰島素注射后沒有起效，需要啟用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處理假設一單位劑量降低3mmol.l-1血糖，使用速效胰島素（門冬胰島素、賴脯胰島素或Apidra）配合注射裝置注射（最大6個單位劑量）胰島素的不規(guī)范使用會引發(fā)死亡和很多嚴重的傷害是必須要避免發(fā)生的，這其中包括不當使用注射裝置。如果病人是清醒的，與病人確認注射劑量是非常重要的（病人對速效胰島素的注射有不同的反應）。血糖水平需要每小時監(jiān)測，第二次注射至少在兩小時之后。Treatmentofhyperglycaemiainapatientwithtype-2diabetesSubcutaneousrapid-actinginsulin0.1IU.kg1shouldbegiven(uptoamaximumof6IU),usingaspecificinsulinsyringe.TheCBGshouldbecheckedhourlyandaseconddoseconsideredonlyafter2h.AVRIIIshouldbeconsideredifthepatientremainshyperglycaemic.2型糖尿病患者高血糖處理使用速效胰島素0.1IU/配合注射裝置注射（最大6個單位劑量）血糖水平需要每小時監(jiān)測，第二次注射至少在兩小時之后。如果高血糖持續(xù)沒有改善，需要啟用VRIII.Treatmentofintra-operativehypoglycaemiaForaCBG4.0–6.0mmol.l1,50mlglucose20%(10g)shouldbegivenintravenously;forhypoglycaemia<4.0mmol.l1adoseof100ml(20g)shouldbegiven.術中低血糖處理如果血糖在4-6mmol.l-1，靜脈注射50ml20%葡萄糖（10g）如果血糖<4.0mmol.l-1，劑量應為100ml（20g）Fluidmanagement體液管理Thereisalimitedevidencebasefortherecommendationofoptimalfluidmanagementoftheadultdiabeticpatientundergoingsurgery.ItisnowrecognisedthatHartmann’ssolutionissafetoadministertopatientswithdiabetesanddoesnotcontributetoclinicallysignificanthyperglycaemia[23].成人糖尿病患者接受手術期間只有理論基礎有限的最佳體液管理的建議。

哈特曼氏溶液認為是較安全的對于糖尿病患者的安全管理，但對于臨床上的顯著高血糖效果較不明顯[23]。FluidmanagementforpatientsrequiringaVRIIITheaimistoprovideglucoseasasubstratetopreventproteolysis,lipolysisandketogenesis,aswellastooptimiseintravascularvolumestatusandmaintainplasmaelectrolyteswithinthenormalrange.Itisimportanttoavoidiatrogenichyponatraemiafromtheadministrationofhypotonicsolutions.Glucose5%solutionshouldbeavoided.Useofglucose4%in0.18%salinecanbeassociatedwithhyponatraemia.需要VRIII治療的病人體液管理其目的是提供葡萄糖以防止蛋白質與脂肪分解，發(fā)生酮癥，同時也是保持血管內體積良好和維持機體電解質正常平衡。避免低滲溶液引起的低鈉血癥非常重要。5%的葡萄糖溶液不可以采用。4%葡萄糖的0.18%生理鹽水也可能引起低鈉血癥。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).基質溶液應用應以病人目前的體液情況為基礎。如果沒有明確的證明一種晶體液優(yōu)于另一種，理論上，半強度的混合葡萄糖的生理鹽水是最佳的解決方案。因此，最初應采取5%葡萄糖的0.45%的生理鹽水預混0.15%（20mmol.l-1）或0.3%（40mmol.l-1）氯化鉀，取決于病人目前的血鉀情況（<3.5mmol.l-1）TheWorkingPartyrecognisesthatthesefluidsmaynotbeavailableinallinstitutions.Itisourviewthattheyshouldbemadeavailableinallareaswherepatientswithdiabeteswillbemanaged.(Hospitalscaringforchildrenwillusuallyhavethesesolutionsalreadyavailableforgeneralpaediatricuse).共識認為補液并不一定適用于所有情況。我們認為在糖尿病人管理治療的各個領域都應該需要借鑒（普通兒科的兒童的醫(yī)院護理將要把此納入常規(guī)應用）Fluidshouldbeadministeredattheratethatisappropriateforthepatient’susualmaintenancerequirements–usually25–50ml.kg_1.day_1(approximately83ml.h_1fora70-kgpatient)[24].補液速率需要根據(jù)病人平時所需情況-一般是25-50ml/kg/天（大約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).偶爾，沒有液體過量的信號下病人會發(fā)生低鈉血癥。在這種情況下，以下的解決方案可作為基質溶液：5%葡萄糖的0.9%生理鹽水預混0.15%氯化鉀（20mmol.l-1）或者5%葡萄糖的0.9%生理鹽水預混0.3%氯化鉀（40mmol.l-1）（再次強調，普通兒科的兒童的醫(yī)院護理將要把此納入常規(guī)應用）AdditionalHartmann’ssolutionoranotherbalancedisotoniccrystalloidsolutionshouldbeusedtooptimiseintravascularvolumestatus.

另外哈特曼氏溶液或者其他的等滲晶體液可以用于改善血管內體積。FluidmanagementforpatientsnotrequiringaVRIIITheaimistoavoidglucose-containingsolutionsunlessthebloodglucoseislow.Itisimportanttoavoidhyperchloraemicmetabolicacidosis;Hartmann’ssolutionshouldbeadministeredtooptimisetheintravascularvolumestatus.Ifthepatientrequiresprolongedpostoperativefluids(>24h),aVRIIIshouldbeconsideredandglucose5%insaline0.45%withpre-mixedpotassiumchloridegivenasabove.不需要VRIII治療的病人體液管理除非低血糖否則不采用含有葡萄糖的溶液。避免高氯血癥代謝性酸中毒非常重要；哈特曼氏溶液有利于改善血管內體積。如果病人需要術后持續(xù)輸液(>24h),需要考慮VRIII與5%葡萄糖的0.45%生理鹽水預混0.15%氯化鉀補液。Returningto‘normal’(pre-operative)medicationanddiet回歸正常（術前）的治療和飲食Thepostoperativebloodglucosemanagementplan,andanyalterationstoexistingmedications,shouldbeclearlycommunicatedtowardstaff.Patientswithdiabetesshouldbeinvolvedinplanningtheirpostoperativecare.Ifsubcutaneousinsulinisrequiredininsulin-na?vepatients,orthetypeofinsulinorthetimeitistobegivenistochange,thespecialistdiabetesteamshouldbecontactedforadvice.應清楚地傳達關于術后血糖管理計劃、對現(xiàn)有藥物的任何改變給病房工作人員。糖尿病患者應參與術后護理的規(guī)劃。如果單純性胰島素患者需要皮下胰島素，胰島素的注射時間或類型需要改變，糖尿病的專家團隊應考慮病人的建議。TransferringfromaVRIIIbacktooraltreatmentorsubcutaneousinsulinIfthepatienthastype-1diabetesandaVRIIIhasbeenused,itmustbecontinuedfor30–60minafterthepatienthashadtheirsubcutaneousinsulin(seebelow).PrematurediscontinuationisassociatedwithiatrogenicDKA.從VRIII轉變?yōu)榭诜幓蚱は伦⑸湟葝u素治療如果1型糖尿病患者已使用VRIII，皮下注射胰島素后需繼續(xù)維持VRIII30-60min（見下）過早的中斷易引起酮癥。RestartingoralhypoglycaemicmedicationOralhypoglycaemicagentsshouldberecommencedatpre-operativedosesoncethepatientisreadytoeatanddrink;withholdingorreductioninsulphonylureasmayberequiredifthefoodintakeislikelytobereduced.Metforminshouldonlyberestartediftheestimatedglomerularfiltrationrateexceeds50ml.min1.1.73m2[25].重新開始口服降糖藥治療當病人可以開始正常飲食時可以考慮重新開始按術前劑量進行口服降糖藥治療；如果飲食減少應該避免或減少磺脲類藥物治療。只有估計腎小球濾過率高于50ml/min1.73/m2時考慮重新開始雙胍類治療[25].RestartingsubcutaneousinsulinforpatientsalreadyestablishedoninsulinConversiontosubcutaneousinsulinshouldcommenceoncethepatientisabletoeatanddrinkwithoutnauseaorvomiting.Thepre-surgicalregimenshouldberestarted,butmayrequireadjustmentbecausetheinsulinrequirementmaychangeasaresultofpostoperativestress,infectionoralteredfoodintake.Thediabetesspecialistteamshouldbeconsultedifthebloodglucoselevelsareoutsidetheacceptablerange(6–12mmol.l1)orifachangeindiabetesmanagementisrequired.已使用胰島素治療的患者恢復皮下胰島素治療當病人可以開始正常飲食并且沒有惡心嘔吐時可以考慮重新開始皮下胰島素治療。因為術后的壓力、感染或者飲食改變可能對胰島素用量有所影響，所以需要調節(jié)劑量重新開始胰島素治療。如重新口服或皮下注射胰島素、重新進行口服降糖藥物、為患者持續(xù)皮下胰島素輸注等。糖尿病患者成功治療的關鍵就是恢復正常飲食習慣。如果血糖不在可接受的范圍（6-12mmol.l-1）之外，糖尿病專家需要商量考慮是否更改糖尿病管理方案。Thetransitionfromintravenoustosubcutaneousinsulinshouldtakeplacewhenthenextmeal-relatedsubcutaneousinsulindoseisdue,forexamplewithbreakfastorlunch.靜脈到皮下的轉變應該在下一餐胰島素皮下劑量確定的時候進行過渡，比如早飯或者午飯時。ForthepatientonbasalandbolusinsulinThereshouldbeanoverlapbetweentheendoftheVRIIIandthefirstinjectionofsubcutaneousinsulin,whichshouldbegivenwithamealandtheintravenousinsulinandfluidsdiscontinued30-60minlater.基礎加餐時胰島素治療的患者VRIII結束的時候胰島素作用時間可能和第一次基礎胰島素有重疊，應該在速效胰島素與液體終止后的30-60min，并在餐時注射基礎胰島素。Ifthepatientwaspreviouslyonalong-actinginsulinanaloguesuchasLantus,LevemirorTresbia,thisshouldhavebeencontinuedandthustheonlyactionshouldbetorestarthis/herusualrapid-actinginsulinatthenextmealasoutlinedabove.Ifthebasalinsulinwasstopped,theinsulininfusionshouldbecontinueduntilabackgroundinsulinhasbeengiven.如果病人之前使用長效胰島素類似物比如甘精、地特和Tresbia，可以繼續(xù)使用只需要在下一餐時按需要重新啟用平常的速效胰島素。如果基礎胰島素已經(jīng)停止，胰島素輸注需要繼續(xù)直到啟用基礎胰島素為止。Forthepatientonatwice-daily,fixed-mixregimenTheinsulinshouldbere-introducedbeforebreakfastorbeforetheeveningmeal,andnotatanyothertime.TheVRIIIshouldbemaintainedfor30-60minafterthesubcutaneousinsulinhasbeengiven.兩針預混治療的患者應該在早餐前或者晚餐前重新啟用，而不是其他任何時間。皮下注射胰島素后需繼續(xù)維持VRIII30-60min。ForthepatientonacontinuoussubcutaneousinsulininfusionThesubcutaneousinsulininfusionshouldberecommencedatthepatient’snormalbasalrate;theVRIIIshouldbecontinueduntilthenextmealbolushasbeengiven.Thesubcutaneousinsulininfusionsshouldnotbere-startedatbedtime.持續(xù)皮下胰島素輸注的患者按找病人正常的基礎胰島素輸注速率重新啟用持續(xù)皮下胰島素輸注；VRIII應該保持到直到下一個餐時大劑量啟用為止。不要在就寢時間重新啟用持續(xù)皮下胰島素輸注。ResumptionofnormaldietThekeytosuccessfulmanagementofthesurgicalpatientwithdiabetesisresumptionofhis/herusualdiet.Thisallowsresumptionofnormaldiabetesmedication.Hospitaldischargeisonlyfeasibleoncethepatienthasresumedeatinganddrinking.重新開始正常飲食伴有糖尿病手術患者成功管理的關鍵就是恢復正常飲食習慣。只有恢復飲食才能恢復藥物治療。重新開始正常飲食治療手段才是可行的。Otheranaestheticconsiderations其他麻醉考慮