(翻譯)2015AAGBI糖尿病患者圍手術(shù)期管理

(翻譯)2015AAGBI糖尿病患者圍手術(shù)期管理LtDGuidelinesPeri-operativemanagementofthesurgicalpatientwithdiabetes2015AssociationofAnaesthetistsofGreatBritainandIreland2015AAGBI糖尿病患者圍手術(shù)期管理英國(guó)和愛爾蘭麻醉醫(yī)師協(xié)會(huì)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(duì)自己血糖的管理經(jīng)驗(yàn)了，本指南的目的是對(duì)糖尿病患者圍手術(shù)期處理提供詳細(xì)的指導(dǎo)，這對(duì)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(jiǎn)介眾所周知流行病學(xué)調(diào)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(shù)更頻繁，并有更長(zhǎng)的住院時(shí)間。相對(duì)于非糖尿患者群，患有糖尿病或高血糖的外科患者相應(yīng)的發(fā)病率和死亡率會(huì)增加，比起非糖尿病患者，圍手術(shù)期死亡率增加50%。導(dǎo)致上述不良結(jié)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??；多重用藥的復(fù)雜性和胰島素處方錯(cuò)誤；圍手術(shù)期和術(shù)后感染的增加；伴有低血糖或高血糖；對(duì)糖尿病或高血糖住院管理制度知識(shí)的缺乏；對(duì)于糖尿病和高血糖患者管理知識(shí)匱乏尤其是在護(hù)理方面。麻醉師和圍手術(shù)期護(hù)理人員對(duì)于護(hù)理糖尿病患者應(yīng)該具有詳盡的知識(shí)和熟練的技能。對(duì)于伴有糖尿病的外殼患者的管理中糖尿病護(hù)理是至關(guān)重要的環(huán)節(jié)，在圍手術(shù)期的護(hù)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(shù)期管理指南。這版詳盡的指南提供了背景知識(shí)以及對(duì)于糖尿病患者護(hù)理的建議。這些建議很多出自循證醫(yī)學(xué)證據(jù)，并且表明，麻醉師和臨床醫(yī)生對(duì)于糖尿病患者的圍手術(shù)護(hù)理需要更精簡(jiǎn)貼近實(shí)際的建議。結(jié)合2011版的這版指南，AAGBI出版了這版更精簡(jiǎn)的指南。之前的2011NHS糖尿病指南在2015也會(huì)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(fēng)險(xiǎn)研究結(jié)果表明圍手術(shù)期和手術(shù)期間的高血糖、高糖化血紅蛋白水平與患者術(shù)后預(yù)后不佳關(guān)系密切，這種預(yù)后不佳無(wú)論是擇期手術(shù)還是急診手術(shù)均有體現(xiàn)，這些手術(shù)包括脊髓、血管、結(jié)腸直腸、心臟、創(chuàng)傷、乳腺、整形、神外以及肝膽手術(shù)等。一項(xiàng)研究顯示這些不良結(jié)局包括：死亡率增加50%、術(shù)后呼吸道感染增加2.4倍、手術(shù)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(shù)前診斷明確的伴有糖尿病的患者和普通患者的預(yù)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?yàn)榛颊咧耙衙鞔_診斷為糖尿病，對(duì)血糖的管理有更為積極的控制。Referralfromprimarycareandplanningsurgery從初級(jí)保健到計(jì)劃手術(shù)的轉(zhuǎn)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(shù)前盡可能地控制良好，避免因?yàn)檠强刂撇患讯中g(shù)延期。遵循2011版的NHS糖尿病指南，擇期手術(shù)情況下HbA1c應(yīng)＜69mmol.mol-1（8.5%），當(dāng)HbA1c≥69mmol-1時(shí)，手術(shù)應(yīng)延遲到血糖控制有所改善的時(shí)候。糖尿病管理策略可以適時(shí)改變以確保手術(shù)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(shù)患者的擇期手術(shù)計(jì)劃應(yīng)該盡可能地把對(duì)患者自我管理的破壞降到最低。?Recommendation:Glycaemiccontrolshouldbecheckedatthetimeofreferralforsurgery.Informationaboutduration,typeofdiabetes,currenttreatmentandcomplicationsshouldbemadeavailabletothesecondarycareteam.建議：轉(zhuǎn)診手術(shù)時(shí)應(yīng)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(shù)期間應(yīng)對(duì)患者血糖控制水平進(jìn)行充分的評(píng)估，理想狀態(tài)是術(shù)前三個(gè)月HbA1c控制在＜69mmol.mol-1（8.5%）當(dāng)HbA1c≥69mmol-1時(shí)，手術(shù)應(yīng)延遲到血糖控制有所改善的時(shí)候。有一小部分的情況患者的血糖可能在術(shù)前難以控制，特別是需要手術(shù)的病因本身就引起血糖控制不佳，如慢性感染；或者手術(shù)比較緊急。這種情況下，需要和病人溝通解釋因此帶來(lái)的風(fēng)險(xiǎn)，患者接受，可以進(jìn)行手術(shù)。在程序適宜的情況下管理病人以滿足日間手術(shù)的標(biāo)準(zhǔn)。糖尿病的良好控制不應(yīng)該是日間手術(shù)的禁忌。Patientswithpoorlycontrolleddiabetesatthetimeofsurgerywillneedclosemonitoringandmayneedtostartavariable-rateintravenousinsulininfusion(VRIII).?Recommendation:Patientswithdiabetesshouldbeidentifiedearlyinthepre-operativepathway.無(wú)法很好控制血糖的糖尿病患者在手術(shù)期間需要嚴(yán)密的監(jiān)測(cè)及采用可調(diào)節(jié)的靜脈胰島素輸注（VRIII）提示：伴有糖尿病的患者應(yīng)在手術(shù)前應(yīng)進(jìn)行提前鑒定Pre-operativeassessment術(shù)前評(píng)估Appropriateandearlypre-operativeassessmentshouldbearranged.Apre-operativeassessmentnursemayundertaketheassessmentwithsupportfromeitherananaesthetistoradiabetesspecialistnurse.Itshouldoccursufficientlyinadvanceoftheplannedsurgerytoensureoptimisationofglycaemiccontrolbeforethedateofproposedsurgery.Theaimistoensurethatallrelevantinvestigationsareavailableandcheckedinadvanceoftheplannedsurgery,thatthepatientunderstandshowtomanagehis/herdiabetesintheperi-operativeperiod,andthattheperiodofpre-operativefastingisminimised.應(yīng)安排適當(dāng)?shù)幕蛟缙诘男g(shù)前評(píng)估。進(jìn)行術(shù)前評(píng)估護(hù)士可能需要來(lái)自麻醉師或糖尿病?？谱o(hù)士的支持。術(shù)前評(píng)估應(yīng)在計(jì)劃手術(shù)之前以確保手術(shù)日期前血糖得到控制優(yōu)化。術(shù)前評(píng)估的目的是：在計(jì)劃手術(shù)前確保獲得所有相關(guān)檢查以及進(jìn)一步的檢查；使患者了解在圍手術(shù)期如何管理他/她的糖尿病；減少術(shù)前禁食時(shí)間。?Recommendation:Testsshouldbeorderedtoassessco-morbiditiesinlinewithNationalInstituteforHealthandCareExcellence(NICE)guidanceonpre-operativetesting[22].ThisshouldincludeureaandelectrolytesandECGforallpatientswithdiabetes;however,arandombloodglucosemeasurementisnotindicated.建議：檢查遵循NICE指南，應(yīng)該包括尿檢、糖尿病患者電解質(zhì)及心電圖檢查；然而，隨機(jī)血糖測(cè)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(shù)前管理（包括日間手術(shù)）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(hù)理。理論上，患者應(yīng)列入手術(shù)隊(duì)列計(jì)劃以盡可能減少禁食期。如果禁食期需要限制患者一次進(jìn)餐，需要相應(yīng)調(diào)整他/她日常的用藥。術(shù)前評(píng)估團(tuán)隊(duì)需要對(duì)病人的手術(shù)期間用藥管理、圍手術(shù)期間的高血糖或者低血糖以及手術(shù)可能對(duì)糖尿病控制帶來(lái)影響的可能因素給予指導(dǎo)，應(yīng)該給患者列一個(gè)可攝入糖的列表，以預(yù)防萬(wàn)一出現(xiàn)的低血糖帶來(lái)手術(shù)取消，舉個(gè)例子詳加說(shuō)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(shí)不能攝入）患者應(yīng)該被警告在術(shù)后可能有幾天的血糖波動(dòng)。?Recommendation:Whenpossible,admissionshouldbeplannedforthedayofsurgery,withboththepatientandthewardstaffawareoftheplannedperi-operativediabetescare,includingaplantomanagehypo-andhyperglycaemia.Surgeryshouldbescheduledatthestartofthetheatrelisttominimisedisruptiontothepatient’sglycaemiccontrol.*建議：只有當(dāng)患者和醫(yī)護(hù)人員確定了糖尿病圍手術(shù)期護(hù)理方案，包括低血糖高血糖管理，才能準(zhǔn)入手術(shù)。手術(shù)應(yīng)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(dāng)?shù)闹敢拢瑧?yīng)允許糖尿病患者進(jìn)行自我藥物管理。許多患者會(huì)有數(shù)年的經(jīng)驗(yàn)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(shù)中和手術(shù)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(duì)患者的用藥進(jìn)行調(diào)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(yùn)動(dòng)）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(diào)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(fēng)險(xiǎn)下可以繼續(xù)使用。是否需要VRIII需要考慮手術(shù)時(shí)間和手術(shù)持續(xù)時(shí)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(yù)計(jì)需要長(zhǎng)時(shí)間禁食，應(yīng)該聽從專業(yè)意見啟用VRIII。Tables1and2havebeendesignedtotakeallofthesefactorsintoconsideration.Theyareapragmaticapproachtothepre-operativemanagementofalltheavailableclassesofagentusedtomanagediabetes.表格1和表格2設(shè)計(jì)考慮了所有因素，對(duì)于各種類型的糖尿病圍手術(shù)期護(hù)理都給出了實(shí)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(diào)節(jié)的靜脈胰島素輸注（VRIII）的應(yīng)用可調(diào)節(jié)的靜脈胰島素輸注（VRIII）對(duì)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(shù)的多數(shù)糖尿病患者?？烧{(diào)節(jié)的靜脈胰島素輸注（VRIII）應(yīng)用和監(jiān)測(cè)應(yīng)該由有經(jīng)驗(yàn)的專業(yè)的醫(yī)護(hù)人員進(jìn)行。VRIII規(guī)則的示范見附件1.Intra-operativecareandmonitoring術(shù)中看護(hù)與監(jiān)測(cè)Theaimofintra-operativecareistomaintaingoodglycaemiccontrolandnormalelectrolyteconcentrations,whileoptimisingcardiovascularfunctionandrenalperfusion.Ifpossible,multimodalanalgesiashouldbeusedalongwithappropriateanti-emeticprophylaxis,toenableanearlyreturntoanormaldietandthepatient’susualdiabetesregimen.術(shù)中看護(hù)與監(jiān)測(cè)的目的是維持良好的血糖水平和正常的電解質(zhì)濃度，同時(shí)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(dāng)?shù)目箛I吐預(yù)防機(jī)制一起進(jìn)行，使患者早日恢復(fù)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(shù)中血糖應(yīng)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(diào)整治療方案的糖尿病患者)醫(yī)護(hù)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(biāo)。血糖水平應(yīng)在麻醉前檢查并且在術(shù)中不斷監(jiān)測(cè)（至少每小時(shí)一次，如果血糖超出目標(biāo)范圍要增加監(jiān)測(cè)頻次）。血糖、胰島素注射速率和基質(zhì)輸入需要記錄在麻醉記錄上。一些圖標(biāo)需要用顏色區(qū)分標(biāo)示不正常的數(shù)值以便于后續(xù)調(diào)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(shù)中低血糖和高血糖的管理如果未使用胰島素血糖超過(guò)12mmol.l-1需檢測(cè)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(guò)11mmol.l-1電解質(zhì)<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(shè)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(gè)單位劑量）胰島素的不規(guī)范使用會(huì)引發(fā)死亡和很多嚴(yán)重的傷害是必須要避免發(fā)生的，這其中包括不當(dāng)使用注射裝置。如果病人是清醒的，與病人確認(rèn)注射劑量是非常重要的（病人對(duì)速效胰島素的注射有不同的反應(yīng)）。血糖水平需要每小時(shí)監(jiān)測(cè)，第二次注射至少在兩小時(shí)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(gè)單位劑量）血糖水平需要每小時(shí)監(jiān)測(cè)，第二次注射至少在兩小時(shí)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(shù)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(yīng)為100ml（20g）Fluidmanagement體液管理Thereisalimitedevidencebasefortherecommendationofoptimalfluidmanagementoftheadultdiabeticpatientundergoingsurgery.ItisnowrecognisedthatHartmann’ssolutionissafetoadministertopatientswithdiabetesanddoesnotcontributetoclinicallysignificanthyperglycaemia[23].成人糖尿病患者接受手術(shù)期間只有理論基礎(chǔ)有限的最佳體液管理的建議。

哈特曼氏溶液認(rèn)為是較安全的對(duì)于糖尿病患者的安全管理，但對(duì)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(zhì)與脂肪分解，發(fā)生酮癥，同時(shí)也是保持血管內(nèi)體積良好和維持機(jī)體電解質(zhì)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(zhì)溶液應(yīng)用應(yīng)以病人目前的體液情況為基礎(chǔ)。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(qiáng)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(yīng)采取5%葡萄糖的0.45%的生理鹽水預(yù)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(shí)認(rèn)為補(bǔ)液并不一定適用于所有情況。我們認(rèn)為在糖尿病人管理治療的各個(gè)領(lǐng)域都應(yīng)該需要借鑒（普通兒科的兒童的醫(yī)院護(hù)理將要把此納入常規(guī)應(yīng)用）Fluidshouldbeadministeredattheratethatisappropriateforthepatient’susualmaintenancerequirements–usually25–50ml.kg_1.day_1(approximately83ml.h_1fora70-kgpatient)[24].補(bǔ)液速率需要根據(jù)病人平時(shí)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(guò)量的信號(hào)下病人會(huì)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(zhì)溶液：5%葡萄糖的0.9%生理鹽水預(yù)混0.15%氯化鉀（20mmol.l-1）或者5%葡萄糖的0.9%生理鹽水預(yù)混0.3%氯化鉀（40mmol.l-1）（再次強(qiáng)調(diào)，普通兒科的兒童的醫(yī)院護(hù)理將要把此納入常規(guī)應(yīng)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(nèi)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(nèi)體積。如果病人需要術(shù)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(yù)混0.15%氯化鉀補(bǔ)液。Returningto‘normal’(pre-operative)medicationanddiet回歸正常（術(shù)前）的治療和飲食Thepostoperativebloodglucosemanagementplan,andanyalterationstoexistingmedications,shouldbeclearlycommunicatedtowardstaff.Patientswithdiabetesshouldbeinvolvedinplanningtheirpostoperativecare.Ifsubcutaneousinsulinisrequiredininsulin-na?vepatients,orthetypeofinsulinorthetimeitistobegivenistochange,thespecialistdiabetesteamshouldbecontactedforadvice.應(yīng)清楚地傳達(dá)關(guān)于術(shù)后血糖管理計(jì)劃、對(duì)現(xiàn)有藥物的任何改變給病房工作人員。糖尿病患者應(yīng)參與術(shù)后護(hù)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(shí)間或類型需要改變，糖尿病的專家團(tuán)隊(duì)?wèi)?yīng)考慮病人的建議。TransferringfromaVRIIIbacktooraltreatmentorsubcutaneousinsulinIfthepatienthastype-1diabetesandaVRIIIhasbeenused,itmustbecontinuedfor30–60minafterthepatienthashadtheirsubcutaneousinsulin(seebelow).PrematurediscontinuationisassociatedwithiatrogenicDKA.從VRIII轉(zhuǎn)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(guò)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(dāng)病人可以開始正常飲食時(shí)可以考慮重新開始按術(shù)前劑量進(jìn)行口服降糖藥治療；如果飲食減少應(yīng)該避免或減少磺脲類藥物治療。只有估計(jì)腎小球?yàn)V過(guò)率高于50ml/min1.73/m2時(shí)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(fù)皮下胰島素治療當(dāng)病人可以開始正常飲食并且沒有惡心嘔吐時(shí)可以考慮重新開始皮下胰島素治療。因?yàn)樾g(shù)后的壓力、感染或者飲食改變可能對(duì)胰島素用量有所影響，所以需要調(diào)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(jìn)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(guān)鍵就是恢復(fù)正常飲食習(xí)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(zhuǎn)變應(yīng)該在下一餐胰島素皮下劑量確定的時(shí)候進(jìn)行過(guò)渡，比如早飯或者午飯時(shí)。ForthepatientonbasalandbolusinsulinThereshouldbeanoverlapbetweentheendoftheVRIIIandthefirstinjectionofsubcutaneousinsulin,whichshouldbegivenwithamealandtheintravenousinsulinandfluidsdiscontinued30-60minlater.基礎(chǔ)加餐時(shí)胰島素治療的患者VRIII結(jié)束的時(shí)候胰島素作用時(shí)間可能和第一次基礎(chǔ)胰島素有重疊，應(yīng)該在速效胰島素與液體終止后的30-60min，并在餐時(shí)注射基礎(chǔ)胰島素。Ifthepatientwaspreviouslyonalong-actinginsulinanaloguesuchasLantus,LevemirorTresbia,thisshouldhavebeencontinuedandthustheonlyactionshouldbetorestarthis/herusualrapid-actinginsulinatthenextmealasoutlinedabove.Ifthebasalinsulinwasstopped,theinsulininfusionshouldbecontinueduntilabackgroundinsulinhasbeengiven.如果病人之前使用長(zhǎng)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(shí)按需要重新啟用平常的速效胰島素。如果基礎(chǔ)胰島素已經(jīng)停止，胰島素輸注需要繼續(xù)直到啟用基礎(chǔ)胰島素為止。Forthepatientonatwice-daily,fixed-mixregimenTheinsulinshouldbere-introducedbeforebreakfastorbeforetheeveningmeal,andnotatanyothertime.TheVRIIIshouldbemaintainedfor30-60minafterthesubcutaneousinsulinhasbeengiven.兩針預(yù)混治療的患者應(yīng)該在早餐前或者晚餐前重新啟用，而不是其他任何時(shí)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(chǔ)胰島素輸注速率重新啟用持續(xù)皮下胰島素輸注；VRIII應(yīng)該保持到直到下一個(gè)餐時(shí)大劑量啟用為止。不要在就寢時(shí)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(shù)患者成功管理的關(guān)鍵就是恢復(fù)正常飲食習(xí)慣。只有恢復(fù)飲食才能恢復(fù)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