1、糖尿病患者手术麻醉,病例概况,女性，62岁，腹痛3日，拟诊上消化道穿孔行剖腹探查术身高158cm，体重85kg，神志淡漠，T39.5高血压病史16年，口服伊诺普利、尼群地平控制血压，平素140/80，入院95/55糖尿病病史8年，口服二甲双胍，血糖控制在6-8mmol/L，入院时血糖26.3，尿酮体+高血脂，他汀类控制，效果佳ECG窦性心动过速（135bpm），ST-T改变,糖尿病（DM）诊断和分型,The spectrum from normal glucose tolerance to diabetes in type 1 DM, type 2 DM, other specific typ
2、es 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,
3、 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 chall
4、enge 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.,分型主要根据病因，而非根据发病年龄和治疗方法。1型病因是胰岛细胞衰竭和胰岛素缺乏；2型病因包括胰岛素缺乏、胰
5、岛素抵抗和糖异生增加,糖尿病（DM）流行病学,糖尿病（DM）流行病学,DM发病率大幅增高老龄化、肥胖、不运动慢性炎症，导致葡萄糖耐量异常的治疗，遗传背景,糖尿病（DM）流行病学,糖尿病影响围手术期的并发症和死亡率2779名DM患者行CABG手术，与正常人群相比，DM患者ICU和住院时间延长正性肌力药、输血、透析肾衰、中风、纵隔炎、伤口感染30日死亡率2.6%1.6%5年累积生存率84.4%91.3%,糖尿病（DM）流行病学,许多2型DM直至手术时才发现DM7310名，CABG,何时发现并开始治疗DM非常重要,DM相关并发症 强直性关节综合征,多见于青少年起病的DM患者关节僵硬，身材矮小，皮肤呈
6、蜡样紧张胶原组织糖基化是可能原因开始于第5指掌指关节和近指关节，可以侵犯包括颈椎和胸椎在内的大关节对于肥胖患者糖尿病是其困难插管的预测因子,DM相关并发症 心血管疾病,DM患者围手术期心血管并发症和死亡率增高2-3倍心血管病变占DM患者死亡原因的80%高血压、冠状动脉疾病、周围动脉疾病、收缩性或舒张性心功能异常、心衰大多数65岁的DM患者存在有/无症状冠状动脉疾病，更多发生无症状心肌缺血，有自主神经病变者应提高警惕DM性心肌病使心室舒张受限，左室充盈压增高，导致心衰,DM相关并发症 心血管疾病,DM患者高血压发生率高于非DM患者，且随DM时间延长而增加，与DM肾病的进展紧密相关。2型DM患者血
7、压控制可能比长期的血糖控制更重要，推荐的血压130/80。ACEI或-blocker可降低DM大血管病变相关的死亡率。,DM相关并发症 微血管病变,糖尿病视网膜病变,DM相关并发症 微血管病变,糖尿病视网膜病变,Diabetic retinopathy results in scattered hemorrhages, yellow exudates, and neovascularization. This patient has neovascular vessels proliferating from the optic disc, requiring urgent pan retin
8、al laser photocoagulation.,DM相关并发症 微血管病变,糖尿病视网膜病变视网膜循环是脑循环的预测因子术前存在视网膜微血管病变严重提示手术后脑功能障碍和死亡率风险增加,DM相关并发症 微血管病变,糖尿病肾病,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
9、from RA DeFranzo, in Therapy for Diabetes Mellitus and Related Disorders, 3d ed. American Diabetes Association, Alexandria, VA, 1998.),DM相关并发症 神经病变,周围神经痛 静息痛、夜间痛、下肢多见感觉异常自主神经包括胆碱能、去甲肾上腺素能、肽能（如胰多肽、P物质等）心血管系统：静息性心动过速，体位性低血压，甚至猝死胃轻瘫、膀胱排空异常上肢多汗，下肢无汗（下肢皮肤干裂，溃疡风险增加）激素释放的反调控机制减弱，导致不能感知低血糖,DM急性并发症 酮症酸中毒,DM急
10、性并发症 酮症酸中毒,Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis).Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH 3.3 mmol/L.Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Init
11、iate 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
12、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
13、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.,治疗,DM急性并发症 高血糖性高渗性昏迷,多见于成年2型糖尿病多尿、体重下降、进食减少数周精神错乱、嗜睡或昏迷严重的脱水、高渗、低血压和心动过速无DKA特有的恶心、呕吐、腹痛及Kussmaul呼吸多由严重的合并症诱发，如
14、心梗、脑梗、脓毒症、肺炎或其他严重感染,临床特点,DM急性并发症 高血糖性高渗性昏迷,DM的治疗,DM的治疗,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 .
15、. . 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 su
16、ggest a goal that is 0.25 mmol/L (10 mg/dL) higher. Source: Adapted from American Diabetes Association, 2007.,DM的治疗,胰岛素分泌刺激剂如磺脲类，通过作用于细胞的ATP敏感性钾通道促进胰岛素释放双胍类如二甲双胍，抑制肝糖异生并增加外周组织糖利用，但可导致乳酸酸中毒糖苷酶抑制剂如米格列醇，延缓葡萄糖吸收而降低餐后高血糖噻唑烷二酮类如匹格列酮，与脂肪细胞细胞核内受体结合来降低胰岛素抵抗,本例患者如何评估,女性，62岁，腹痛3日，拟诊上消化道穿孔行剖腹探查术身高158cm，体重85kg，神
17、志淡漠，T39.5高血压病史16年，口服伊诺普利、尼群地平控制血压，平素140/80，入院95/55糖尿病病史8年，口服二甲双胍，血糖控制在6-8mmol/L，入院时血糖26.3，尿酮体+高血脂，他汀类控制，效果佳ECG窦性心动过速（135bpm），ST-T改变,术前评估,是否确诊？是否可争取时间内科治疗？膈下游离气体、急腹症腹痛3日，未禁食，估计腹腔感染严重,争取时间，尽快完善术前准备，同时尽早开始内科治疗，处理酮症,术前评估,术前还需哪些检查？,动脉血气电解质肝肾功能,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
18、,术前评估,术前内科治疗水化胰岛素纠酸电解质,术中管理,麻醉和手术对葡萄糖代谢的影响七氟烷和异氟烷对葡萄糖耐量的损害程度相同，与手术刺激无关手术可产生应激反应，使机体处于分解代谢状态，改变程度与手术大小有关硬膜外麻醉可减少应激反应激素的释放而对血糖影响小,术中管理,麻醉方法的选择全麻插管保护气道椎管内阻滞、神经阻滞对机体代谢影响小,术中管理,择期手术手术当日胰岛素的用法反复测量血糖是关键未使用胰岛素的2型DM患者，术晨不给降糖药，二甲双胍术前24h停药，一般手术无需输注含糖液体，大手术及术后几天不能进食者应静脉给予含糖液，并使用胰岛素,术中管理,择期手术手术当日胰岛素的用法使用胰岛素的患者接受
19、大于2h的手术，同时输注葡萄糖和胰岛素可能对患者有益。5%的葡萄糖125ml/h或2ml/kg.h，胰岛素5U负荷量，维持的速度为最近测得的血糖（mg/dl）/150（严重感染或应激大的手术100），或者1U/h重要的是密切监测血糖和电解质,术中管理,本例患者如何监测？,术中管理,如何处理术中高血糖？血糖超过14mmol/l需静脉给予胰岛素单次剂量胰岛素5-10u，成人胰岛素一般1u降低血糖0.6mmol/l，或者降低1mmol/l血糖需胰岛素1.7u持续输注胰岛素,术中管理,如何识别和处理术中低血糖？全身麻醉下表现为难以解释的休克和,Neuroglycopenic symptoms of h
20、ypoglycemia 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 pe
21、rception 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) su
22、ch 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
23、 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
24、are often observable. Transient focal neurologic deficits occur occasionally. Permanent neurologic deficits are rare.,术中管理,如何识别和处理术中低血糖？全身麻醉下临床表现被掩盖，常出现难以解释的大汗、低血压、心动过速确诊依靠血糖监测Oral treatment with glucose tablets or glucose-containing fluids, candy, or food is appropriate if the patient is able and w
25、illing to take these. A reasonable initial dose is 20 g of glucose. If the patient is unable or unwilling, because of neuroglycopenia, to take carbohydrates orally, parenteral therapy is necessary. Intravenous glucose (25 g) should be given and followed by a glucose infusion guided by serial plasma
26、glucose measurements. If intravenous therapy is not practical, subcutaneous or intramuscular glucagon (1.0 mg in adults) can be used, particularly in patients with T1DM. Because it acts by stimulating glycogenolysis, glucagon is ineffective in glycogen-depleted individuals (e.g., those with alcohol-
27、induced hypoglycemia). It also stimulates insulin secretion and is therefore less useful in T2DM. These treatments raise plasma glucose concentrations only transiently, and patients should therefore be urged to eat as soon as is practical to replete glycogen stores.70Kg成年人每推注4.5g葡萄糖可使血糖升高约1mmol/L,谢谢,
