糖尿病患者手术麻醉糖尿病患者手术麻醉病例概况病例概况p女女性性，62岁，腹腹痛痛3日日，拟诊上上消消化化道道穿穿孔孔行行剖剖腹腹探探查术p身高身高158cm，体重，体重85kg，神志淡漠，神志淡漠，T39.5p高高血血压病病史史16年年，口口服服伊伊诺普普利利、尼尼群群地地平平控控制制血血压，平素，平素140/80，入院，入院95/55p糖糖尿尿病病病病史史8年年，口口服服二二甲甲双双胍胍，血血糖糖控控制制在在6-8mmol/L，入院，入院时血糖血糖26.3，尿，尿酮体体+p高血脂，他汀高血脂，他汀类控制，效果佳控制，效果佳pECG窦性心性心动过速（速（135bpm），），ST-T改改变糖尿病（糖尿病（DM）诊断和分型）诊断和分型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. 分分型型主主要要根根据据病病因因，而而非非根根据据发发病病年年龄龄和和治治疗疗方方法法。1型型病病因因是是胰胰岛岛细细胞胞衰衰竭竭和和胰胰岛岛素素缺缺乏乏；2型型病病因因包包括括胰胰岛岛素素缺缺乏乏、胰胰岛岛素素抵抵抗抗和和糖异生增加糖异生增加糖尿病（糖尿病（DM）流行病学）流行病学糖尿病（糖尿病（DM）流行病学）流行病学pDM发病率大幅增高病率大幅增高老老龄化、肥胖、不运化、肥胖、不运动慢慢性性炎炎症症，导致致葡葡萄萄糖糖耐耐量量异异常常的的治治疗，遗传背景背景糖尿病（糖尿病（DM）流行病学）流行病学p糖尿病影响糖尿病影响围手手术期的并期的并发症和死亡率症和死亡率2779名名DM患患者者行行CABG手手术，与与正正常常人人群群相相比比，DM患者患者ICU和住院和住院时间延延长正性肌力正性肌力药、输血、透析血、透析肾衰、中衰、中风、纵隔炎、隔炎、伤口感染口感染30日死亡率日死亡率2.6%1.6%5年累年累积生存率生存率84.4%91.3%糖尿病（糖尿病（DM）流行病学）流行病学p许多多2型型DM直至手直至手术时才才发现DM7310名，名，CABG复复苏再插管再插管围手手术期死亡率期死亡率非糖尿病非糖尿病1.7%2.1%0.9%未未诊断出的断出的DM4.2%5.0%2.4%已已诊断出的断出的DM1.5%3.5%1.4%何时发现并开始治疗何时发现并开始治疗DMDM非常重要非常重要DM相关并发症相关并发症 强直性关直性关节综合征合征多多见于青少年起病的于青少年起病的DM患者患者关关节僵硬，身材矮小，皮肤呈蜡僵硬，身材矮小，皮肤呈蜡样紧张胶原胶原组织糖基化是可能原因糖基化是可能原因开开始始于于第第5指指掌掌指指关关节和和近近指指关关节，可可以以侵侵犯犯包包括括颈椎和胸椎在内的大关椎和胸椎在内的大关节对于肥胖患者糖尿病是其困于肥胖患者糖尿病是其困难插管的插管的预测因子因子DM相关并发症相关并发症 心血管疾病心血管疾病DM患者患者围手手术期心血管并期心血管并发症和死亡率增高症和死亡率增高2-3倍倍心血管病心血管病变占占DM患者死亡原因的患者死亡原因的80%高高血血压、冠冠状状动脉脉疾疾病病、周周围动脉脉疾疾病病、收收缩性性或或舒舒张性心功能异常、心衰性心功能异常、心衰大大多多数数65岁的的DM患患者者存存在在有有/无无症症状状冠冠状状动脉脉疾疾病病，更更多多发生生无无症症状状心心肌肌缺缺血血，有有自自主主神神经病病变者者应提高警惕提高警惕DM性性心心肌肌病病使使心心室室舒舒张受受限限，左左室室充充盈盈压增增高高，导致心衰致心衰DM相关并发症相关并发症 心血管疾病心血管疾病DM患患者者高高血血压发生生率率高高于于非非DM患患者者，且且随随DM时间延延长而而增增加加，与与DM肾病病的的进展展紧密密相相关关。2型型DM患患者者血血压控控制制可可能能比比长期期的的血血糖糖控控制制更更重重要要，推推荐荐的的血血压130/80。ACEI或或-blocker可降低可降低DM大血管病大血管病变相关的死亡率。相关的死亡率。DM相关并发症相关并发症 微血管病微血管病变糖尿病糖尿病视网膜病网膜病变DM相关并发症相关并发症 微血管病微血管病变糖尿病糖尿病视网膜病网膜病变Diabetic retinopathy results in scattered hemorrhages, yellow exudates, and neovascularization. This patient has neovascular vessels proliferating from the optic disc, requiring urgent pan retinal laser photocoagulation.DM相关并发症相关并发症 微血管病微血管病变糖尿病糖尿病视网膜病网膜病变视网膜循网膜循环是是脑循循环的的预测因子因子术前前存存在在视网网膜膜微微血血管管病病变严重重提提示示手手术后后脑功能障碍和死亡率功能障碍和死亡率风险增加增加DM相关并发症相关并发症 微血管病微血管病变糖尿病糖尿病肾病病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相相关关并并发发症症 神神经病病变周周围神神经痛痛 静息痛、夜静息痛、夜间痛、下肢多痛、下肢多见感感觉异常异常自主神自主神经包括胆碱能、去甲包括胆碱能、去甲肾上腺素能、上腺素能、肽能（如胰多能（如胰多肽、P物物质等）等）心血管系心血管系统：静息性心：静息性心动过速，体位性低血速，体位性低血压，甚至猝死，甚至猝死胃胃轻瘫、膀胱排空异常、膀胱排空异常上肢多汗，下肢无汗（下肢皮肤干裂，上肢多汗，下肢无汗（下肢皮肤干裂，溃疡风险增加）增加）激素激素释放的反放的反调控机制减弱，控机制减弱，导致不能感知低血糖致不能感知低血糖DM急急性性并并发发症症 酮症症酸酸中中毒毒DM急急性性并并发发症症 酮症症酸酸中中毒毒1.Confirm diagnosis (plasma glucose, positive serum ketones, metabolic acidosis).2.Admit to hospital; intensive-care setting may be necessary for frequent monitoring or if pH 7.00 or unconscious.3.Assess: Serum electrolytes (K+, Na+, Mg2+, Cl-, bicarbonate, phosphate); Acid-base statuspH, HCO3-, PCO2, b-hydroxybutyrate; Renal function (creatinine, urine output)4.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).5.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.6.Assess patient: What precipitated the episode (noncompliance, infection, trauma, infarction, cocaine)? Initiate appropriate workup for precipitating event (cultures, CXR, ECG).7.Measure capillary glucose every 12 h; measure electrolytes (especially K+, bicarbonate, phosphate) and anion gap every 4 h for first 24 h.8.Monitor blood pressure, pulse, respirations, mental status, fluid intake and output every 14 h.9.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.10.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.11.Administer intermediate or long-acting insulin as soon as patient is eating. Allow for overlap in insulin infusion and subcutaneous insulin injection.治疗治疗DM急性并发症急性并发症 高血糖性高渗性昏迷高血糖性高渗性昏迷多多见于成年于成年2型糖尿病型糖尿病多尿、体重下降、多尿、体重下降、进食减少数周食减少数周精神精神错乱、嗜睡或昏迷乱、嗜睡或昏迷严重的脱水、高渗、低血重的脱水、高渗、低血压和心和心动过速速无无DKA特有的特有的恶心、呕吐、腹痛及心、呕吐、腹痛及Kussmaul呼吸呼吸多多由由严重重的的合合并并症症诱发，如如心心梗梗、脑梗梗、脓毒毒症症、肺肺炎炎或或其其他他严重感染重感染临床特点临床特点DM急性并发症急性并发症 高血糖性高渗性昏迷高血糖性高渗性昏迷DM的治疗的治疗DM的治疗的治疗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 . . . 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的治疗的治疗胰胰岛素素分分泌泌刺刺激激剂如如磺磺脲类，通通过作作用用于于 细胞胞的的ATP敏感性敏感性钾通道促通道促进胰胰岛素素释放放双双胍胍类如如二二甲甲双双胍胍，抑抑制制肝肝糖糖异异生生并并增增加加外外周周组织糖利用，但可糖利用，但可导致乳酸酸中毒致乳酸酸中毒 糖糖苷苷酶抑抑制制剂如如米米格格列列醇醇，延延缓葡葡萄萄糖糖吸吸收收而而降低餐后高血糖降低餐后高血糖噻唑烷二二酮类如如匹匹格格列列酮，与与脂脂肪肪细胞胞细胞胞核核内受体内受体结合来降低胰合来降低胰岛素抵抗素抵抗本例患者如何评估本例患者如何评估p女女性性，62岁，腹腹痛痛3日日，拟诊上上消消化化道道穿穿孔孔行行剖剖腹腹探探查术p身高身高158cm，体重，体重85kg，神志淡漠，神志淡漠，T39.5p高高血血压病病史史16年年，口口服服伊伊诺普普利利、尼尼群群地地平平控控制制血血压，平素，平素140/80，入院，入院95/55p糖糖尿尿病病病病史史8年年，口口服服二二甲甲双双胍胍，血血糖糖控控制制在在6-8mmol/L，入院，入院时血糖血糖26.3，尿，尿酮体体+p高血脂，他汀高血脂，他汀类控制，效果佳控制，效果佳pECG窦性心性心动过速（速（135bpm），），ST-T改改变术前评估术前评估是否确是否确诊？是否可争取？是否可争取时间内科治内科治疗？l膈下游离气体、急腹症膈下游离气体、急腹症l腹痛腹痛3日，未禁食，估日，未禁食，估计腹腔感染腹腔感染严重重争取时间，尽快完善术前准备，同时尽争取时间，尽快完善术前准备，同时尽早开始内科治疗，处理酮症早开始内科治疗，处理酮症术前评估术前评估术前前还需哪些需哪些检查？l动脉血气脉血气l电解解质l肝肝肾功能功能K+ 3.2，Na+ 136，Cl- 99，HCO3 9，pH 7.05，CO2 33，肌，肌酐、尿素氮稍升高、尿素氮稍升高 ，白蛋白，白蛋白 28术前评估术前评估术前内科治前内科治疗l水化水化l胰胰岛素素l纠酸酸l电解解质术中管理术中管理麻醉和手麻醉和手术对葡萄糖代葡萄糖代谢的影响的影响l七七氟氟烷和和异异氟氟烷对葡葡萄萄糖糖耐耐量量的的损害害程程度度相相同同，与手与手术刺激无关刺激无关l手手术可可产生生应激激反反应，使使机机体体处于于分分解解代代谢状状态，改，改变程度与手程度与手术大小有关大小有关l硬硬膜膜外外麻麻醉醉可可减减少少应激激反反应激激素素的的释放放而而对血血糖影响小糖影响小术中管理术中管理麻醉方法的麻醉方法的选择l全麻插管保全麻插管保护气道气道l椎管内阻滞、神椎管内阻滞、神经阻滞阻滞对机体代机体代谢影响小影响小术中管理术中管理择期手期手术手手术当日胰当日胰岛素的用法素的用法l反复反复测量血糖是关量血糖是关键l未未使使用用胰胰岛素素的的2型型DM患患者者，术晨晨不不给降降糖糖药，二二甲甲双双胍胍术前前24h停停药，一一般般手手术无无需需输注注含含糖糖液液体体，大大手手术及及术后后几几天天不不能能进食食者者应静脉静脉给予含糖液，并使用胰予含糖液，并使用胰岛素素术中管理术中管理择期手期手术手手术当日胰当日胰岛素的用法素的用法l使使用用胰胰岛素素的的患患者者接接受受大大于于2h的的手手术，同同时输注注葡葡萄萄糖糖和和胰胰岛素素可可能能对患患者者有有益益。5%的的葡葡萄萄糖糖125ml/h或或2ml/kg.h，胰胰岛素素5U负荷荷量量，维 持持 的的 速速 度度 为 最最 近近 测 得得 的的 血血 糖糖（mg/dl）/150（严重重感感染染或或应激激大大的的手手术100），或者），或者1U/h重要的是密切重要的是密切监测血糖和血糖和电解解质术中管理术中管理本例患者如何本例患者如何监测？术中管理术中管理如何如何处理理术中高血糖？中高血糖？l血糖超血糖超过14mmol/l需静脉需静脉给予胰予胰岛素素l单次次剂量量胰胰岛素素5-10u，成成人人胰胰岛素素一一般般1u降降低低血血糖糖0.6mmol/l，或或者者降降低低1mmol/l血血糖糖需需胰胰岛素素1.7ul持持续输注胰注胰岛素素术中管理术中管理如何如何识别和和处理理术中低血糖？中低血糖？l全身麻醉下表全身麻醉下表现为难以解以解释的休克和的休克和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.术中管理术中管理如何如何识别和和处理理术中低血糖？中低血糖？l全身麻醉下全身麻醉下临床表床表现被掩盖，常出被掩盖，常出现难以解以解释的大汗、低血的大汗、低血压、心、心动过速速l确确诊依靠血糖依靠血糖监测lOral treatment with glucose tablets or glucose-containing fluids, candy, or food is appropriate if the patient is able and willing 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 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-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.l70Kg成年人每推注成年人每推注4.5g葡萄糖可使血糖升高葡萄糖可使血糖升高约1mmol/L谢谢谢谢