胰岛素剂量设置胰岛素剂量设置和调理的根本方法和调理的根本方法美敦力公司湖南技美敦力公司湖南技美敦力公司湖南技美敦力公司湖南技术术代表代表代表代表 龙军龙军首先确定血糖控制目的首先确定血糖控制目的为每个病人确定个人的血糖控制目的。为每个病人确定个人的血糖控制目的。成年病人的普通控制目的：成年病人的普通控制目的： 餐前：餐前：80-110mg/dl (4.4-6.1mmol/l)80-110mg/dl (4.4-6.1mmol/l) 餐后餐后2 2小时：小时： 180mg/dl (10mmol/l) 180mg/dl (90mg/dl (5mmol/l)90mg/dl (5mmol/l) 假设反复出现低血糖，适当提高控制目的：假设反复出现低血糖，适当提高控制目的： 餐前：餐前：100-160mg/dl (5.6-8.9mmol/l)100-160mg/dl (5.6-8.9mmol/l) 假设怀孕，适当减低目的血糖值：假设怀孕，适当减低目的血糖值： 餐后：餐后： 120mg/dl (6.7mmol/l) 120mg/dl (6.7mmol/l) 留意前后两次血糖的差值留意前后两次血糖的差值 50mg/dl (2.8mmol/l) 目的目的 降低降低 ICRDateDate1st Day1st DayNocturnalNocturnalPre-BPre-BPost-BPost-BPre-LPre-LPost-LPost-LPre-DPre-DPost-DPost-DTimeTime3 3 :00:007 7 :00:009:159:15BGBG1221229090CarbsCarbs-60 60 gmsgmsMeal BolusMeal Bolus-4.0 4.0 u uCorr. BolusCorr. Bolus-DateDate2nd Day2nd DayNocturnalNocturnalPre-BPre-BPost-BPost-BPre-LPre-LPost-LPost-LPre-DPre-DPost-DPost-DTimeTimeBGBGCarbsCarbsMeal BolusMeal BolusCorr. BolusCorr. Bolus202I:C 1:153:001227:0060 gms5.0 u9:15要确定能否正确要确定能否正确计算碳水化合算碳水化合物系数物系数尝试 I:C 1:12确确认/调整碳水化合物系数整碳水化合物系数99125 178 125比比较餐前和餐后餐前和餐后2hr血糖血糖Basal Rate: 0:00 0.5 u/hr 3 :00 0.7 u/hr 7 :00 0.6 u/hr餐后血糖餐后血糖 50 mg /dl DateDate1st Day1st DayNocturnalNocturnalPre-BPre-BPost-BPost-BPre-LPre-LPost-LPost-LPre-DPre-DPost-DPost-DTimeTime5 5 :00:007 7 :00:009:159:1513:0013:0015:2515:2518:0018:00BGBG25025011011013613679791281288888CarbsCarbs-60 60 gmsgms-4545gmgm6060gmgmMeal BolusMeal Bolus_6.0 6.0 u u_4.5 4.5 u u6.06.0Corr. BolusCorr. Bolus3.0 3.0 u u_DateDate2nd Day2nd DayNocturnalNocturnalPre-BPre-BPost-BPost-BPre-LPre-LPost-LPost-LPre-DPre-DPost-DPost-DTimeTime3 3 :00:007 7 :00:009:159:1513:0013:0015:2515:2518:0018:0020:1020:10BGBG1201209090136136132132128128188188CarbsCarbs60 60 gmsgms4545gmgmMeal BolusMeal Bolus6.0 6.0 u u3.0 3.0 u u7.5 7.5 u uCorr. BolusCorr. Bolus当患者当患者纠正他的高血糖正他的高血糖时，应在在2hr内内进展血糖展血糖监测，以确定血糖能否达，以确定血糖能否达标75 gm+1.8 u125188 100 = 1.8 u 50 9.3 u当前BG - 目的 BG (100) = # UISF (50) 250 100 50 = 3.0 units补充大充大剂量量Basal Rate: 0:00 0.5 u/hr 3 :00 0.7 u/hr 9 :00 0.5 u/hrICR: 1:10ISF: 50胰胰岛素敏感系数素敏感系数 补充大充大剂量量胰胰岛素敏感系数素敏感系数 1. 确定确定ISF，需求，需求对比比: 2. 输注注补充大充大剂量前的血糖与量前的血糖与输注注补充大充大剂量后的血糖量后的血糖3. 当符合以下条件当符合以下条件时，ISF已被正确已被正确调整整 :4. 调整后整后2 hr血糖不超越目的血糖不超越目的值30 mg/d 5. (目的目的值 : 100 mg/dL 120 mg/dL)6. 3小小时内再内再测一次血糖以确一次血糖以确认血糖在目的范血糖在目的范围内内确定胰确定胰岛素敏感系数素敏感系数(ISF)将学到的运用在将学到的运用在实际中中 !优化血糖管理化血糖管理 患者患者: 22 岁 MDI = 52 u / 天天无法感知的低血糖无法感知的低血糖时而而发生生体重体重: lb. HbA1c = 7.7 ICR: 1:12 ISF = 40DateDate1st Day1st DayNocturnalNocturnalPre-BPre-BPost-BPost-BPre-LPre-LPost-LPost-LPre-DPre-DPost-DPost-DHSHSTimeTime12:0012:00 14:1514:15 17:5517:55 18:3018:3023:1523:15BGBG 72 72 131 131 56 56 112 112 88 88CarbsCarbs 37 37 gmgm - 0 - - 0 - 60 60 gmgm - 0 - - 0 - 12 12 gmgmMeal BolusMeal Bolus3.0 3.0 u u - 0 - - 0 - 5.0 5.0 u u - 0 - - 0 -1.0u1.0uCorr. BolusCorr. Bolus - 0 - - 0 - - 0 - - 0 - 1.1 - 1.1 u u+ 3.9 u+ 3.9 u - 0 - - 0 - DateDate2nd Day2nd DayNocturnalNocturnalPre-BPre-BPost-BPost-BPre-LPre-LPost-LPost-LPre-DPre-DPost-DPost-DHSHSTimeTime 3:10 3:107:157:15 9:36 9:3612:3012:30 14:4414:44 18:3518:35 20:5520:5523:3023:30BGBG 90 90 68 68 125 125 55 55 142 142 61 61 106 106 92 92CarbsCarbs - 0 - 0 54 54 gmgm - 0 - - 0 - 75 75 gmgm - 0 - - 0 - 66 66 gmgm - 0 - - 0 - - 0 - - 0 -Meal BolusMeal Bolus 4.5 4.5 u u 6.2 6.2 u u 5. 5.5 u5 uCorr. BolusCorr. Bolus- -0.8 u0.8 u 3.7 u 3.7 u- - - - 1.1 1.1- - 5.1 5.1用用泵前前7pm Changed BR 0:00 0.5 u/hrBasal Rate: 0:00 0.6 u/hr 调整根底率整根底率患者患者: 22 岁 MDI = 52 u / 天天无法感知的低血糖无法感知的低血糖时而而发生生体重体重: lb. HbA1c = 7.7 ICR: 1:12 ISF = 40 125 125 128 128 86 86 129 129 74 74 126 126 88 88 124 124BGBG Corr. BolusCorr. Bolus - 0 - - 0 - 6.0 u 6.0 u 5.7 u 5.7 u 5.0 u 5.0 uMeal BolusMeal Bolus - 0 - - 0 - - 0 - - 0 - 72gm 72gm 68 gm 68 gm60gm60gm - 0 - - 0 -CarbsCarbs 23:15 23:15 21:25 21:25 19:00 19:00 16:00 16:00 13:45 13:45 10:30 10:308:128:12 3:08 3:08TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnaNocturnal l4th Day4th DayDateDateWalkingCorr. BolusCorr. Bolus 6.0 u 6.0 u 5.0 u 5.0 u 4.0 u4.0 uMeal BolusMeal Bolus - 0 - - 0 - - 0 - - 0 - 71gm 71gm - 0 - - 0 - 60 gm 60 gm48 gm48 gmCarbsCarbs 122 122 120 120 78 78 84 84 134 134 66 66 117 117BGBG23:0023:00 20:14 20:14 18:06 18:06 15:12 15:1212:4512:45 9:22 9:227:037:03 3:05 3:05TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-L Pre-L Pre-LPost-BPost-BPre-BPre-B Nocturnal Nocturnal3rd Day3rd DayDateDate12am 0.5 u/hr. 3am 0.4 u / hr. 7am 0.5 u/hrBasal Rate: 0:00 0.5 u/hr调整根底率整根底率患者患者: 32 岁: Type 1, G4 P2 A1,怀孕孕11周周. MDI = 96 u day WT: 182 lb. HbA1c = 8.2 1.6 u 1.6 u_ 1.2 u 1.2 u +0.2 +0.2 2.5 2.5 1.5 u 1.5 u+0.3 u+0.3 u 7.3 u 7.3 uCorr. BolusCorr. Bolus _ _ 9.0 u 9.0 u 2.3 u 2.3 u_ 7.0 u 7.0 u Meal BolusMeal Bolus - 0 - - 0 - - 0 - - 0 - 74 gm 74 gm - 0 - - 0 - 18 gm 18 gm - 0 - - 0 -49 gm49 gm - 0 - 0 CarbsCarbs 104 104 171 171 71 71 158 158 105 105 168 168 108 108 106 106BGBG23:0023:00 20:35 20:35 18:25 18:25 15:40 15:40 13:30 13:30 9:15 9:157:057:05 3:10 3:10TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal2nd Day2nd DayDateDate 2.0 u 2.0 u 1.7 u 1.7 u +4.4 +4.4 8.5 8.5Corr. BolusCorr. Bolus - 0 - - 0 - 8.0 u 8.0 u - 0 - - 0 -4.3 u4.3 uMeal BolusMeal Bolus - 0 - - 0 - 56 gm 56 gm - 0 - - 0 -30 gm30 gmCarbsCarbs 102 102 183 183 97 97 172 172 210 210BGBG23:1523:15 20:00 20:00 17:40 17:4014:5514:5512:4512:45TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal1st Day1st DayDateDate用用泵前洗脱期前洗脱期ICR = 1:6Basal Rate: 0:00 1.2 u/hr ICR = 1:7ISF = 1:25餐后高血糖餐后高血糖调整碳水化合物系数整碳水化合物系数患者患者: 32 岁: Type 1, G4 P2 A1,怀孕孕11周周. MDI = 96 u day WT: 182 lb. HbA1c = 8.2 1.8 u 1.8 u Corr. BolusCorr. Bolus 7.5 u 7.5 u 8.4 u 8.4 u 7.5 u7.5 uMeal BolusMeal Bolus 112 112 12 9 12 9 95 95 118 118 69 69 154 154 89 89 115 115BGBG23:0023:00 20:12 20:12 18:00 18:00 15:10 15:1012:4512:45 9:28 9:287:227:22 3:05 3:05TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal3rd Day3rd DayDateDateICR 1:6 Corr. Corr. BolusBolus 7.5 u 7.5 u 8.4 u 8.4 u 9.0 u9.0 uMeal BolusMeal Bolus - 0 - - 0 - 45 gm 45 gm - 0 - - 0 - 51 gm 51 gm45 gm45 gmCarbsCarbs 101 101 105 105 83 83 101 101 84 84 126 126 88 88 108 108BGBG 0:15 0:15 20:00 20:00 17:45 17:45 15:30 15:30 13:15 13:15 10:00 10:008:128:12 3:08 3:08TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal4th Day4th DayDateDate ICR = 1:5 Breakfast (only) ICR = 1:6 (L & D)Basal Rate: 0:00 1.2 u/hr ISF: 1:25调整碳水化合物系数整碳水化合物系数Hx: 44 岁岁: Type 2: 胰胰岛岛素抵抗，高血糖素抵抗，高血糖 MDI = 200 u day WT: 260 lb. HgA1c 16.5 5.0u 5.0u 17 u 17 u 14.0 u 14.0 uCorr. Corr. BolusBolus 12 u 12 u - -Meal Meal BolusBolus 60 gm 60 gm - -CarbsCarbs 238 238 177 177 312 312BGBG 9:44 9:44 7:30 7:30 3:15 3:15TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnalDateDate - - 7.5 u 7.5 u 13.5 u 13.5 u 9.5 u 9.5 u 27.5 u 27.5 u 7.5 u 7.5 u 14.5 14.5 30.5 u 30.5 u2nd Day2nd DayCorr. Corr. BolusBolus - - 6.0 u 6.0 u 18 u 18 u - - 16 u 16 uMeal Meal BolusBolus - 0 - - 0 - 30 gm 30 gm 90 gm 90 gm - 0 - - 0 - 80 gm 80 gmCarbsCarbs 250 250 210 210 245 245 218 218 315 315BGBG23:3523:35 20:20 20:20 17:45 17:45 14:12 14:1211:4811:48TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal1st Day1st DayDateDatePre-Pump Start BR = 2.2ICR 1:4 SF = 1014.0 u12:0010880 gms20 u 14:30145 17:5518845gm11 u9.0 u20:3023:00192Basal Rate: 0:00 2.0 u/hr ICR: 1:5ISF: 15全面全面调理血糖理血糖Corr. Corr. BolusBolusMeal BolusMeal BolusCarbsCarbsBGBGTimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal4th Day4th DayDateDate 9u 9u 26 u 26 u 11u 11u 26 u 26 u 17 u 17 u 29 u 29 uCorr. Corr. BolusBolus17 u17 u15 u15 u12u12uMeal BolusMeal Bolus69 gm69 gm60 gm60 gm48 gm48 gmCarbsCarbs166166155155198198150150212212142142267267228228BGBG22:4822:4820:2620:2618:0018:0014:3014:3012:1012:109:189:186:506:503:143:14TimeTimeHSHSPost-DPost-DPre-DPre-DPost-LPost-LPre-LPre-LPost-BPost-BPre-BPre-BNocturnalNocturnal3rd Day3rd DayHx: 44 岁岁: Type 2: 胰胰岛岛素抵抗，高血糖素抵抗，高血糖 MDI = 200 u day WT: 260 lb. HgA1c 16.5 8:30 pm Increased BR12 am 2.5 u / hr.3:061447:0013040 3u 13u9:22 14012:309868 gm17 u14:4414618:0011244 gm11 u 1u 12 u20:1512823:0012610 uBasal Rate: 0:00 2.2 u/hr ICR = 1:4ISF = 10全面全面调理血糖理血糖术术前前快速粗快速粗调调参考胰参考胰岛岛素素泵泵治治疗疗粗粗调调章章节节由于手由于手术术前一日晚开前一日晚开场场禁食，故停禁食，故停顿顿早餐前大早餐前大剂剂量量术术中中上麻醉前上麻醉前测测血糖，普通全麻血糖，普通全麻时时需停需停泵泵低代低代谢谢终终了了时时即恢复根底率即恢复根底率局麻或硬膜外麻运用根底率局麻或硬膜外麻运用根底率维维持持术术后后如禁食那么根底率如禁食那么根底率维维持不加餐前量，普通根底持不加餐前量，普通根底率率1010-30-30应应激反响激反响如如进进流流质质那么那么10pm-6am10pm-6am根底量不根底量不变变，把原来餐前量，把原来餐前量的的50508080平均分布到原来平均分布到原来6am-10pm6am-10pm的根底率上的根底率上一围手术期胰岛素泵得运用一围手术期胰岛素泵得运用二恢复打针剂量参考二恢复打针剂量参考A.强化治疗一天用4次RI早餐前打RI的量短效：用泵时早餐前加6am-11am的根底量总和再添加10%-20%的量西餐前打针量短效：用泵西餐前量加11am-5 pm的根底量总和再添加10%-20%的量晚餐前打针量短效：用泵晚餐前量加5pm-10 pm的根底量总和再添加10%-20%的量睡前打针量中效：10pm-6am的根底量总和再添加10%-20%的量B.改用两次打针 早餐前打早餐前打RIRI的量：的量： 用泵时早餐前量用泵时早餐前量+ +6am-6pm6am-6pm的根底量总和的根底量总和+ + 短效短效RIRI 中效中效RIRI 用泵西餐前量用泵西餐前量+添加添加10%-20%10%-20%的量的量 中效中效RIRI晚餐前打晚餐前打RIRI的量：的量： 用泵时晚餐前量用泵时晚餐前量+ +6pm-6am6pm-6am的根底量总和的根底量总和+ 短效短效RIRI 中效中效RIRI 添加添加10%-20%10%-20%的量的量注：看一看短效与中效的比例，注：看一看短效与中效的比例，1 1：2 2为为30R30R， 1 1：1 1为为50R50R三生病期间的本卷须知三生病期间的本卷须知继续运用胰岛素：特别是根底率；除非接受静脉继续运用胰岛素：特别是根底率；除非接受静脉用胰岛素，否那么不能停顿胰岛素泵的运用。用胰岛素，否那么不能停顿胰岛素泵的运用。从生病开场监测血糖，从生病开场监测血糖，2-42-4小时一次，测尿酮体每小时一次，测尿酮体每天一次，并作好记录天一次，并作好记录血糖血糖200mg/dl200mg/dl，并且不能进食：假设尿，并且不能进食：假设尿KetKet- -，每，每4 4小时给一次胰岛素追加量直至血糖正常；小时给一次胰岛素追加量直至血糖正常；假设尿假设尿KetKet+ +，每，每2 2小时给一次胰岛素追加量直小时给一次胰岛素追加量直至血糖正常。至血糖正常。血糖接近正常时，进食或者喝一些含糖的饮料以血糖接近正常时，进食或者喝一些含糖的饮料以消除酮体消除酮体运动时的本卷须知估计临床情况：代谢形状、心血管系统的功能、估计临床情况：代谢形状、心血管系统的功能、并发症的情况并发症的情况合理的运动方案：强度、继续时间、频率合理的运动方案：强度、继续时间、频率血糖自我监测的重要性血糖自我监测的重要性认识立刻出现和延迟出现的低血糖认识立刻出现和延迟出现的低血糖运动时胰岛素剂量调整情况情况对策对策如果在早餐前或者正餐前如果在早餐前或者正餐前4-64-6小时运动小时运动50% 50% 基础率（有时在基础率（有时在运动前运动前30-6030-60分钟前开始分钟前开始如果暂时停泵，时间不要如果暂时停泵，时间不要超过超过2 2小时小时停泵超过停泵超过2-42-4小时，需要小时，需要额外皮下注射胰岛素额外皮下注射胰岛素如果餐后如果餐后1-31-3小时内运动小时内运动餐前量餐前量短时间的剧烈活动短时间的剧烈活动不必调整胰岛素用量不必调整胰岛素用量冬季运动本卷须知保证胰岛素泵的适当温度保证胰岛素泵的适当温度冬季运动时，葡萄糖的利用更迅速：维持体温耗冬季运动时，葡萄糖的利用更迅速：维持体温耗费更多的热卡以及活动本身费更多的热卡以及活动本身适当减少根底率和餐前量适当减少根底率和餐前量妊娠期间的血糖目的空腹血糖空腹血糖6090mg/dl6090mg/dl餐前和睡前血糖餐前和睡前血糖6090mg/dl6090mg/dl餐后餐后1 1小时血糖小时血糖120140mg/dl120140mg/dl2am6pm2am6pm60mg/dl60mg/dlHbAHbA1C1C接近接近6%6%妊娠期间胰岛素剂量的调整时间时间原因原因变化变化前三个月前三个月恶心、呕吐，恶心、呕吐，夜间低血糖夜间低血糖InsIns用量用量妊娠后期妊娠后期胎盘分泌的对胎盘分泌的对抗抗InsIns激素激素InsIns用量用量（加倍）（加倍）