临床实践中控制住院患者血糖达标的方案

SAN FRANCISCO (EGMN) – Meeting the targets in consensus recommendations on inpatient glycemic control requires different protocols for different kinds of patients.

For hospitalized patients who are not critically ill, a protocol employing scheduled subcutaneous insulin therapy with basal, nutritional, and correctional components is effective, Dr. Mary T. Korytkowski said. For critically ill inpatients, intravenous insulin infusion protocols are better for achieving and maintaining glycemic control, she said at a meeting sponsored by the American Diabetes Association.

Many hospitals further subdivide the protocol for critically ill patients to have different glycemic targets for surgical and nonsurgical ICU patients, added Dr. Korytkowski, professor of medicine at the University of Pittsburgh’s Center for Diabetes and Endocrinology.

A 2009 consensus statement from the American Association of Clinical Endocrinologists and the American Diabetes Association recommended maintaining glucose levels between 140 and 180 mg/dL in most critically ill patients, but added that glucose levels of 110-140 mg/dL may be appropriate in some, such as those in cardiothoracic intensive care.

“We don’t have the data to prove that outside the surgical intensive care studies,” she said, “so many hospitals now have two protocols – one for their surgical patients, and one for nonsurgical patients.”

In noncritically ill inpatients, the consensus statement recommends targeting premeal glucose levels of 100-140 mg/dL and random glucose test results below 180 mg/dL (Endocr. Pract. 2009;15:353-69 and Diabetes Care 2009;32:1119-31).

Prolonged therapy with “sliding scale” insulin alone is not recommended, Dr. Korytkowski stressed. “This whole idea of putting patients on sliding scale insulin and continuing it for the duration of their hospitalization independent of what their blood sugar levels are needs to be stopped,” she said.

The 2009 consensus recommendations steered clinicians away from aiming for lower glucose levels of 80-110 mg/dL in hospitalized patients to reduce risk for complications related to uncontrolled hyperglycemia while also minimizing risk for severe hypoglycemia.

Institutions can choose from a number of published protocols for managing inpatient glucose levels to meet the consensus recommendations, she said. For critically ill patients, it’s better to initiate insulin infusions when their glucose levels reach the lower end of the 140-180 mg/dL range rather than wait for levels to climb above 180 mg/dL, she suggested.

Her institution initiates insulin therapy by obtaining or estimating the patient’s weight in kilograms, then calculating the total daily dose of insulin as 0.2-0.4 units/kg per day. Clinicians then choose the dosing schedule, usually giving 50%-60% of the total daily dose as basal insulin, with the remainder as premeal or nutritional bolus insulin divided up in three or four doses. Correction insulin is given when blood glucose levels exceed the goal range.

“This is not a one-stop process,” Dr. Korytkowski said. Each day, the glucose levels are evaluated and the insulin regimen is adjusted to avoid both hyper- and hypoglycemia.

The basal-bolus insulin protocol was shown to be safe when compared with sliding scale insulin in a prospective, randomized, controlled trial of 130 inpatients with type 2 diabetes, she noted (Diabetes Care 2007;30:2181-6).

Dr. Korytkowski also recommends monitoring glucose for at least 48 hours in all hospitalized patients who are starting glucocorticoid therapy or enteral or parenteral nutrition, because these are associated with increased risk for hyperglycemia. Prescribe insulin therapy as needed in these patients based on bedside blood glucose monitoring, and be proactive about adjusting insulin therapy especially during initiation and tapering of steroid therapy, she advised.

“One thing that’s very important when patients go home and their steroid doses are tapered is that they need to know how to taper their insulin along with tapering their steroid, so they don’t come back in 2-3 weeks in a hyperglycemic event,” she said.

Dr. Korytkowski and her associates published a glycemic management algorithm for patients receiving enteral nutrition that was shown to be safe in a prospective, randomized trial in 50 inpatients (Diabetes Care 2009;32:594-6).

Establishing a formal protocol for patients who enter the hospital on insulin pumps also can reduce confusion and treatment variability, she added. At her institution, patients who used insulin pumps before entering the hospital can continue to use them as inpatients provided that they have the mental and physical capacity to do so. Ideally, hospital staff who have experience in insulin pumps should be available if needed.

Dr. Korytkowski said she has no conflicts of interest to disclose.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

旧金山(EGMN)——对于不同类型的住院患者，需要采用不同方案将血糖控制达到共识建议的目标。

对于非重症住院患者，采用有计划的皮下基础、营养和校正胰岛素治疗是有效的，Mary T. Korytkowski博士说。对于重症住院患者，静脉胰岛素输注的方案更有利于达到和维持血糖控制的目标，她在美国糖尿病协会发起的一次会议上指出。

很多医院将对重症住院患者的治疗方案做出进一步划分，对外科和非外科ICU患者分别制定不同的血糖控制目标，匹兹堡大学糖尿病与内分泌中心的医学教授Korytkowski博士补充道。

在美国临床内分泌医师协会与美国糖尿病协会2009年发布的联合共识声明中建议，对于多数重症患者，将血糖水平维持于140~180 mg/dl之间，但另外指出，对于一些患者，血糖降至110~140 mg/dl的水平是适当的，如胸心外科重症监护病房中的患者。

“但在外科重症监护研究之外，尚无数据证实，”她说，“因此，当前很多医院采用两套方案——一套针对外科患者，另一套针对非外科患者。”

在非重症住院患者中，共识声明建议的餐前血糖目标水平为100~140 mg/dl，随机血糖检测结果低于180 mg/dl(Endocr. Pract. 2009;15:353-69 and Diabetes Care 2009;32:1119-31)。

不鼓励使用可调量性胰岛素持续输注作为住院期间的单一胰岛素治疗方案，Korytkowski博士强调。“这种无论患者血糖水平如何，而在患者整个住院期间采用持续胰岛素输注的整体观念亟待改变，”她说。

2009年共识建议指导临床医生转变将住院患者血糖控制降至80~110 mg/dl以降低高血糖控制不良相关并发症风险的观点，同时指出，需要最大限度降低严重低血糖风险。

医疗机构可从一系列公布的方案中选择适当治疗，将住院患者血糖水平控制在共识建议的范围内，她说。对于重症患者，在其血糖水平达到140~180 mg/dl范围低限的时候启动胰岛素输注的做法优于等血糖达到180 mg/dl以上再输注胰岛素的治疗，她建议。

在Korytkowski博士供职的临床机构中，启动胰岛素治疗时需首先测量或估计患者的体重(kg)，然后根据每日每kg体重0.2~0.4 个单位的剂量计算出需给予的胰岛素量，下一步是由临床医生选择用药方案，通常给予的基础胰岛素占每日总剂量的50%~60%，其他为餐前或营养餐时胰岛素，可分3次或4次给药。当血糖水平超过目标范围时需给予校正胰岛素。

“这不是一个一站式流程，” Korytkowski博士说。为了同时避免出现高血糖和低血糖，需要每天评估血糖水平并调整胰岛素治疗方案。

在一项包括130例2型糖尿病患者的前瞻性、随机、对照试验中显示，基础－餐时胰岛素治疗方案较可调量性胰岛素持续输注更安全，她指出(Diabetes Care 2007;30:2181-6)。

Korytkowski博士还建议，对于所有开始糖皮质激素治疗及肠内或肠外营养治疗的住院患者，至少应在48h内监测血糖，因为这些治疗与高血糖风险增高相关。对于此类患者，根据床旁血糖监测的结果，需要时处方胰岛素治疗，尤其是在启动甾体激素治疗或激素逐渐减量过程中需积极调整胰岛素治疗，她建议。

“另一项非常重要的注意事项是，当患者出院并逐渐减低甾体激素剂量时，需要了解如何在激素减量同时减少胰岛素剂量，以防在出院后2~3周内因高血糖事件而再次入院，”她说。

Korytkowski博士及其同事公布了一种针对接受肠内营养患者的血糖控制规则，并且已在一项包括50例住院患者的前瞻性、随机试验中证实了这一规则的安全性(Diabetes Care 2009;32:594-6)。

建立针对正在使用胰岛素泵治疗的入院患者的正规治疗方案也可减少治疗中的混乱和分歧，她补充道。在她供职的医疗机构中，如住院前使用胰岛素泵的住院患者可证明其具有控制胰岛素泵的精神和身体能力，则其可继续胰岛素泵治疗。理想的情况是，在患者需要帮助时，有胰岛素泵使用经验的医院工作人员可立即到位。

Korytkowski博士报告称无利益冲突。

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