血糖精細(xì)調(diào)節(jié)

胰島素泵的精細(xì)調(diào)節(jié)1為什么要進(jìn)行血糖精細(xì)調(diào)節(jié)

通過(guò)與胰島素需求量相匹配的胰島素輸注以獲得最佳的血糖控制盡可能將胰島素泵的作用發(fā)揮出來(lái)讓患者感到更滿意2血糖精細(xì)調(diào)節(jié)的三個(gè)步驟準(zhǔn)備和學(xué)習(xí)設(shè)定血糖目標(biāo)值嘗試并調(diào)整劑量基礎(chǔ)率餐前大劑量

補(bǔ)充大劑量3準(zhǔn)備工作基礎(chǔ)率和大劑量選項(xiàng)的特征回顧大劑量向?qū)Ю斫夥讲ê碗p波大劑量選項(xiàng)對(duì)患者的意義血糖測(cè)試提醒0.05單位為步長(zhǎng)的基礎(chǔ)率增加4設(shè)定血糖目標(biāo)值將血糖控制的目標(biāo)轉(zhuǎn)化為具體的值在一天的不同時(shí)間設(shè)定不同的血糖目標(biāo)白天 90–110mg/dL妊娠 60-90mg/dL

5Paradigm?胰島素泵

B糖尿病管理邁出新的一步6基礎(chǔ)率12am@0.6u/hr.基礎(chǔ)率回顧緩慢持續(xù)的輸注

持續(xù)輸注

從設(shè)置一個(gè)基礎(chǔ)率開(kāi)始調(diào)整/增加基礎(chǔ)率目的:模仿一個(gè)正常功能的胰腺,維持血糖穩(wěn)定0.60.50.60.70.70.60.70.70.70.50.50.52.3am@0.7u/hr.3.8am@0.5u/hr.7大劑量進(jìn)餐&高血糖大劑量進(jìn)餐&零食1:10如何糾正高血糖早餐

60gms

6.0units

午餐

48gms4.8units

血糖監(jiān)測(cè)

250mg/dl250-100=+3u50血糖監(jiān)測(cè)70mg/dl70-100=-0.6u50BG-100=#UnitsSF(胰島素敏感系數(shù))

1:506.0u(meal)+3.0u

(highBG)9.0u4.8u(meal)-0.6u

(highBG)4.2u(1單位胰島素/?gms碳水化合物)8MiniMedEstimateDetailsEsttotal: Foodintake: BG: Food: Correction: Activeins: ACTtoproceed,ESCtobackup

大劑量向?qū)榛颊咦詣?dòng)計(jì)算胰島素大劑量

MiniMedParadigm胰島素泵治療的金標(biāo)準(zhǔn)!8.0U20060gr2.0UICR1:10gr200-100=2.0u50(SF)ParadigmPump6.0UFood:Correction:Esttotal:9大劑量向?qū)莻€(gè)選擇性的功能，可以打開(kāi)，也可以關(guān)閉。Paradigm?胰島素泵PressACT打開(kāi)主菜單

MiniMedMainMenuBolusSuspendBasalPrimeUtilities如何使用大劑量向?qū)?/p>

BolusSuspendBasalBolusPrimeUtilities10Paradigm?Pump如何使用大劑量向?qū)iniMedBolusMenuSetBolusBolusHistoryBolusWizardSetUpMaxBolusDual/SquareBolusEasyBolusBGReminderBolusWizardSetUp11MiniMedWIZARDSETUPEditSettingsReviewSettingsEditSettingsMiniMedEditSettingsWizard: Carbunits: CarbRatios: BGUnits: Sensitivity: BGTargets:

ongrams10mg/dL

50100MiniMedReviewSettingsCarbRatios:12:00A 1011:30A 126:00P 15ReviewSettingsCarbRatios:

offexchanges每餐的碳水化合物系數(shù)可以不同

mmol/L每天克設(shè)置多達(dá)8個(gè)不同值EditSettings如何使用大劑量向?qū)?2MiniMedBolusMenuUseBolusWizardManualBolusBolusHistoryBolusWizardSetUpMaxBolusDual/SquareBolusEasyBolusBGReminderMiniMedEnterBG

mg/dL

200MiniMedBolusMenuUseBolusWizardManualBolusBolusHistoryBolusWizardSetUpMaxBolusDual/SquareBolusEasyBolusBGReminderUseBolusWizard200MiniMedEnterFood grams060如何使用大劑量向?qū)?3MiniMedEstimateDetailsEsttotal: Foodintake: BG: Food: Correction: Activeins: ACTtoproceed,ESCtobackup

TheBolusWizard自動(dòng)計(jì)算胰島素大劑量

MiniMedParadigm?Pump胰島素泵治療的金標(biāo)準(zhǔn)8.0U20060gr2.0U6.0UFood:Correction:Esttotal:Activeins:7.0U1.0UFoodintake:ACTtpproceed14MiniMedSETBOLUSEstimate

7.0

u用“大劑量向?qū)А边M(jìn)行大劑量輸注.1

u.2

u.3

u.4

u.5

u.6

u7.0

u15胰島素泵的精細(xì)調(diào)節(jié)3個(gè)決定因素基礎(chǔ)率碳水化合物比率胰島素敏感系數(shù)16基礎(chǔ)率:12AM@0.6u/h調(diào)整夜間基礎(chǔ)率

穩(wěn)定而良好的基礎(chǔ)率BedTimeNocturnalPre-BPost-BTimeBGCarbs---------------MealBolus---------------Corr.Bolus---------------11PM1203AM1177AM90保持非進(jìn)餐狀態(tài)的血糖穩(wěn)定

(夜間&兩餐間)正確設(shè)定夜間基礎(chǔ)率:穩(wěn)定而良好的基礎(chǔ)率17血糖上升，應(yīng)增加基礎(chǔ)率BedTimeNocturnalPre-BPost-BTimeBGCarbsMealBolusCorr.BolusDate:BedTimeNocturnalPre-BPost-BTimeBGCarbs基礎(chǔ)率:12AM@0.6u/h11PM1203AM1257AM188BasalRate:1.12am@0.6u/h2.3am@0.7u/hr3.7am@0.6u/hr11PM1203AM1257AM82---基礎(chǔ)率一次增加0.1單位良好而穩(wěn)定的基礎(chǔ)率夜間基礎(chǔ)率調(diào)節(jié)不好黎明現(xiàn)象在血糖開(kāi)始升高或降低的2－3個(gè)小時(shí)前就開(kāi)始調(diào)整基礎(chǔ)率18

消除夜間發(fā)生低血糖的危險(xiǎn)

患者可以整晚安然而睡

提高患者的依從性

患者新的一天從良好的血糖開(kāi)始

先進(jìn)行夜間基礎(chǔ)率的調(diào)整確認(rèn)/調(diào)整夜間基礎(chǔ)率19DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AMBG12290Carbs---MealBolus---Corr.Bolus---DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTimeBGCarbsMealBolusCorr.Bolus基礎(chǔ)率:12AM@0.5u/hr3AM@0.7u/hr7AM@0.6u/hr60gmsICR:1:154.0u餐后血糖控制在目標(biāo)范圍內(nèi)，ICR是正確的9:25AM136Note:餐后BG應(yīng)比餐前略高，但不超過(guò)餐前血糖50mg/dl確認(rèn)/調(diào)整碳水化合物系數(shù)

餐前與餐后2hr的血糖對(duì)比20餐后血糖>目標(biāo)

降低ICRDateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:15BG12290Carbs---60gmsMealBolus---4.0uCorr.Bolus------DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTimeBGCarbsMealBolusCorr.Bolus202I:C1:123AM1227AM60gms5.0u9:15要確定患者是否正確計(jì)算碳水化合物系數(shù)嘗試I:C1:10確認(rèn)/調(diào)整碳水化合物系數(shù)99125178125比較餐前和餐后2hr血糖BasalRate:12AM@0.5u/hr3AM@0.7u/hr7AM@0.6u/hr21餐后血糖<目標(biāo)增加ICRDateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:15BG1229066Carbs---60gmsMealBolus---4.0uCorr.Bolus------DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTimeBGCarbsMealBolusCorr.BolusICR:1:183AM1227AM9960gms3.3u9:15130確認(rèn)/調(diào)整碳水化合物系數(shù)比較餐前和餐后2hr血糖BasalRate:12AM@0.5u/hr3AM@0.7u/hr7AM@0.6u/hr90ICR:1:2012522

確定ICR，需要比較:

餐前血糖與餐后2小時(shí)血糖在開(kāi)始調(diào)整階段，應(yīng)保持進(jìn)食低脂肪餐/碳水化合物含量較為固定的食物

ICR估算正確的表現(xiàn):

血糖在餐后2小時(shí)沒(méi)有顯著的升高或降低：

不超過(guò)50–70mg/dl

*請(qǐng)牢記，早，中，晚餐的ICR可能會(huì)有所不同確認(rèn)/調(diào)整碳水化合物系數(shù)23DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:151:003:256:00BG1221101365012862Carbs---60gms----45gmMealBolus___4.0u____3.0uCorr.Bolus____________DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:151:003:256:008:30BGCarbsMealBolusCorr.Bolus如果餐前BG很低，應(yīng)考慮降低白天基礎(chǔ)率BasalRate:1.12am@0.5u/hr2.3am@0.7u/hr3.9am@0.5u/hr12260gms6.0u1368245gm3.01287875gm5.0u125Note:可能需要調(diào)整白天基礎(chǔ)率的起始時(shí)間確認(rèn)/調(diào)整白天基礎(chǔ)率99調(diào)整后要測(cè)試血糖BasalRate:12AM@0.5u/hr3AM@0.7u/hr7AM@0.6u/hrICR:1:1024DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:151:003:256:00BG122110136188128172Carbs---60gms----45gmMealBolus___4.0u____3.0uCorr.Bolus____________DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:151:003:256:008:30BG122991369012888125CarbsMealBolusCorr.Bolus如果餐前血糖高于餐后血糖，應(yīng)增加白天基礎(chǔ)率BasalRate:1.12am@0.5u/h2.3am@0.7u/hr3.9am@0.6u/hr60gms6.0u45gm3.075gm5.0u確認(rèn)/調(diào)整白天基礎(chǔ)率BasalRate:12AM@0.5u/hr3AM@0.7u/hr9AM@0.5u/hrICR:1:1025確認(rèn)/調(diào)整白天基礎(chǔ)率讓患者遵照他們的飲食習(xí)慣進(jìn)餐:

但不要在兩餐之間進(jìn)食將餐后2hr血糖與下一餐的餐前血糖進(jìn)行對(duì)比;

如果血糖升高增加基礎(chǔ)率如果血糖降低降低基礎(chǔ)率

確認(rèn)血糖的變化

調(diào)整的2－3天內(nèi)進(jìn)行多次血糖監(jiān)測(cè)

-觀察血糖的變化趨勢(shì)Goal:餐后2hr血糖與餐前血糖比較，相差不應(yīng)>50mg/dl26DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime5AM7AM9:151:003:256:00BG2501101367912888Carbs---60gms----45gm60gmMealBolus____6.0u____4.5u6.0Corr.Bolus3.0u________DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:151:003:256:008:10BG12090136132128188Carbs60gms45gmMealBolus6.0u3.0u7.5uCorr.Bolus當(dāng)患者糾正他的高血糖時(shí)，應(yīng)在2hr內(nèi)進(jìn)行血糖監(jiān)測(cè)，以確定血糖是否達(dá)標(biāo)75gm+1.8u125188–100=1.8u509.3u當(dāng)前BG-目標(biāo)BG(100)=#UCF(50)250–100

50=3.0units補(bǔ)充大劑量BasalRate:12AM@0.5u/hr3AM@0.7u/hr9AM@0.5u/hrICR:1:10SF:50胰島素敏感系數(shù)27補(bǔ)充大劑量胰島素敏感系數(shù)

確定ISF，需要對(duì)比:

輸注補(bǔ)充大劑量前的血糖與輸注補(bǔ)充大劑量后的血糖

當(dāng)符合下列條件時(shí)，ISF已被正確調(diào)整:

調(diào)整后2hr血糖不超過(guò)目標(biāo)值30mg/d

(目標(biāo)值:100mg/dL–120mg/dL)

3小時(shí)內(nèi)再測(cè)一次血糖以確認(rèn)血糖在目標(biāo)范圍內(nèi)確定胰島素敏感系數(shù)(ISF)28選擇一個(gè)患者情緒和血糖都較為穩(wěn)定的日子進(jìn)行調(diào)節(jié)讓患者在某一餐禁食每2小時(shí)監(jiān)測(cè)一次血糖觀察血糖變化

-

如果血糖升高增加基礎(chǔ)率

-

如果血糖降低降低基礎(chǔ)率進(jìn)行適當(dāng)?shù)恼{(diào)整確認(rèn)調(diào)整是正確的–反復(fù)測(cè)試血糖

確定/精細(xì)調(diào)節(jié)白天基礎(chǔ)率

如果發(fā)生低血糖：及時(shí)治療低血糖適當(dāng)調(diào)整基礎(chǔ)率重復(fù)測(cè)試29DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:151:003:256:00BG122908678Carbs-----------45gmMealBolus___________3.0uCorr.Bolus____________DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DTime3AM7AM9:1511:301:304:006:30BGCarbsMealBolusCorr.Bolus

當(dāng)禁食后的血糖保持穩(wěn)定，證明基礎(chǔ)率的設(shè)定是正確的1229060gms6.0u1361188882如果血糖保持穩(wěn)定，說(shuō)明基礎(chǔ)率調(diào)節(jié)是正確的SkipBreakfastSkipLunch確定/精細(xì)調(diào)節(jié)白天基礎(chǔ)率應(yīng)選擇一天餐前血糖在正常范圍內(nèi)開(kāi)始進(jìn)行基礎(chǔ)率調(diào)節(jié)BasalRate:12AM@0.5u/hr3AM@0.7u/hr7AM@0.6u/hrICR:1:1030將學(xué)到的應(yīng)用在實(shí)踐中!優(yōu)化血糖管理31患者:22歲MDI=52u/天無(wú)法感知的低血糖時(shí)而發(fā)生體重:138lb.HbA1c

=7.7ICR:1:15SF=40DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DHSTime12:002:155:558:3011:15BG721315611288Carbs37gm-0-60gm-0-12gmMealBolus3.0u-0-5.0u-0-11:35Corr.Bolus-0--0--1.1u+3.9u-0-135DateNocturnalPre-BPost-BPre-LPost-LPre-DPost-DHSTime3:107:159:3612:302:446:358:5511:30BG9068125551426110692Carbs-054gm-0-75gm-0-66gm-0--0-MealBolus

4.5u6.2u5.6uCorr.Bolus-1.2u3.3u-1.15.1用泵前7pmChangedBR12AM@0.5u/hrBasalRate:12AM@0.6u/hr

調(diào)整基礎(chǔ)率32患者:22歲MDI=52u/天無(wú)法感知的低血糖時(shí)而發(fā)生體重:138lb.HbA1c

=7.7ICR:1:15SF=40125128861297412688124BG2.2u

Corr.Bolus-0-6.0u5.7u5.0uMealBolus-0--0-72gm68gm60gm-0-Carbs11:159:257:004:001:4510:308:123:08TimeHSPost-DPre-DPost-LPre-LPost-BPre-BNocturnalDateWalkingCorr.Bolus6.0u5.0u4.0uMealBolus-0--0-71gm-0-60gm48gmCarbs122120781388413466117BG11:008:146:063:1212:459:227:033:05TimeHSPost-DPre-DPost-L

Pre-LPost-BPre-B

NocturnalDate12am@0.5u/hr.

3am@0.4u/hr.7am@0.5u/hrBasalRate:12AM@0.5u/hr調(diào)整基礎(chǔ)率33患者:32歲:Type1,G4P2A1,懷孕11周.MDI=96udayWT:182lb.HbA1c

=8.21.5u_____1.8u+0.22.51.8u+.2u7.3uCorr.Bolus_____9.0u2.3u_____7.0u

MealBolus-0--0-74gm-0-18gm-0-49gm-0Carbs10417171158105168108106BG11:008:356:253:401:309:157:053:10TimeHSPost-DPre-DPost-LPre-LPost-BPre-BNocturnalDate1.5u1.1u4.1uCorr.Bolus-0-8.0u-0-4.3uMealBolus

-0-56gm-0-30gmCarbs10218397172210BG11:158:005:402:5512:45TimeHSPost-DPre-DPost-LPre-LPost-BPre-BNocturnalDate用泵前洗脫期ICR=1:6BasalRate:12AM@1.2u/hrICR=1:7SF=1:25餐后高血糖調(diào)整碳水化合物系數(shù)34患者:32歲:Type1,G4P2A1,懷孕11周.MDI=96udayWT:182lb.HbA1c

=8.21.8uCorr.Bolus7.5u8.4u4.0uMealBolus112129951186915489115BG11:008:126:003:1012:459:287:223:05TimeHSPost-DPre-DPost-LPre-LPost-BPre-BNocturnalDateICR1:6

Corr.Bolus7.5u8.4u4.0uMealBolus-0-45gm-0-51gm45gmCarbs101105831018412688108BG12:158:005:453:301:1510:008:123:08TimeHSPost-DPre-DPost-LPre-LPost-BPre-BNocturnalDate

ICR=1:5Breakfast(only)

ICR=1:6(L&D)BasalRate:12AM@1.2u/hrSF:1:25調(diào)整碳水化合物系數(shù)35Hx:44歲:Type2:胰島素抵抗，高血糖MDI=200udayWT:260lb.HgA1c16.5

5.0u17u14.0uCorr.Bolus12u-----MealBolus

60gm-----Carbs238177312BG9:447:303:15TimeHSPost-DPre-DPost-LPre-LPost-BPre-BNoct