1、糖尿病患者的胰岛素治疗糖尿病患者最大的悲剧不是罹患糖尿病，而是没有控制好糖尿病。糖尿病患者最大的悲剧不是罹患糖尿病，而是没有控制好糖尿病。如果我们改变不了结局，我们应该努力改变进程。最有效的控糖手段-“五驾马车”教教 育育运运 动动饮饮 食食监监 测测药药 物物为什么要使用胰岛素？2型糖尿病是一种进展性的疾病Slow decline phase：1.7%/yearRapid decline phase:18.2%/year适用对象基于胰岛B细胞功能时间时间(年年)诊诊断断 胰胰岛岛素素补补充治充治疗疗胰胰岛岛素替代治素替代治疗疗胰胰岛岛素强化治素强化治疗疗胰岛素优势：降糖疗效强局限低血糖体重增
2、加皮下注射，使用不便如何正确使用胰岛素？胰岛素的种类u速效胰岛素Aspart(诺和锐)、Lispro(优泌乐)u短效胰岛素Regular(普通胰岛素)u中长效胰岛素NPH、Lente、Ultralente、Glargine(来得时)AdvancementsTime胰岛素制剂的持续改进Animal insulin preparationsIsolation of insulin(Banting&Best)1922第一代第一代Rapid-acting insulin analoguesBasal insulin analoguesBiphasic insulin analogues1990s200
3、0s第三代第三代Recombinant human insulin1977第二代第二代Recombinant human insulin1977New-generationinsulin analogues/combination insulinsDegludecDegludecPlus新一代新一代12非糖尿病者血糖及胰岛素的变化9.06.03.007 8 91011121 2 3 4 5 6 7 8 9InsulinInsulinGlucoseGlucosea.m.p.m.BreakfastBreakfastLunchLunchSupperSupper7550250Basal insulin
4、Basal insulinBasal glucoseBasal glucoseInsulinInsulin(U/mL)(U/mL)GlucoseGlucose(mmo/L)(mmo/L)Time of Day13正常人的血糖变化曲线Blood Glucose(mmol/L)10-8-6-4-2-0 8am noon 6pm 2am 4am 8am TimewContinuous InfusionBlood Glucose(mmol/L)8am noon 6pm 2am 4am 8am Time10-8-6-4-2-0 预混胰岛素的种类Multiple Insulin Injection The
5、rapyINSULININJECTION10/9020/8030/7040/6050/50Post-prandial hyperglycemiaPre-prandial hyperglycemia不同的胰岛素使用方案Multiple Insulin Injection TherapyINSULININJECTION Two doses:The usual dosing commonly used.Initial insulin therapy Three doses:Used for active patients.Patients taking two main meals.Four dos
6、es:Brittle diabetic patient.Pregnant mothers specially type 1.Four doses:Brittle diabetic patient.Pregnant mothers specially type 1.Motivated patients.血糖可能的变化图谱INSULININJECTION使用预混胰岛素Multiple Insulin Injection TherapyINSULININJECTIONu 相对方便u 不同的预混比例(25/75，30/70，50/50).u 常见午餐后高血糖.高血糖窗Multiple Insulin
7、Injection TherapyINSULININJECTIONCause:Lack of insulin Lunch effect afternoon snacksEffect:Pre-meal hyperglycemia HbA1c by 1.7%高血糖窗Multiple Insulin Injection TherapyINSULININJECTION Treat by adding regular dose pre-lunch高血糖窗Multiple Insulin Injection TherapyINSULININJECTION Treat by adding regular d
8、ose pre-meals and small one before sleep低血糖窗Multiple Insulin Injection TherapyINSULININJECTIONHypoglycemiaWindowCause:NPH evening dose?Late sleep Effect:Somogyi effect Week end or night shift work Problem低血糖窗Multiple Insulin Injection TherapyINSULININJECTION低血糖窗Multiple Insulin Injection TherapyINSU
9、LININJECTION胰岛素可能的使用方法Many different potential regimens!Oral+hs insulin(basal)Oral+AM insulin(basal)Pre-mixed insulin with breakfast and supper Short-acting with meals+bedtime basal Pre-mixed with breakfast and supper+R/H with lunch.NPH with breakfast and supper+R/H with breakfast and lunch and supp
10、er.Pre-mixed insulin with breakfast or lunch or supper Pre-mixed insulin with breakfast+R/H with supper R/H insulin with breakfast and lunch and supper如何精细调节胰岛素的用量？确定血糖控制目标为每个病人确定其最适宜的血糖控制目标。成年病人的一般控制目标：餐前：4.4-6.1mmol/L；餐后2小时：5.0mmol/L若反复出现低血糖，适当提高控制目标：餐前：5.6-8.9mmol/L若怀孕，则应适当减低目标血糖值：餐后 6.7mmol/L注意餐
11、前后两次血糖的差值 目标血糖 降低 ICR11.2I:C 1:153:006.87:0060 gms5.0 u9:15要确定是否正确要确定是否正确计计算碳水化合算碳水化合物系数物系数尝试尝试 I:C 1:12确认/调整碳水化合物系数（ICR）5.56.9比较餐前和餐后2hr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 目标血糖增加 ICRICR:1:153:006.77:005.560 gms3.3 u9:15确认/调整碳水化合物系数（ICR）比较餐前和餐后2hr血糖Basal Rate:0:00 0.5 u/hr 3:0
12、0 0.7 u/hr 7:00 0.6 u/hrICR:1:18 6.9u 确定ICR，需要比较:餐前血糖与餐后2小时血糖 在开始调整阶段，应保持进食低脂肪餐和碳水化合物含量较为固定的食物u ICR 估算正确的表现:血糖在餐后2小时没有显著的升高或降低：不超过2.8 3.9mmol/L *请牢记，早，中，晚餐的ICR可能会有所不同确认/调整碳水化合物系数当患者纠正他的高血糖时，应在2hr内进行血糖监测，以确定血糖是否达标75 gm+1.8 u6.9(10.4 5.6)18 =1.8 u 50 9.3 u当前当前BG -目目标标 BG(100)=#UISF(50)(13.9 5.6)18 50
13、=3.0 units补充大剂量Basal Rate:0:00 0.5 u/hr 3:00 0.7 u/hr 9:00 0.5 u/hrICR:1:10ISF:50胰岛素敏感系数 u确定ISF，需要对比:输注补充大剂量前的血糖与输注补充大剂量后的血糖u当符合下列条件时，ISF已被正确调整:调整后2 hr血糖不超过目标值(5.6-6.7mmol/L)1.7mmol/L以上 u3小时内再测一次血糖以确认血糖在目标范围内补充大剂量的计算：确定胰岛素敏感系数（ISF）影响血糖控制的非胰岛素因素举例注射部位的选择把好教育关；时常留心注射部位；血糖不随胰岛素量的变化而变化。预混胰岛素是否混匀？u在使用之前，
14、应将胰岛素水平滚动和上下翻动各10次，使 瓶内药液充分混匀，直至胰岛素转变成均匀的云雾状白色 液体。u比例改变的影响将一直持续至药量用完。1.King L.Subcutaneous insulin injection technique.Nurs Stand.2003;17:45-52.2.Jehle PM,Micheler C,Jehle DR,Breitig D,Boehm BO.Inadequate suspension of neutral protamine Hagendorn(NPH)insulin in pens.Lancet 1999;354:1604-7.3.Brown A,
15、Steel JM,Duncan C,Duncun A,McBain AM.An assessment of the adequacy of suspension of insulin in pen injectors.Diabet Med 2004;21:604-608.4.Nath C.Mixing insulin:shake,rattle or roll?Nursing 2002;32:10.5.Springs MH.Shake,rattle,or roll?.Challenging traditional insulin injection practices Am J Nurs 199
16、9;99:14.注射时间的灵活运用以患者的血糖变化谱为基础；不要拘泥于是否餐前；并非总是提前半小时或10分钟。注射部位还应考虑胰岛素在不同部位的吸收差异腹部腹部 8787分钟分钟 50%50%较快较快适合短效胰岛素适合短效胰岛素臀部臀部 较慢较慢适合长效胰岛素适合长效胰岛素 或中效胰岛素或中效胰岛素大腿大腿 164164分钟分钟 50%50%中等至较慢中等至较慢手臂手臂 141141分钟分钟 50%50%中等至较慢中等至较慢适合长效胰岛素适合长效胰岛素或中效胰岛素或中效胰岛素不同注射部位胰岛素吸收不同（分钟）：研究显示，50%胰岛素吸收所需要的时间腹部最快，手臂中等，大腿和臀部较慢11.The
17、 American Journal of Nursing,Vol.98,No.7,pp.55+571.Clauson PG,Linde B.Absorption of rapid-acting insulin in obese and nonobese NIDDM patients.Diabetes Care 1995;18:986-91.2.Jamal R,Ross SA,Parkes JL,Pardo S,Ginsberg BH.Role of injection technique in use of insulin pens:prospective evaluation of a 31
18、-gauge,8mm insulin pen needle.Endocr Pract 1999;5:245-50.3.Birkebaek N,Solvig J,Hansen B,Jorgensen C,Smedegaard J,Christiansen J.A 4mm needle reduces the risk of intramuscular injections without increasing backflow to skin surface in lean diabetic children and adults.Diabetes Care.2008 Sep;22(9):e65
19、.4.Gibney MA,Arce CH,Byron KJ,Hirsch LJ.Skin and subcutaneous adipose layer thickness in adults with diabetes at sites used for insulin injections:Implications for needle length recommendations.Curr MedRes Opin 2010;26:1519-30.5.Hirsch L,Klaff L,Bailey T,Gibney M,Albanese J,Qu S,et al.Comparative gl
20、ycemic control,safety and patient ratings for a new 4 mm32G insulin pen needle in adults with diabetes.Curr Med Res Opin 2010;26:1531-41.6.Kreugel G,Keers JC,Jongbloed A,Verweij-Gjaltema AH,Wolffenbuttel BHR.The influence of needle length on glycemic control and patient preference in obese diabetic
21、patients.Diabetes 2009;58:A117.7.Kreugel G,Beijer HJM,Kerstens MN,ter Maaten JC,Sluiter WJ,Boot BS.Influence of needle size for SC insulin administration on metabolic control and patient acceptance.Europ Diab Nursing 2007;4:1-5.8.Van Doorn LG,Alberda A,Lytzen L.Insulin leakage and pain perception wi
22、th NovoFine 6 mm and NovoFine 12 mm needle lengths in patients with type 1 or type 2 diabetes.Diabet Med 1998;1:S50.9.Solvig J,Christiansen JS,Hansen B,Lytzen L.Localisation of potential insulin deposition in normal weight and obese patients with diabetes using Novofine 6 mm and Novofine 12 mm needl
23、es.Meeting Federation European Nurses in Diabetes,Jerusalem,Israel,2000(Abstract).留心进针的角度u使用较短（4mm或5mm）的针头时，大部分患者无需捏起皮肤，并 可90进针；u使用较长（8mm）的针头时，需要捏皮或45角以降低肌肉注射风 险；如何正确的捏皮？u捏皮时力度不得过大导致皮肤发白或疼痛 A3u不能用整只手来提捏皮肤，以避免将肌肉及皮下组织一同捏起u最佳的注射步骤为：p捏起皮肤形成皮褶 p和皮褶表面呈90角进针后，缓慢推注胰岛素 p当活塞完全推压到底后，针头在皮肤内停留10秒钟p拔出针头 p松开皮褶 总 结胰岛素适用于不同病程的所有患者掌握不同剂型胰岛素的药动学特点了解糖尿病患者的血糖变化规律正确使用胰岛素的方法如何精确调节胰岛素的量影响血糖控制的非胰岛素因素Thanks！
