1、胰島素泵的臨床應(yīng)用胰島素泵的臨床應(yīng)用一、胰島素泵的應(yīng)用基礎(chǔ)胰島素泵的應(yīng)用基礎(chǔ)與現(xiàn)狀與現(xiàn)狀糖尿病檢測(cè)技術(shù)的進(jìn)展史Insulin InjectionsUrine Test StripsGlucose SensorArtificialPancreas1999197819221900s1977Urine Tasting1776BG MetersInsulin Pump Therapy胰島素泵的應(yīng)用病例數(shù)（不完全統(tǒng)計(jì)數(shù)）6,6008,70011,40015,00020,00026,50035,00043,00060,00081,000100,000150,000010,00020,00030,00040

2、,00050,00060,00070,00080,00090,000100,000110,000120,000130,000140,000150,000909192939495969798990002DCCTDCCT: Diabetes Care 1995; 18:361-376Unknown2%Pump42%MDI56%正常胰島素分泌規(guī)律胰島素泵模擬胰島素分泌Basal RatePancreas DeliveryMealBolusesPharmacokinetic Advantages:CSII vs MDI Uses only Regular insulin More predictabl

3、e absorption than with modified insulins (variation 3% vs 52%*) Uses one injection site for 2 to 3 days Reduces variations in absorption due to site rotation Eliminates most of the subcutaneous insulin depot Programmable insulin delivery allows closest match with physiologic needs* Lauritzen: Diabet

4、ologia 1983; 24:326-9胰島素泵的優(yōu)點(diǎn) 降低降低HbA1cHbA1c 減少低血糖減少低血糖 提高生活質(zhì)量提高生活質(zhì)量 降低治療費(fèi)用降低治療費(fèi)用胰島素泵降低胰島素泵降低HbA1cInvestigatorNHbA1c (%)Observation Time (yrs)Bode (96)557.73.1DCCT Research Group (95)1246.84.5Wredling (93)407.64.0-5.6降低HbA1c 益處： 降低微血管病變 降低大血管病變（應(yīng)用胰島素尚有爭(zhēng)論） 促進(jìn)傷口愈合 減少感染 提高心梗后生存率 降低自由基對(duì)組織的損傷1357911131567

5、89101112RetinopNephNeuropMicroalbRELATIVE RISKHbA1cSkyler: Endo Met Cl N Am 1996HbA1c 和并發(fā)癥的相對(duì)危險(xiǎn)性HbA1c 和慢性并發(fā)癥控制餐后血糖水平與冠心病危險(xiǎn)性的關(guān)系致死性冠心病危險(xiǎn)性和血糖濃度的關(guān)系. p0.001冠心病總發(fā)病率和血糖濃度的關(guān)系. p0.01n=8006例男性0 01010202030304040505060607070致死性冠心病致死性冠心病冠心病總發(fā)病率冠心病總發(fā)病率1 12 23 34 45 5冠心病危險(xiǎn)性（1/1000）1.40-114mg/dl2.115-133mg/dl3.134

6、-156mg/dl4.157-189mg/dl5.190-532mg/dl1234521%21%14%14%47%47%39%39%19%19%外周血管心肌梗死糖尿病相關(guān)死亡微血管白內(nèi)障摘除 HbA1C每增加每增加1%，將增加以下并發(fā)癥發(fā)生危險(xiǎn)，將增加以下并發(fā)癥發(fā)生危險(xiǎn)胰島素泵 降低了低血糖的發(fā)生率13813822222626393936360 05050100100150150Pre CSIIPre CSII1 yr1 yr2 yr2 yr3 yr3 yr4 yr4 yr- With CSII-低血糖減少后的益處： 減少了低血糖腦病減少了低血糖腦病 減少了低血糖的死亡減少了低血糖的死亡 提高

7、了患者對(duì)低血糖的感知提高了患者對(duì)低血糖的感知Lifetime Benefits of EffectiveIntensive Therapy (DCCT) Gain of 15.3 years of complication free living compared to conventional therapy Gain of 5.1 years of life compared to conventional therapyDCCT Study Group, JAMA 1996;276:1409-1415.降低醫(yī)療開(kāi)支$108,400$130,700$167,800$207,300PumpM

8、DIConventional(DCCT)Conventional(GeneralPopulation)FHbA1c 7% 8% 9% 10%FIndirect $1,000 $21,400 $44,900 $61,700FDirect $108,400 $109,300 $122,900 $145,600DirectCostsDirectCostsDirectCostsDirectCostsAssumption: Patients follow typical scenario. Dollars are Expected Net Present ValueSource: Quattro CSI

9、I Economic Analysis Model 1999Improved Quality of LifePump patients demonstrate: Lower anxiety and depression scores Greater family cohesion Improved interpersonal sensitivity Significantly less distress from hypoglycemia Coping with diabetes less difficult (adolescents)二、胰島素泵的應(yīng)用方法胰島素泵的應(yīng)用方法胰島素劑量的分配5

10、0%BasalPre-Pump DosePump Starting Dose(70-75% of Pre-Pump Dose)50%Bolus基礎(chǔ)率的調(diào)整 測(cè)三餐前后、入睡時(shí)及12am, and 2-4am血糖 跳餐來(lái)測(cè)空腹血糖 按2-4am 及早餐前的血糖來(lái)調(diào)整晚間基礎(chǔ)率 調(diào)整量不大于0.1 u/hr 調(diào)整餐前量 以碳水化合攝入量來(lái)計(jì)算確定餐前胰島素量 按對(duì)胰島素敏感性的個(gè)體差異來(lái)確定用量 再根據(jù)餐后血糖及下一餐的餐前血糖來(lái)調(diào)整用量胰島素泵應(yīng)用指征 HbA1c控制差 頻繁低血糖 黎明現(xiàn)象 運(yùn)動(dòng)者 兒科患者 懷孕 胃輕癱 忙亂的生活方式 轉(zhuǎn)移性工作者 2型糖尿病 酮癥酸中毒 嚴(yán)重慢性病并發(fā)癥者

11、 圍手術(shù)期患者 代謝不穩(wěn)定者Summary Pump Therapy is becoming widely recognized as the best way to treat insulin requiring diabetes Continuous Glucose Monitoring makes pumps an even more powerful tool Both Pump Therapy and Continuous Glucose Monitoring are easy to implement in a medical practice小小 結(jié)結(jié) 臨時(shí)胰島素泵的應(yīng)用臨時(shí)胰島

12、素泵的應(yīng)用 (I)v適用適用DKA的病人的病人:給予生理劑量胰島素給予生理劑量胰島素,快速改快速改變糖代謝紊亂變糖代謝紊亂,糾正酸堿失衡糾正酸堿失衡.v適用高滲昏迷的嚴(yán)重糖代謝紊亂的病人適用高滲昏迷的嚴(yán)重糖代謝紊亂的病人:全面全面治療的同時(shí)理想地糾正糖代謝紊亂治療的同時(shí)理想地糾正糖代謝紊亂,穩(wěn)妥地恢復(fù)穩(wěn)妥地恢復(fù)血漿滲透壓及心、腦、腎等臟器的功能血漿滲透壓及心、腦、腎等臟器的功能.v適用多臟器功能衰竭伴高血糖的病人適用多臟器功能衰竭伴高血糖的病人:可以減可以減少輸液量少輸液量,避免進(jìn)一步加重器官功能衰竭并糾正避免進(jìn)一步加重器官功能衰竭并糾正高血糖高血糖.v適用于胰島素抵抗的病人適用于胰島素抵抗的病人:可以摸索胰島素的可以摸索胰島素的治療劑量治療