胰岛素泵的应用.ppt
胰岛素泵的临床应用胰岛素泵的临床应用一、胰岛素泵的应用基础胰岛素泵的应用基础与现状与现状糖尿病检测技术的进展史Insulin InjectionsUrine Test StripsGlucose SensorArtificialPancreas1999197819221900s1977Urine Tasting1776BG MetersInsulin Pump Therapy胰岛素泵的应用病例数（不完全统计数）6,6008,70011,40015,00020,00026,50035,00043,00060,00081,000100,000150,000010,00020,00030,00040,00050,00060,00070,00080,00090,000100,000110,000120,000130,000140,000150,000909192939495969798990002DCCTDCCT:Diabetes Care 1995;18:361-376Unknown2%Pump42%MDI56%正常胰岛素分泌规律胰岛素泵模拟胰岛素分泌Basal RatePancreas DeliveryMealBolusesPharmacokinetic Advantages:CSII vs MDI Uses only Regular insulin More predictable 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:Diabetologia 1983;24:326-9胰岛素泵的优点 降低降低HbA1cHbA1c 减少低血糖减少低血糖 提高生活质量提高生活质量 降低治疗费用降低治疗费用胰岛素泵降低胰岛素泵降低HbA1cInvestigatorNHbA1c(%)Observation Time(yrs)Bode(96)557.73.1DCCT Research Group(95)1246.84.5Wredling(93)407.64.0-5.6降低HbA1c 益处：降低微血管病变 降低大血管病变（应用胰岛素尚有争论）促进伤口愈合 减少感染 提高心梗后生存率 降低自由基对组织的损伤135791113156789101112RetinopNephNeuropMicroalbRELATIVE RISKHbA1cSkyler:Endo Met Cl N Am 1996HbA1c 和并发症的相对危险性HbA1c 和慢性并发症控制餐后血糖水平与冠心病危险性的关系致死性冠心病危险性和血糖浓度的关系.p0.001冠心病总发病率和血糖浓度的关系.p0.01n=8006例男性0 01010202030304040505060607070致死性冠心病致死性冠心病冠心病总发病率冠心病总发病率1 12 23 34 45 5冠心病危险性（1/1000）1.40-114mg/dl2.115-133mg/dl3.134-156mg/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关死亡微血管白内障摘除 HbA1C每增加每增加1%，将增加以下并发症发生危险，将增加以下并发症发生危险胰岛素泵 降低了低血糖的发生率13813822222626393936360 05050100100150150Pre CSIIPre CSII1 yr1 yr2 yr2 yr3 yr3 yr4 yr4 yr-With CSII-低血糖减少后的益处：减少了低血糖脑病减少了低血糖脑病 减少了低血糖的死亡减少了低血糖的死亡 提高了患者对低血糖的感知提高了患者对低血糖的感知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.降低医疗开支$108,400$130,700$167,800$207,300PumpMDIConventional(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 CSII 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、胰岛素泵的应用方法胰岛素泵的应用方法胰岛素剂量的分配50%BasalPre-Pump DosePump Starting Dose(70-75%of Pre-Pump Dose)50%Bolus基础率的调整 测三餐前后、入睡时及12am,and 2-4am血糖 跳餐来测空腹血糖 按2-4am 及早餐前的血糖来调整晚间基础率 调整量不大于0.1 u/hr 调整餐前量 以碳水化合摄入量来计算确定餐前胰岛素量 按对胰岛素敏感性的个体差异来确定用量 再根据餐后血糖及下一餐的餐前血糖来调整用量胰岛素泵应用指征 HbA1c控制差 频繁低血糖 黎明现象 运动者 儿科患者 怀孕 胃轻瘫 忙乱的生活方式 转移性工作者 2型糖尿病 酮症酸中毒 严重慢性病并发症者 围手术期患者 代谢不稳定者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 结结 临时胰岛素泵的应用临时胰岛素泵的应用(I)v适用适用DKA的病人的病人:给予生理剂量胰岛素给予生理剂量胰岛素,快速改快速改变糖代谢紊乱变糖代谢紊乱,纠正酸碱失衡纠正酸碱失衡.v适用高渗昏迷的严重糖代谢紊乱的病人适用高渗昏迷的严重糖代谢紊乱的病人:全面全面治疗的同时理想地纠正糖代谢紊乱治疗的同时理想地纠正糖代谢紊乱,稳妥地恢复稳妥地恢复血浆渗透压及心、脑、肾等脏器的功能血浆渗透压及心、脑、肾等脏器的功能.v适用多脏器功能衰竭伴高血糖的病人适用多脏器功能衰竭伴高血糖的病人:可以减可以减少输液量少输液量,避免进一步加重器官功能衰竭并纠正避免进一步加重器官功能衰竭并纠正高血糖高血糖.v适用于胰岛素抵抗的病人适用于胰岛素抵抗的病人:可以摸索胰岛素的可以摸索胰岛素的治疗剂量治疗剂量.v减少低血糖的发生减少低血糖的发生.v防止高渗透压防止高渗透压-低渗透压波动所致的脑水肿低渗透压波动所致的脑水肿综合效益综合效益 减少住院天数减少住院天数,利于周转利于周转 减少病人的费用支出减少病人的费用支出 直接费用直接费用:间接费用间接费用:胰岛素泵的应用前景 胰岛素泵的高科技发展趋势 胰岛素泵的需求伴随糖尿病的发病率而升高 物质条件的改善使糖尿病人的需求变为现实
