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1、低血糖的急诊处理及相关问题讨论王超杰 Still waters run deep.流静水深流静水深,人静心深人静心深 Where there is life,there is hope。有生命必有希望。有生命必有希望为什么讲低血糖？为什么讲低血糖？诊断简单治疗简单短期预后良好治疗者有成就感美国医学会杂志内科学(JAMA Internal Medicine)2014年3月10日在线发表的一项研究显示，与2型糖尿病“过度严格”胰岛素控制相关的重度低血糖每年导致近10万例次急诊就诊和3万例次住院，并且特别常见于老年患者By:MARY ANN MOON,Clinical Endocrinology N
2、ews Digital Network Severe hypoglycemia related to overly tight insulin control for type 2 diabetes prompts nearly 100,000 emergency department visits and 30,000 hospitalizations each year and is particularly common among older patients,according to a report published online March 10 in JAMA Interna
3、l Medicine.In an analysis of data from a nationally representative sample of hospitals in the National Electronic Injury Surveillance System-Cooperative Adverse Drug Event Surveillance project,researchers estimated that 97,648 ED visits occurred annually during a 5-year period among adults with type
4、 2 diabetes who presented with hypoglycemia-related shock,loss of consciousness,seizure,injury or fall,or altered mental status.Most cases involved blood glucose levels of 50 mg/dL or less,said Dr.Andrew I.Geller of the division of healthcare quality promotion at the Centers for Disease Control and
5、Prevention,Atlanta,and his associates.The case rate was 34.9 per 1,000 insulin-treated patients among those aged 80 years and older.In comparison,the rate was only 13.7 per 1,000 among those aged 45-64 years.Older patients were more than twice as likely as younger ones to require an ED visit and nea
6、rly five times as likely to require hospitalization,Dr.Geller and his associates said(JAMA Intern.Med.2014 March 10 doi:10.1001/jamainternmed.2014.136).The most common precipitating factor was meal-related misadventure failing to eat shortly after taking rapid-acting insulin or failing to adjust the
7、 insulin regimen to account for a missed meal or a very small meal.Hypoglycemia also was frequently preceded by the patient taking the wrong dose of insulin or the wrong insulin product,usually taking rapid-acting insulin instead of long-acting insulin.These data probably underestimate the total bur
8、den of hypoglycemic events because hypoglycemia,although a frequent cause of emergency medical services calls,is most often cared for outside the ED setting.Patients who have hypoglycemia unawareness and whose episodes do not result in EMS or ED care were not counted,nor were those who died en route
9、 to the ED,they added.No financial conflicts of interest were reported.View on the News Drug industry fuels overuse of insulin Severe insulin-related hypoglycemia is not just remarkably common,it also differs from most other causes of emergency department visits in that it is almost always iatrogeni
10、c,said Dr.Sei J.Lee.And as noted by Dr.Geller and his associates,the 50%increase in insulin use during the past decade is fueling this epidemic of hypoglycemia.That,in turn,can be attributed to the drug industrys all-too-effective efforts.to encourage patients and providers to intensify glycemic tre
11、atment.Pharmaceutical companies have shaped the current widespread belief in tight glycemic control that has led to aggressive prescribing of insulin,he said.We should not accept the current rates of hypoglycemia as inevitable or as an acceptable price to pay for treatment,Dr.Lee said.Rather,we shou
12、ld begin using a multipronged approach to decrease the overuse of insulin and minimize the risk of hypoglycemia.Dr.Lee is with the division of geriatrics at the University of California and the Veterans Affairs Medical Center,both in San Francisco.He reported no relevant financial conflicts of inter
13、est.These remarks were taken from his invited commentary accompanying Dr.Gellers report(JAMA Intern.Med.2014 March 10 doi:10.1001/jamainternmed.2013.13307).中华老年医学杂志上的一项研究表明，2型糖尿病（T2DM）患者严重低血糖事件中性别、Ccr、HbA1c、胰岛素和胰岛素促泌剂的使用是主要危险因素，对于高危患者应及早采取措施预防低血糖发生。暨南大学医学院第四附属医院广州市红十字会医院内分泌科的研究人员纳入了49例因严重低血糖而收入院的T2D
14、M患者，并选取同期非低血糖住院的T2DM患者98例作为对照。采用单因素分析比较两组间临床和生化指标，进一步通过多因素回归分析，建立Logistic模型，用ROC曲线评价Logistic模型的预报能力。严重低血糖是指糖尿病患者发生低血糖后需要外界的帮助并输注碳水化合物后缓解，同时监测血糖≤3.9 mmol/L。结果显示，低血糖组低血糖发作时平均血糖水平为（2.3±0.7）mmol/L。与非低血糖组比较，低血糖组平均年龄显著更高，糖化血红蛋白（HbA1c）水平显著更低，内生肌酐清除率（Ccr）显著更低。Logistic回归分析显示，性别、Ccr和HbA1c是发生严重低血糖的独立
15、危险因素；胰岛素和胰岛素促泌剂等降糖方案增加了低血糖发生风险；而糖尿病病程、体质指数和尿微量白蛋白对低血糖发生无显著影响。Logistic模型的ROC曲线下面积为97。问题是不是低血糖都能由简单的测快速血糖来确定或除外诊断？诊断完成后是不是推糖致血糖升高到正常水平就好了？患者神志清醒或者症状消失是不是就好了？成就感能否被患者及家属认同？什么是低血糖？低血糖症血糖2.8mmol/L（50mg/dl）+低血糖症状体征，及进糖后可缓解低血糖反应有低血糖相应的临床症状和体征，但血糖值不一定2.8mmol/L，主要与血糖下降速度过快引起升糖激素释放（如儿茶酚胺）所致的症状及体征有关常见类型常见类型反应性
16、低血糖：多发生在2型糖尿病早期或发病前，与胰岛素分泌高峰延迟有关药物性低血糖：可能发生低血糖的药物也可有无知觉性低血糖尤应注意分级轻度：仅有饥饿感，可伴有一过性的出汗、心悸，可自行缓解。中度：心悸、出汗、饥饿感明显，可伴手抖、头晕，需补充含糖食物后缓解重度：是在中度基础上伴随中枢神经系统功能不足的表现，如嗜睡、意识障碍、昏迷甚至死亡，须急诊及时处理及时、有效、足够长时间地急症处理密切随查，防止低血糖复发，有的需长达一周的处理，应嘱病人去除诱因血糖恢复、神志清楚后，要注意防止糖尿病恶化及酮症酸中毒预防：糖尿病健康教育，特别是用胰岛素治疗的病人病例分析一男性，50多岁，一天中3次呼叫急救车：第一次
17、5小时前午睡起床后出现躁动谵语，家属呼叫120，医生看过后未做任何检查签字返回；第二次同样症状于3小时前再次呼叫，120于送安定医院，同样未做任何检查；第三次患者清醒，为转院呼叫120.了解病史患者有近20年糖尿病史，长期每日四次注射胰岛素三短一中强化治疗，近10天来用量为20、20、20、10.患者家中有血糖仪但从不监测血糖患者无精神病史结果安定医院测血糖2.3mmol/L推糖治疗复测为8.8mmol/L，患者神志转清，无不适感，转北大医院继续治疗。讨论患者家中有血糖仪，未测血糖医生未详细问病史，未测血糖责任谁负？医生！医生！在确定精神问题或者神经官能症之前必须除外器质性病变！病例讨论二86
18、岁女性，脑梗后遗症长期卧床且无表达能力2年余，于1小时前突然“清醒”，能认人并不停骂人，询问患者自诉无不适。了解病史无确诊高血压、糖尿病、心脏病史未下胃管，平素每日三餐喂半流食，3小时前喂晚餐时出现呛咳即停止喂食，喂食量不足平时1/3.结果测快速血糖1.7mmol/L推糖治疗复测血糖10.8mmol/L，患者恢复发病前状态，无法正确认人及回答问题。送医院进一步治疗讨论效果如何？不去医院行不行？分析低血糖的常见发生原因饮食相关：1、不吃或不想吃 2、不让吃或吃不到 3、腹泻或呕吐 4、其他高代谢性疾病主食进食不足 5、正常进食但过量运动药物相关 1、降糖药相关 2、减肥药 3、其它促进代谢的药物
19、低血糖的药物相关常见发生原因初诊糖尿病者对疾病及相关药物认识不足或因对疾病的恐惧而过度节食、过量用药长期治疗者疏忽监测，且老年人肾血流量减少导致药物蓄积因记忆力差重复用药因季节或饮食问题出现胃肠功能紊乱时不能或不敢减量用药老年人调节能力差，当出现血糖降低时不能及时分泌升高血糖激素健康教育的开展长期性艰巨性广泛性健康教育的内容饮食药物活动体检及监测关于饮食糖尿病（Diabetologia）杂志的一项新研究发现，一天只吃早餐和午餐两顿大餐，比所谓少吃多餐的一天吃六次小餐，更有利于减肥、稳定血糖。该研究评估了54例患者，年龄30至70岁，要求他们遵循上述两种热量限制饮食方案中的一种。结果发现，两餐方
20、案的体重下降更明显（分别下降3.7kg和2.3kg），肝脂肪含量也下降较多（分别下降0.04%和0.03%）。此外，两餐方案组的空腹血糖和C肽水平下降也更多。两餐方案组的空腹胰高血糖素水平有所下降，而六餐方案组则有所增加。两组的口服葡萄糖胰岛素敏感性都有所增加，但两餐组增加更多。两组都没有出现不良事件。健康教育应注意的问题有效降糖：使血糖达标安全降糖：不出现低血糖并发症平稳降糖：减少波动近年来揭晓的糖尿病糖尿病心血管风险行动研究结论显示，强化降糖不仅不能降低受试者的心血管终点事件发生率，反而使其死亡率和严重低血糖事件显著增加。2008年揭晓的强化降糖与微血管和大血管并发症关系的研究也未能证实强化降糖有好的收益，反而不良事件发生率增加。两项试验并没有否定降糖的益处！荟萃分析显示过高或过低的血糖均会增加死亡率！恪守中庸之道，降糖过犹不及，因人而异，适度为好。谢谢！