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1、胰岛素泵的临床应用,一、胰岛素泵的应用基础与现状,糖尿病检测技术的进展史,Insulin Injections,Urine Test Strips,Glucose Sensor,ArtificialPancreas,1999,1978,1922,1900s,1977,Urine Tasting,1776,BG Meters,Insulin Pump Therapy,胰岛素泵的应用病例数（不完全统计数）,DCCT,DCCT:Diabetes Care 1995;18:361-376,正常胰岛素分泌规律,胰岛素泵模拟胰岛素分泌,Basal Rate,Pancreas Delivery,MealBo
2、luses,Pharmacokinetic Advantages:CSII vs MDI,Uses only Regular insulinMore predictable absorption than with modified insulins(variation 3%vs 52%*)Uses one injection site for 2 to 3 daysReduces variations in absorption due to site rotationEliminates most of the subcutaneous insulin depotProgrammable
3、insulin delivery allows closest match with physiologic needs,*Lauritzen:Diabetologia 1983;24:326-9,胰岛素泵的优点,降低HbA1c减少低血糖提高生活质量降低治疗费用,胰岛素泵降低HbA1c,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,RELATIVE RISK,HbA1c,Skyler:Endo Met Cl N Am 1996,HbA1c 和并发症的相对危险性,HbA1c 和慢性并发症,控制,足溃疡 心绞痛
4、 心血管 冠脉搭桥 卒中 失眠 截肢 透析 肾移植,微量白蛋白尿 视网膜病（轻）神经病变（轻）,白蛋白尿 增生性视网膜病 牙周病 阳蒌 胃轻瘫 抑郁,危险性,控制良好,控制差,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,冠心病危险性（1/1000）,1.40-114mg/dl2.115-133mg/dl3.134-156mg/dl4.157-189mg/dl5.190-532mg/dl,1,2,3,4,5,HbA1C每增加1%，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,低血糖减少
5、后的益处：,减少了低血糖脑病减少了低血糖的死亡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 therapyGain of 5.1 years of life compared to conventional therapy,DCCT Study Group,JAMA 1996;276:1409-1415.,降低医疗开支,HbA1c 7%8%9%10%Indirect
6、$1,000$21,400$44,900$61,700Direct$108,400$109,300$122,900$145,600,DirectCosts,DirectCosts,DirectCosts,DirectCosts,Assumption:Patients follow typical scenario.Dollars are Expected Net Present ValueSource:Quattro CSII Economic Analysis Model 1999,Improved Quality of Life,Pump patients demonstrate:Lowe
7、r anxiety and depression scoresGreater family cohesionImproved interpersonal sensitivitySignificantly less distress from hypoglycemiaCoping with diabetes less difficult(adolescents),二、胰岛素泵的应用方法,胰岛素剂量的分配,50%Basal,Pre-Pump Dose,Pump 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,
8、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 d
9、iabetesContinuous Glucose Monitoring makes pumps an even more powerful toolBoth Pump Therapy and Continuous Glucose Monitoring are easy to implement in a medical practice,小 结 临时胰岛素泵的应用(I),适用DKA的病人:给予生理剂量胰岛素,快速改变糖代谢紊乱,纠正酸碱失衡.适用高渗昏迷的严重糖代谢紊乱的病人:全面治疗的同时理想地纠正糖代谢紊乱,稳妥地恢复血浆渗透压及心、脑、肾等脏器的功能.,适用多脏器功能衰竭伴高血糖的病人:可以减少输液量,避免进一步加重器官功能衰竭并纠正高血糖.适用于胰岛素抵抗的病人:可以摸索胰岛素的治疗剂量.减少低血糖的发生.防止高渗透压-低渗透压波动所致的脑水肿,小 结 临时胰岛素泵的应用(II),综合效益,减少住院天数,利于周转减少病人的费用支出 直接费用: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,
