胰岛素泵的精细调节为什么要进行血糖精细调节通过与胰岛素需求量相匹配的胰岛素输注以获得最佳的血糖控制尽可能将胰岛素泵的作用发挥出来让患者感到更满意血糖精细调节的三个步骤准备和学习设定血糖目标值尝试并调整剂量基础率餐前大剂量补充大剂量准备工作基础率和大剂量选项的特征回顾大剂量向导理解方波和双波大剂量选项对患者的意义血糖测试提醒0.05 单位为步长的基础率增加设定血糖目标值将血糖控制的目标转化为具体的值在一天的不同时间设定不同的血糖目标白天90 –110 mg/dL  妊娠60 - 90 mg/dL 									 * * Paradigm 胰岛素泵B 糖尿病管理迈出新的一步基础率12 am  @ 0.6 u / hr. 基础率回顾缓慢持续的输注持续输注从设置一个基础率开始调整/增加基础率目的:模仿一个正常功能的胰腺,维持血糖稳定0.6 0.5 0.6 0.7 0.7 0.6 0.7 0.7 0.7  0.5 0.5 0.5 2. 3 am @ 0.7 u / hr.  3. 8 am @ 0.5 u / hr.  大剂量进餐& 高血糖大剂量进餐& 零食1:10 如何纠正高血糖早餐60 gms  6 .0 units  午餐48 gms 4.8 units 血糖监测250 mg/dl 250 - 100 =  + 3 u  50 血糖监测70 mg/dl 70 - 100 =  - 0.6 u  50 BG - 100 = # Units  SF ( 胰岛素敏感系数) 1:50 6.0  u (meal) + 3.0 u  (high BG) 9.0 u 4.8  u (meal) - 0.6 u  (high BG) 4.2 u (1 单位胰岛素/ ? gms 碳水化合物) MiniMed Estimate Details Est total:		 Food intake:	  BG:		 Food:	  	 Correction:	 Active ins:	 ACT to proceed, ESC to back up	 		 大剂量向导为患者自动计算胰岛素大剂量MiniMed Paradigm 胰岛素泵治疗的金标准! 8.0 U 200 60 gr  2.0 U ICR  1:10 gr  200 - 100  = 2.0 u  50 (SF) Paradigm Pump 6.0 U Food: Correction: Est total: 大剂量向导是个选择性的功能，可以打开，也可以关闭。Paradigm  胰岛素泵Press ACT 打开主菜单MiniMed Main Menu Bolus Suspend Basal Prime Utilities 如何使用大剂量向导Bolus Suspend Basal Bolus Prime Utilities Paradigm Pump 如何使用大剂量向导MiniMed Bolus Menu Set Bolus Bolus History Bolus Wizard Set Up Max Bolus Dual/Square Bolus Easy Bolus BG Reminder Bolus Wizard Set Up MiniMed WIZARD SETUP Edit Settings Review Settings Edit Settings MiniMed Edit Settings Wizard:	 Carb units:	 Carb Ratios:	  BG Units:		 Sensitivity:	  BG Targets:	 on grams 10 mg/dL  50 100 MiniMed Review Settings Carb Ratios: 12:00 A	 10  11:30 A	 12 6:00 P	 15 Review Settings Carb Ratios: off exchanges 每餐的碳水化合物系数可以不同mmol/L 每天克设置多达8个不同值Edit Settings 如何使用大剂量向导MiniMed Bolus Menu Use Bolus Wizard Manual Bolus Bolus History Bolus Wizard Set Up Max Bolus Dual/Square Bolus Easy Bolus BG Reminder MiniMed Enter BG 	 		 mg/dL 		 200 MiniMed Bolus Menu Use Bolus Wizard Manual Bolus Bolus History Bolus Wizard Set Up Max Bolus Dual/Square Bolus Easy Bolus BG Reminder Use Bolus Wizard 200 MiniMed Enter Food 		 grams  0 60 如何使用大剂量向导MiniMed Estimate Details Est total:		 Food intake:	  BG:		 Food:	  	 Correction:	 Active ins:	 ACT to proceed, ESC to back up	 		 The Bolus Wizard 自动计算胰岛素大剂量MiniMed Paradigm Pump 胰岛素泵治疗的金标准8.0 U 200 60 gr  2.0 U 6.0 U Food: Correction: Est total: Active ins: 7.0 U 1.0 U Food intake: ACT tp proceed MiniMed SET BOLUS Estimate  7.0 u 用“大剂量向导”进行大剂量输注.1 u  .2 u  .3 u  .4 u  .5 u  .6 u 7.0 u 胰岛素泵的精细调节3 个决定因素基础率碳水化合物比率胰岛素敏感系数基础率: 12 AM @ 0.6 u/h 调整夜间基础率稳定而良好的基础率----- ----- ----- Corr. Bolus ----- ----- ----- Meal Bolus ----- ----- ----- Carbs BG Time Post-B Pre-B Nocturnal Bed Time 11 PM 120 3 AM 117 7 AM 90 保持非进餐状态的血糖稳定( 夜间& 两餐间) 正确设定夜间基础率: 稳定而良好的基础率血糖上升，应增加基础率Carbs BG Time Post-B Pre-B Nocturnal Bed Time Date: Corr. Bolus Meal Bolus Carbs BG Time Post-B Pre-B Nocturnal Bed Time 基础率: 12 AM @ 0.6 u/h 11 PM 120 3 AM 125 7 AM 188 Basal Rate: 1. 12 am @  0.6 u/h 2. 3 am @  0.7 u/hr 3. 7 am @  0.6 u/hr 11 PM 120 3 AM 125 7 AM 82 --- 基础率一次增加0.1 单位良好而稳定的基础率夜间基础率调节不好黎明现象在血糖开始升高或降低的2－3个小时前就开始调整基础率消除夜间发生低血糖的危险患者可以整晚安然而睡提高患者的依从性患者新的一天从良好的血糖开始先进行夜间基础率的调整确认/调整夜间基础率Meal Bolus Carbs Corr. Bolus BG Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date --- Corr. Bolus --- Meal Bolus --- Carbs 90 122 BG 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date 基础率: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  7 AM @ 0.6 u/hr 60 gms ICR: 1:15 4.0 u 餐后血糖控制在目标范围内，ICR 是正确的9:25 AM 136 Note: 餐后BG 应比餐前略高，但不超过餐前血糖50 mg/dl  确认/调整碳水化合物系数餐前与餐后2 hr 的血糖对比餐后血糖> 目标降低ICR Corr. Bolus Meal Bolus Carbs BG Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date --- --- Corr. Bolus 4.0 u --- Meal Bolus 60 gms --- Carbs 90 122 BG 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date 202 I:C 1:12 3 AM 122 7 AM 60 gms 5.0 u 9:15 要确定患者是否正确计算碳水化合物系数尝试I:C  1:10 确认/调整碳水化合物系数99 125  178 125 比较餐前和餐后2 hr 血糖Basal Rate: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  7 AM @ 0.6 u/hr 餐后血糖< 目标增加ICR Corr. Bolus Meal Bolus Carbs BG Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date --- --- Corr. Bolus 4.0 u --- Meal Bolus 60 gms --- Carbs 66 90 122 BG 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date ICR: 1:18 3 AM 122 7 AM 99 60 gms 3.3 u 9:15 130 确认/调整碳水化合物系数比较餐前和餐后2 hr 血糖Basal Rate: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  7 AM @ 0.6 u/hr 90 ICR: 1:20 125  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/碳水化合物含量较为固定的食物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50 –70 mg/dl * 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Corr. Bolus Meal Bolus Carbs BG 8:30 6:00 3:25 1:00 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date ____ ____ ____ Corr. Bolus 3.0 u ____ 4.0 u ___ Meal Bolus 45 gm ---- 60 gms --- Carbs 62 128 50 136 110 122 BG 6:00 3:25 1:00 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date 如果餐前BG 很低，应考虑降低白天基础率Basal Rate: 1. 12 am @  0.5 u/hr 2. 3 am @  0.7 u/hr 3. 9 am @  0.5 u/hr 122 60 gms 6.0 u 136 82 45 gm 3.0 128 78 75 gm 5.0 u 125 Note: 可能需要调整白天基础率的起始时间确认/调整白天基础率99 调整后要测试血糖Basal Rate: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  7 AM @ 0.6 u/hr ICR: 1:10 Corr. Bolus Meal Bolus Carbs 125 88 128 90 136 99 122 BG 8:30 6:00 3:25 1:00 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date ____ ____ ____ Corr. Bolus 3.0 u ____ 4.0 u ___ Meal Bolus 45 gm ---- 60 gms --- Carbs 172 128 188 136 110 122 BG 6:00 3:25 1:00 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date 如果餐前血糖高于餐后血糖，应增加白天基础率Basal Rate: 1. 12 am @  0.5 u/h 2. 3 am @  0.7 u/hr 3. 9 am @  0.6 u/hr 60 gms 6.0 u 45 gm 3.0 75 gm 5.0 u 确认/调整白天基础率Basal Rate: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  9 AM @ 0.5 u/hr ICR: 1:10 确认/调整白天基础率让患者遵照他们的饮食习惯进餐:  但不要在两餐之间进食将餐后2 hr 血糖与下一餐的餐前血糖进行对比; 如果血糖升高增加基础率如果血糖降低降低基础率确认血糖的变化调整的2－3天内进行多次血糖监测 - 观察血糖的变化趋势Goal:  餐后2 hr 血糖与餐前血糖比较，相差不应> 50 mg /dl Corr. Bolus 7.5 u 3.0 u 6.0 u Meal Bolus 45 gm 60 gms Carbs 188 128 132 136 90 120 BG 8:10 6:00 3:25 1:00 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date ____ ____ 3.0 u Corr. Bolus 6.0 4.5 u ____ 6.0 u ____ Meal Bolus 60 gm 45 gm ---- 60 gms --- Carbs 88 128 79 136 110 250 BG 6:00 3:25 1:00 9:15 7 AM 5 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date 当患者纠正他的高血糖时，应在2 hr 内进行血糖监测，以确定血糖是否达标75 gm +1.8 u 125 188 –100 = 1.8 u  50  9.3 u 当前BG -  目标BG (100) = # U CF (50) 250 –100 50 =  3.0 units 补充大剂量Basal Rate: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  9 AM @ 0.5 u/hr ICR: 1:10 SF:  50 胰岛素敏感系数补充大剂量胰岛素敏感系数确定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30 mg/d ( 目标值: 100 mg/dL –120 mg/dL)  3 小时内再测一次血糖以确认血糖在目标范围内确定胰岛素敏感系数( ISF) 选择一个患者情绪和血糖都较为稳定的日子进行调节让患者在某一餐禁食每2小时监测一次血糖观察血糖变化-  如果血糖升高增加基础率-  如果血糖降低降低基础率进行适当的调整确认调整是正确的–反复测试血糖确定/精细调节白天基础率如果发生低血糖：及时治疗低血糖适当调整基础率重复测试Corr. Bolus Meal Bolus Carbs BG 6:30 4:00 1:30 11:30 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date ____ ____ ____ Corr. Bolus 3.0 u ____ ____ ___ Meal Bolus 45 gm ---- ---- --- Carbs 78 86 90 122 BG 6:00 3:25 1:00 9:15 7 AM 3 AM Time Post-D Pre-D Post-L Pre-L Post-B Pre-B Nocturnal Date 当禁食后的血糖保持稳定，证明基础率的设定是正确的122 90 60 gms 6.0 u 136 118 88 82 如果血糖保持稳定，说明基础率调节是正确的Skip Breakfast Skip Lunch 确定/精细调节白天基础率应选择一天餐前血糖在正常范围内开始进行基础率调节Basal Rate: 12 AM @ 0.5 u/hr  3 AM @ 0.7 u/hr  7 AM @ 0.6 u/hr ICR: 1:10 * *