(翻譯)2023AAGBI糖尿病患者圍手術(shù)期管理

1、GuidelinesPeri-operative management of the surgical patient with diabetes2023Association of Anaesthetists of Great Britain and Ireland2023AAGBI糖尿病患者圍手術(shù)期管理英國和愛爾蘭麻醉醫(yī)師協(xié)會Membership of the Working Party: P. Barker, P. E. Creasey, K. Dhatariya,1 N. Levy, A. Lipp,2M. H. Nathanson (Chair), N. Penfold,3 B. W

2、atson and T. Woodcock1 Joint British Diabetes Societies Inpatient Care Group2 British Association of Day Surgery3 Royal College of AnaesthetistsSummaryDiabetes affects 1015% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and

3、length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c 69 mmol.mol1); deciding if the patient can be managed by simple manipulation of pre-existing treatment duringa shor

4、t starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with

5、poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurateand well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guidelin

6、e is to provide detailed guidance on the peri-operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant.摘要糖尿病影響著近10% 15% 的手術(shù)患者，并且，接受外科手術(shù)的糖尿病患者的手術(shù)并發(fā)癥發(fā)生率、死亡率和住院天數(shù)都相對較高?，F(xiàn)代的針對伴有糖尿病的手術(shù)患者的管理重點是：通過術(shù)前評估和對糖尿病病情的

7、強化管理糖化血紅蛋白 69 mmol.mol-1；如果患者可以簡單地采用之前既有的調(diào)整方案加之一定的飲食控制就能管理好血糖水平，就不要采取可調(diào)節(jié)的胰島素靜脈輸注；當后者是唯一選擇需要使用時要注意平安性，例如急診患者、手術(shù)后預(yù)期不能馬上恢復(fù)正常飲食的患者、糖尿病控制很差的患者等。另外，醫(yī)療保健專業(yè)人員之間以及和患者之間的溝通準確是當務(wù)之急，整個過程都需要溝通順暢。大多數(shù)糖尿病患者都有多年的對自己血糖的管理經(jīng)驗了，本指南的目的是對糖尿病患者圍手術(shù)期處理提供詳細的指導(dǎo)，這對麻醉師很有特殊的意義，并且確?，F(xiàn)行指南的一致性。IntroductionThe demographics describing

8、the dramatic increase in the number of patients with diabetes are well known. Patients with diabetes require surgical procedures more frequently and have longer hospital stays than those without the condition 2. The presence of diabetes or hyperglycaemia in surgical patients has been shown to lead t

9、o increased morbidity and mortality, with perioperative mortality rates up to 50% greater than the non-diabetic population 2. The reasons for these adverse outcomes are multifactorial, but include: failureto identify patients with diabetes or hyperglycaemia 3, 4; multiple co-morbidities including mi

10、crovascular and macrovascular complications 5; complex polypharmacy and insulin prescribing errors 6; increased peri-operative and postoperative infections 2, 7, 8; associated hypoglycaemia and hyperglycaemia 2; a lack of, or inadequate, institutional guidelines for management of inpatient diabetes

11、or hyperglycaemia 2, 9; and inadequateknowledge of diabetes and hyperglycaemia management amongst staff delivering care 10.Anaesthetists and other peri-operative care providers should be knowledgeable and skilled in the care of patients with diabetes. Management of diabetes is a vital element in the

12、 management of surgical patients with diabetes. It is not good enough for the diabetic care to be a secondary, or sometimes forgotten, element of the peri-operative care package.指南簡介眾所周知流行病學(xué)調(diào)查顯示糖尿病患者的數(shù)量在急劇增加。糖尿病患者需要外科手術(shù)更頻繁，并有更長的住院時間。相對于非糖尿患者群，患有糖尿病或高血糖的外科患者相應(yīng)的發(fā)病率和死亡率會增加，比起非糖尿病患者，圍手術(shù)期死亡率增加 50%。導(dǎo)致上述不良

13、結(jié)果的原因是多方面的，包括：未能確定患者患有糖尿病或高血糖；包括微血管和大血管并發(fā)癥的多種疾病；多重用藥的復(fù)雜性和胰島素處方錯誤；圍手術(shù)期和術(shù)后感染的增加；伴有低血糖或高血糖；對糖尿病或高血糖住院管理制度知識的缺乏；對于糖尿病和高血糖患者管理知識匱乏尤其是在護理方面。麻醉師和圍手術(shù)期護理人員對于護理糖尿病患者應(yīng)該具有詳盡的知識和熟練的技能。對于伴有糖尿病的外殼患者的管理中糖尿病護理是至關(guān)重要的環(huán)節(jié)，在圍手術(shù)期的護理中是第一位的。Previous guidelinesIn April 2023 NHS Diabetes (now part of NHS Improving Quality) pu

14、blished a document: NHS Diabetes Guideline for the Peri-operative Management of the Adult Patient with Diabetes, in association with the Joint British Diabetes Societies (JBDS) 1 (an almost identical version, Management of Adults with Diabetes Undergoing Surgery and Elective Procedures: ImprovingSta

15、ndards, is available at .uk/JBDS/JBDS.htm). This comprehensive guideline provided both background information and advice to clinicians caring for patients with diabetes. Some of the recommendations in that document were due for review in the light of new evidence and, in addit

16、ion, it was felt that anaesthetists and other practitioners caring for patients with diabetes in the peri-operative period needed shorter, practical advice. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) offered to co-author this shortened guideline, in collaboration with coll

17、eagues involved with the 2023 document. The previous 2023 NHS Diabetes guidelines will also be updated in 2023.先前的指南在2023年4月NHS和JBDS發(fā)表了一版成年糖尿病患者圍手術(shù)期管理指南。這版詳盡的指南提供了背景知識以及對于糖尿病患者護理的建議。這些建議很多出自循證醫(yī)學(xué)證據(jù)，并且說明，麻醉師和臨床醫(yī)生對于糖尿病患者的圍手術(shù)護理需要更精簡貼近實際的建議。結(jié)合2023版的這版指南，AAGBI出版了這版更精簡的指南。之前的2023NHS糖尿病指南在2023也會更新。The risks

18、 of poor diabetic controlStudies have shown that high pre-operative and perioperative glucose and glycated haemoglobin (HbA1c) levels are associated with poor surgical outcomes. These findings have been seen in both elective and emergency surgery including spinal 11, vascular 12, colorectal 13, card

19、iac 14, 15, trauma 16, breast17, orthopaedic 18, neurosurgical, and hepatobiliary surgery 19, 20. One study showed that the adverse outcomes include a greater than 50% increase in mortality,a 2.4-fold increase in the incidence of postoperative respiratory infections, a doubling of surgical site infe

20、ctions, a threefold increase in postoperative urinary tract infections, a doubling in the incidence of myocardial infarction, and an almost twofold increase in acute kidney injury 2. Paradoxically, there are some data to show that the outcomes of patients with diabetes maynot be different from, or m

21、ay indeed be better than, those without diabetes if the diagnosis is known before surgery 21. The reasons for this are unknown, but may be due to increased vigilance surrounding glucose control for those with a diagnosis of diabetes.糖尿病控制不佳的風(fēng)險研究結(jié)果說明圍手術(shù)期和手術(shù)期間的高血糖、高糖化血紅蛋白水平與患者術(shù)后預(yù)后不佳關(guān)系密切，這種預(yù)后不佳無論是擇期手術(shù)還

22、是急診手術(shù)均有表達，這些手術(shù)包括脊髓、血管、結(jié)腸直腸、心臟、創(chuàng)傷、乳腺、整形、神外以及肝膽手術(shù)等。一項研究顯示這些不良結(jié)局包括：死亡率增加50%、術(shù)后呼吸道感染增加2.4倍、手術(shù)部位感染加倍、尿道感染增加三倍、心肌梗死的發(fā)生率加倍，急性腎損傷幾乎增加兩倍。矛盾的是，也有一些數(shù)據(jù)說明術(shù)前診斷明確的伴有糖尿病的患者和普通患者的預(yù)后沒有差異，甚至更好。但是這是什么原因還不得而知，也許是因為患者之前已明確診斷為糖尿病，對血糖的管理有更為積極的控制。Referral from primary care and planning surgery 從初級保健到方案手術(shù)的轉(zhuǎn)診The aim is to ens

23、ure that diabetes is as well controlled as possible before elective surgery and to avoid delays to surgery due to poor control. The Working Party supports the consensus advice published in the 2023 NHS Diabetes guideline that the HbA1c should be 69 mmol.mol1 (8.5%) for elective cases 1, andthat elec

24、tive surgery should be delayed if it is 69 mmol.mol1, while control is improved. Changesto diabetes management can be made concurrently withreferral to ensure the patients diabetes is as well controlled as possible at the time of surgery. Elective surgery in patients with diabetes should be planned

25、with the aim of minimising disruption to their self-management.其目的是確保糖尿病在擇期手術(shù)前盡可能地控制良好，防止因為血糖控制不佳而手術(shù)延期。遵循2023 版的 NHS 糖尿病指南，擇期手術(shù)情況下 HbA1c 應(yīng) 69 mmol.mol-18.5%，當HbA1c 69 mmol-1時，手術(shù)應(yīng)延遲到血糖控制有所改善的時候。糖尿病管理策略可以適時改變以確保手術(shù)期患者的糖尿病可以盡可能地控制到最好。伴有糖尿病的手術(shù)患者的擇期手術(shù)方案應(yīng)該盡可能地把對患者自我管理的破壞降到最低。 Recommendation: Glycaemic cont

26、rol should bechecked at the time of referral for surgery. Information about duration, type of diabetes, current treatment and complications should be made available to the secondary care team.建議：轉(zhuǎn)診手術(shù)時應(yīng)檢查血糖控制水平、病程、類型、現(xiàn)有治療方案和并發(fā)癥。Surgical outpatient clinicThe adequacy of diabetes control should be asse

27、ssed again at the time of listing for surgery, ideally with a recorded HbA1c 69 mmol.mol1); and most patients with diabetes requiring emergency surgery. Variable-rate intravenous insulin infusions should be administered and monitored by appropriately experienced and qualified staff. An example of a

28、VRIII regimen is provided in Appendix 1.可調(diào)節(jié)的靜脈胰島素輸注VRIII的應(yīng)用可調(diào)節(jié)的靜脈胰島素輸注VRIII對于以下人群是首選：需要節(jié)食至少一餐的患者；沒有胰島素注射史的 I 型糖尿病患者；糖尿病控制不佳定義為糖化血紅蛋白 69 mmol.mol-1；需急診外科手術(shù)的多數(shù)糖尿病患者?？烧{(diào)節(jié)的靜脈胰島素輸注VRIII應(yīng)用和監(jiān)測應(yīng)該由有經(jīng)驗的專業(yè)的醫(yī)護人員進行。VRIII規(guī)那么的示范見附件1.Intra-operative care and monitoring術(shù)中看護與監(jiān)測The aim of intra-operative care is to mai

29、ntain good glycaemic control and normal electrolyte concentrations,while optimising cardiovascular function and renal perfusion. If possible, multimodal analgesia should be used along with appropriate anti-emetic prophylaxis,to enable an early return to a normal dietand the patients usual diabetes r

30、egimen.術(shù)中看護與監(jiān)測的目的是維持良好的血糖水平和正常的電解質(zhì)濃度，同時優(yōu)化心血管功能和腎臟灌注。如果可能的話，可以將多種模式鎮(zhèn)痛與適當?shù)目箛I吐預(yù)防機制一起進行，使患者早日恢復(fù)正常的飲食規(guī)律和常規(guī)糖尿病治療。 Recommendation: An intra-operative CBG range of 610 mmol.l1 should be aimed for (an upper limit of 12 mmol.l1 may be tolerated at times, e.g. if the patient has poorly controlled diabetes and

31、is being managed by a modification of his/her normal medication without a VRIII). It should be understood by all staff that a CBG within the range of610 mmol.l1 is acceptable and that there is no requirment for a CBG of 6 mmol.l1 to be the target.The CBG should be checked before induction of anaesth

32、esia and monitored regularly during the procedure (at least hourly, or more frequently if the results are outside the target range). The CBG, insulin infusion rate and substrate infusion should be recorded on the anaesthetic record. Some charts use colour-coded areas to highlight abnormalresults req

33、uiring further intervention or a change of treatment (see Appendix 2).*提示：術(shù)中血糖應(yīng)控制在6-10mmol.l-1 (特殊情況下最高控制在12mmol.l-1 例如：血糖控制較差沒有接受VRIII治療，正在調(diào)整治療方案的糖尿病患者)醫(yī)護人員需要明確血糖范圍在6-10mmol.l-1 都是可以接受的，沒有必要以控制在6 mmol.l-1 為目標。血糖水平應(yīng)在麻醉前檢查并且在術(shù)中不斷監(jiān)測至少每小時一次，如果血糖超出目標范圍要增加監(jiān)測頻次。血糖、胰島素注射速率和基質(zhì)輸入需要記錄在麻醉記錄上。一些圖標需要用顏色區(qū)分標示不正常的數(shù)

34、值以便于后續(xù)調(diào)整或改變治療方案見附件2Management of intra-operative hyperglycaemia and hypoglycaemiaIf the CBG exceeds 12 mmol.l1 and insulin has been omitted, capillary blood ketone levels should be measured if possible (point-of-care devices are available). If the capillary blood ketones are 3 mmol.l1 or there is si

35、gnificant ketonuria ( 2+ on urine sticks) the patient should be treated as having diabetic ketoacidoketoacidosis(DKA). Diabetic ketoacidosis is a triad of ketonaemia 3.0 mmol.l1, blood glucose 11.0 mmol.l1,and bicarbonate 15.0 mmol.l1 or venous pH 7.3.Diabetic ketoacidosis is a medical emergency and

36、 specialisthelp should be obtained from the diabetes team.If DKA is not present, the high blood glucose should be corrected using subcutaneous insulin (see below) or by altering the rate of the VRIII (if in use).If two subcutaneous insulin doses do not work, a VRIII should be started.術(shù)中低血糖和高血糖的管理如果未

37、使用胰島素血糖超過12mmol.l-1 需檢測血酮水平可用床旁診斷如果血酮大于3mmol.l-1 或者有明顯的酮尿大于+,需要視為糖尿病酮癥酸中毒處理。血酮大于3mmol.l-1血糖超過11mmol.l-1 電解質(zhì)-1 或者PH7.3即可診斷。糖尿病酮癥酸中毒是急性并發(fā)癥需要糖尿病專業(yè)人員處理。如果沒有發(fā)生酮癥，需要采取皮下胰島素注射降低血糖見下文或者改變VRIII輸注速率已采用的情況下。如果兩次皮下胰島素注射后沒有起效，需要啟用VRIII.Treatment of hyperglycaemia in a patient with type-1 diabetesSubcutaneous rap

38、id-acting insulin (such as Novorapid, Humalog or Apidra) should be given (up toa maximum of 6 IU), using a specific insulin syringe,assuming that 1 IU will drop the CBG by 3 mmol.l1.Death or severe harm as a result of maladministration of insulin, including failure to use the specific insulin syring

39、e, is a Never Event. If the patient is awake, it is important to ensure that the patient is content with proposed dose (patients may react differently to subcutaneous rapid-acting insulin). The CBG should be checked hourly and a second dose considered onlyafter 2 h.1型糖尿病患者高血糖處理假設(shè)一單位劑量降低3mmol.l-1 血糖，

40、使用速效胰島素門冬胰島素、賴脯胰島素或Apidra配合注射裝置注射最大6個單位劑量胰島素的不標準使用會引發(fā)死亡和很多嚴重的傷害是必須要防止發(fā)生的，這其中包括不當使用注射裝置。如果病人是清醒的，與病人確認注射劑量是非常重要的病人對速效胰島素的注射有不同的反響。血糖水平需要每小時監(jiān)測，第二次注射至少在兩小時之后。Treatment of hyperglycaemia in a patient with type-2 diabetesSubcutaneous rapid-acting insulin 0.1 IU.kg1 should be given (up to a maximum of 6 I

41、U), using a specific insulin syringe. The CBG should be checked hourly and a second dose considered only after 2 h. A VRIII should be considered if the patient remains hyperglycaemic.2型糖尿病患者高血糖處理使用速效胰島素0.1IU/配合注射裝置注射最大6個單位劑量血糖水平需要每小時監(jiān)測，第二次注射至少在兩小時之后。如果高血糖持續(xù)沒有改善，需要啟用VRIII.Treatment of intra-operative

42、 hypoglycaemiaFor a CBG 4.06.0 mmol.l1, 50 ml glucose 20% (10 g) should be given intravenously; for hypoglycaemia 4.0 mmol.l1 a dose of 100 ml (20 g) should be given.術(shù)中低血糖處理如果血糖在4-6mmol.l-1 ，靜脈注射50ml 20%葡萄糖10g如果血糖 4.0mmol.l-1 ，劑量應(yīng)為100ml20gFluid management體液管理There is a limited evidence base for the

43、recommendation of optimal fluid management of the adult diabetic patient undergoing surgery. It is now recognised that Hartmanns solution is safe to administer to patients with diabetes and does not contribute to clinically significant hyperglycaemia 23.成人糖尿病患者接受手術(shù)期間只有理論根底有限的最正確體液管理的建議。哈特曼氏溶液認為是較平安的

44、對于糖尿病患者的平安管理，但對于臨床上的顯著高血糖效果較不明顯23。Fluid management for patients requiring a VRIIIThe aim is to provide glucose as a substrate to prevent proteolysis, lipolysis and ketogenesis, as well asto optimise intravascular volume status and maintain plasma electrolytes within the normal range. It isimportant

45、to avoid iatrogenic hyponatraemia from the administration of hypotonic solutions. Glucose 5% solution should be avoided. Use of glucose 4% in 0.18% saline can be associated with hyponatraemia.需要VRIII治療的病人體液管理其目的是提供葡萄糖以防止蛋白質(zhì)與脂肪分解，發(fā)生酮癥，同時也是保持血管內(nèi)體積良好和維持機體電解質(zhì)正常平衡。防止低滲溶液引起的低鈉血癥非常重要。5%的葡萄糖溶液不可以采用。4%葡萄糖的0.

46、18%生理鹽水也可能引起低鈉血癥。The substrate solution to be used should be based on the patients current electrolyte concentrations.While there is no clear evidence that one type of balanced crystalloid fluid is better than another, half-strength normal saline combined with glucose is, theoretically,a reasonable

47、compromise to achieve these aims. Thus, the initialfluid should be glucose 5% in saline 0.45% pre-mixed with either potassium chloride0.15% (20 mmol.l_1) or potassium chloride 0.3%(40 mmol.l_1), depending on the presence of hypokalaemia( 3.5 mmol.l_1).基質(zhì)溶液應(yīng)用應(yīng)以病人目前的體液情況為根底。如果沒有明確的證明一種晶體液優(yōu)于另一種，理論上，半強度

48、的混合葡萄糖的生理鹽水是最正確的解決方案。因此，最初應(yīng)采取5%葡萄糖的0.45%的生理鹽水預(yù)混0.15%20 mmol.l-1 或0.3%40 mmol.l-1 氯化鉀，取決于病人目前的血鉀情況 24 h), a VRIII should be considered and glucose 5% in saline 0.45% with pre-mixed potassium chloride given as above.不需要VRIII治療的病人體液管理除非低血糖否那么不采用含有葡萄糖的溶液。防止高氯血癥代謝性酸中毒非常重要；哈特曼氏溶液有利于改善血管內(nèi)體積。如果病人需要術(shù)后持續(xù)輸液( 2

49、4 h),需要考慮VRIII與5%葡萄糖的0.45%生理鹽水預(yù)混0.15%氯化鉀補液。Returning to normal (pre-operative) medication and diet回歸正常術(shù)前的治療和飲食The postoperative blood glucose management plan,and any alterations to existing medications, should be clearly communicated to ward staff. Patients with diabetes should be involved in planni

50、ng their postoperative care. If subcutaneous insulin is required in insulin-nave patients, or the type of insulin or the time it is to be given is to change, the specialist diabetes team should be contacted for advice.應(yīng)清楚地傳達關(guān)于術(shù)后血糖管理方案、對現(xiàn)有藥物的任何改變給病房工作人員。糖尿病患者應(yīng)參與術(shù)后護理的規(guī)劃。如果單純性胰島素患者需要皮下胰島素，胰島素的注射時間或類型需要

51、改變，糖尿病的專家團隊應(yīng)考慮病人的建議。Transferring from a VRIII back to oral treatment or subcutaneous insulinIf the patient has type-1 diabetes and a VRIII has been used, it must be continued for 3060 min after the patient has had their subcutaneous insulin (see below).Premature discontinuation is associated with ia

52、trogenic DKA.從VRIII轉(zhuǎn)變?yōu)榭诜幓蚱は伦⑸湟葝u素治療如果1型糖尿病患者已使用VRIII，皮下注射胰島素后需繼續(xù)維持VRIII30-60min見下過早的中斷易引起酮癥。Restarting oral hypoglycaemic medicationOral hypoglycaemic agents should be recommenced at pre-operative doses once the patient is ready to eat and drink; withholding or reduction in sulphonylureas may be req

53、uired if the food intake is likely to be reduced. Metformin should only be restarted if the estimated glomerular filtration rate exceeds 50 ml.min1.1.73 m2 25.重新開始口服降糖藥治療當病人可以開始正常飲食時可以考慮重新開始按術(shù)前劑量進行口服降糖藥治療；如果飲食減少應(yīng)該防止或減少磺脲類藥物治療。只有估計腎小球濾過率高于50ml/min1.73/m2時考慮重新開始雙胍類治療25.Restarting subcutaneous insulin

54、for patients already established on insulinConversion to subcutaneous insulin should commence once the patient is able to eat and drink without nausea or vomiting. The pre-surgical regimen should be restarted, but may require adjustment because the insulin requirement may change as a result of posto

55、perative stress, infection or altered food intake. The diabetes specialist team should be consulted if the blood glucose levels are outside the acceptable range (612 mmol.l1) or if a change in diabetes management is required.已使用胰島素治療的患者恢復(fù)皮下胰島素治療當病人可以開始正常飲食并且沒有惡心嘔吐時可以考慮重新開始皮下胰島素治療。因為術(shù)后的壓力、感染或者飲食改變可能對

56、胰島素用量有所影響，所以需要調(diào)節(jié)劑量重新開始胰島素治療。如重新口服或皮下注射胰島素、重新進行口服降糖藥物、為患者持續(xù)皮下胰島素輸注等。糖尿病患者成功治療的關(guān)鍵就是恢復(fù)正常飲食習(xí)慣。如果血糖不在可接受的范圍6-12mmol.l-1之外，糖尿病專家需要商量考慮是否更改糖尿病管理方案。The transition from intravenous to subcutaneous insulin should take place when the next meal-related subcutaneous insulin dose is due, for example with breakfas

57、t or lunch.靜脈到皮下的轉(zhuǎn)變應(yīng)該在下一餐胰島素皮下劑量確定的時候進行過渡，比方早飯或者午飯時。For the patient on basal and bolus insulinThere should be an overlap between the end of the VRIII and the first injection of subcutaneous insulin,which should be given with a meal and the intravenous insulin and fluids discontinued 30-60 min later.

58、根底加餐時胰島素治療的患者VRIII結(jié)束的時候胰島素作用時間可能和第一次根底胰島素有重疊，應(yīng)該在速效胰島素與液體終止后的30-60min，并在餐時注射根底胰島素。If the patient was previously on a long-acting insulin analogue such as Lantus, Levemir or Tresbia, this should have been continued and thus the only action should be to restart his/her usual rapid-acting insulin at the

59、 next meal as outlined above. If the basal insulin was stopped, the insulin infusion should be continued until a background insulin has been given.如果病人之前使用長效胰島素類似物比方甘精、地特和Tresbia，可以繼續(xù)使用只需要在下一餐時按需要重新啟用平常的速效胰島素。如果根底胰島素已經(jīng)停止，胰島素輸注需要繼續(xù)直到啟用根底胰島素為止。For the patient on a twice-daily, fixed-mix regimenThe ins

60、ulin should be re-introduced before breakfast or before the evening meal, and not at any other time. The VRIII should be maintained for 30-60 min after the subcutaneous insulin has been given.兩針預(yù)混治療的患者應(yīng)該在早餐前或者晚餐前重新啟用，而不是其他任何時間。皮下注射胰島素后需繼續(xù)維持VRIII30-60min。For the patient on a continuous subcutaneous i