选择最为合适的镇痛治疗和给药方案时,需对患者合并症加以考量。
哮喘
心衰
避免将非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)用于心力衰竭患者(基于专家意见)。
请注意药品名称和品牌、药品处方或地区之间的配方/用药途径和剂量可能有所不同。治疗建议针对患者特定群体提出:查看免责声明
如果患者为孕妇或儿童,请勿使用该工具进行合并症选择。采用标准治疗流程,并就合并症寻求专科医生建议。
增加了以下合并症:
注意该图标: 指代由于受患者合并症影响而改变或添加的治疗选择。
若无紧急考量因素,对急性结石事件初步治疗的主要目标是缓解症状,并根据需要进行补液和镇痛。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com[46]Afshar K, Jafari S, Marks AJ, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. Cochrane Database Syst Rev. 2015 Jun 29;(6):CD006027.https://www.doi.org/10.1002/14651858.CD006027.pub2http://www.ncbi.nlm.nih.gov/pubmed/26120804?tool=bestpractice.com [ ]Is there randomized controlled trial evidence to support the use of nonsteroidal anti-inflammatory drugs (NSAIDS) compare with other analgesics and each other in people with acute renal colic?https://cochranelibrary.com/cca/doi/10.1002/cca.920/full展示答案
在疼痛管理方面,请给予:
使用一种非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)作为一线治疗,任何给药途径均可[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118[47]Davenport K, Waine E. The role of non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals (Basel). 2010 Apr 28;3(5):1304-10.https://www.mdpi.com/1424-8247/3/5/1304/htmhttp://www.ncbi.nlm.nih.gov/pubmed/27713303?tool=bestpractice.com[证据 C]f4ca9417-e30c-45fd-adf3-eddc765b257bguidelineC对于有症状肾结石或输尿管结石患者,非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)对于急性疼痛管理的临床有效性如何?[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
非甾体抗炎药已被证实能够有效缓解急性肾结石相关的疼痛,并且其副作用少于阿片类药物和对乙酰氨基酚。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com
肠外 NSAID 疼痛缓解作用最为持久,且与阿片类药物相比不良反应更少。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com[49]Gu HY, Luo J, Wu JY, et al. Increasing nonsteroidal anti-inflammatory drugs and reducing opioids or paracetamol in the management of acute renal colic: based on three-stage study design of network meta-analysis of randomized controlled trials. Front Pharmacol. 2019;10:96.https://www.doi.org/10.3389/fphar.2019.00096http://www.ncbi.nlm.nih.gov/pubmed/30853910?tool=bestpractice.com
如果禁忌使用 NSAID 或该药对患者的镇痛效果不足,应静脉使用对乙酰氨基酚。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
只有在禁忌使用 NSAID 和静脉对乙酰氨基酚或这两种药物对患者的镇痛效果不足时,才可考虑阿片类药物。[47]Davenport K, Waine E. The role of non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals (Basel). 2010 Apr 28;3(5):1304-10.https://www.mdpi.com/1424-8247/3/5/1304/htmhttp://www.ncbi.nlm.nih.gov/pubmed/27713303?tool=bestpractice.com 如果给予阿片类药物,应同时开具止吐药控制阿片类药物引起的恶心。
请勿对疑似肾绞痛患者使用解痉药。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
心衰 慢性肾脏病 (CKD) 哮喘
选择最为合适的镇痛治疗和给药方案时,需对患者合并症加以考量。
避免将非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)用于心力衰竭患者(基于专家意见)。
对于肾功能减退患者, 调整阿片类药物剂量非常重要。
如果肾脏无法排泄,包括吗啡在内的数种阿片类药物活性代谢物就会出现积聚。[80]Davison SN. Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol. 2019 Jun 7;14(6):917-31https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556722/http://www.ncbi.nlm.nih.gov/pubmed/30833302?tool=bestpractice.com
避免将 NSADI 用于 CKD 患者。[81]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
糖尿病 痴呆 COPD 卒中 心衰 Frailty 高血压 冠状动脉病 慢性肾脏病 (CKD) 抑郁
在决定患者是居家治疗,还是需要入院治疗和/或专家评估时,患者的合并症是一项重要的考虑因素。
需考虑患者临床疾病总体严重性和稳定性,及其在家中进行自我照护的能力。
即使是虚弱患者或慢性疾病患者的轻度疾病也可能导致其身体机能下降,以致其无法居家进行安全地自理,而且可能无法立即获得照护者的支持。
若患者年龄 ≥65 岁,则在适当的时候应用临床衰弱量表(Clinical Frailty Scale, CFS)评估患者的衰弱程度,作为整体评估的一部分。[82]NHS Specialised Clinical Frailty Network. Clinical frailty scale. 2018 [internet publication]https://www.scfn.org.uk/clinical-frailty-scale
请勿使用 CFS 评估较年轻患者或者存在长期稳定残疾(例如脑性瘫痪)、学习障碍或孤独症的患者。[82]NHS Specialised Clinical Frailty Network. Clinical frailty scale. 2018 [internet publication]https://www.scfn.org.uk/clinical-frailty-scale
如果患者可以居家安全继续接受治疗,确保为其提供充分随访服务,并给予安全保障建议。建议患者在病情未改善或者出现恶化时寻求医疗建议或返院接受再评估。
必要时咨询专家意见。
布洛芬 : 儿童:咨询专科医生,获取剂量指导;成人:300-600 mg,口服(速释型),根据需要每 6-8 小时一次,每日最多 2400 mg
或
双氯芬酸钠 : 儿童:咨询专科医生,获得剂量指导;成人:75 mg,肌内注射,需要时每日一次或两次
或
双氯芬酸钾 : 儿童:咨询专科医生,获得剂量指导;成人:75-150 mg/d,口服(速释型),需要时分 2-3 次给药
对乙酰氨基酚 : 儿童:咨询专科医生,获得剂量指导;成人:15 mg/kg(每剂最大剂量为 1000 mg),静脉使用,需要时每 4-6 小时一次,每日最大剂量为 4000 mg
硫酸吗啡 : 儿童:咨询专科医生,获取剂量指导;成人:5-10mg,口服(速释型)/皮下/静脉/肌内注射,最初每 4 小时一次,根据疗效调整剂量
布洛芬 : 儿童:咨询专科医生,获取剂量指导;成人:300-600 mg,口服(速释型),根据需要每 6-8 小时一次,每日最多 2400 mg
或
双氯芬酸钠 : 儿童:咨询专科医生,获得剂量指导;成人:75 mg,肌内注射,需要时每日一次或两次
或
双氯芬酸钾 : 儿童:咨询专科医生,获得剂量指导;成人:75-150 mg/d,口服(速释型),需要时分 2-3 次给药
对乙酰氨基酚 : 儿童:咨询专科医生,获得剂量指导;成人:15 mg/kg(每剂最大剂量为 1000 mg),静脉使用,需要时每 4-6 小时一次,每日最大剂量为 4000 mg
硫酸吗啡 : 儿童:咨询专科医生,获取剂量指导;成人:5-10mg,口服(速释型)/皮下/静脉/肌内注射,最初每 4 小时一次,根据疗效调整剂量
如果患者有肾或输尿管结石并伴有梗阻体征和症状,应将其转诊立即接受泌尿科会诊。在有一块梗阻性结石的情况下发生泌尿道感染属于急症,需要进行抗生素治疗和肾减压以降低发生危及生命的脓毒性休克的可能性。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/[44]Sammon JD, Ghani KR, Karakiewicz PI, et al. Temporal trends, practice patterns, and treatment outcomes for infected upper urinary tract stones in the United States. Eur Urol. 2013 Jul;64(1):85-92.http://www.ncbi.nlm.nih.gov/pubmed/23031677?tool=bestpractice.com
引流的方式有两种。泌尿科医生可在梗阻部位放置一根输尿管支架,实现引流。另外还可通过影像学介入技术进行经皮肾造瘘置管。
推迟确定性取石术,直至:[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
已进行引流数日
完成一个完整疗程的抗微生物药物治疗即可消除感染。
然后根据结石部位和大小处理结石(见下文)。
针对特定患者群中所有患者的治疗建议
在有一块梗阻性结石的情况下发生泌尿道感染属于急症,需要进行抗生素治疗和肾内减压以降低发生致死性脓毒性休克的可能性。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/[44]Sammon JD, Ghani KR, Karakiewicz PI, et al. Temporal trends, practice patterns, and treatment outcomes for infected upper urinary tract stones in the United States. Eur Urol. 2013 Jul;64(1):85-92.http://www.ncbi.nlm.nih.gov/pubmed/23031677?tool=bestpractice.com
在等待基于尿液分析培养的药敏结果期间,应开始经验性广谱抗生素治疗。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/ 经验性治疗方案因地区不同而异,请遵循当地指南并参考本地抗菌谱。
推迟确定性取石术,直至:[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
已进行引流数日
完成一个完整疗程的抗微生物药物治疗即可消除感染。
然后根据结石部位和大小处理结石(见下文)。
针对特定患者群中所有患者的治疗建议
在患者入院时检查其血糖水平和 HbA1c。
排除低血糖、糖尿病酮症酸中毒(diabetic ketoacidosis, DKA),以及高渗性高血糖状态,这些均为医学急症。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[84]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
入院 HbA1c 可能会提示您患者既往糖尿病控制情况,并可能影响出院时的治疗(基于专家意见)。
对于患急性疾病或发生损伤的 1 型糖尿病患者,切勿停止使用基础胰岛素(长效/背景胰岛素 [例如,地特胰岛素、甘精胰岛素或德谷胰岛素])。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
胰岛素缺乏(例如由于用药延迟或漏用)会迅速引起酮症酸中毒。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
将任何使用胰岛素泵入院的糖尿病患者转诊至糖尿病专家团队。[86]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
一般情况下,所有接受基础胰岛素治疗的 2 型糖尿病患者均应继续接受治疗,但情况可能并非总是如此,因此应咨询您上级医生和/或糖尿病专科医生团队意见(基于专家意见)。
在患者入院时,考虑是否需要调整其胰岛素剂量。
如果 1 型或 2 型糖尿病患者正在使用胰岛素,血糖控制良好,入院时未出现严重的高血糖,则可能适当将基础胰岛素剂量减少 20%,尤其是当他们的进食量不及平时在家中时。需要考虑到的另一个因素是医院的膳食通常比患者在家的膳食含有更少的碳水化合物。
相反,危重症感染患者有时需要更高剂量的胰岛素。
定期监测血糖(每日至少 4 次)有助于指导合理调整胰岛素剂量。如有疑问,应寻求专家意见。
应尽早向糖尿病住院团队寻求专家建议,尤其是当诊疗较为复杂(例如,存在代谢紊乱、复发性或重度低血糖、持续高血糖),或者患者需要接受一段时间的肠内喂饲时。[87]Joint British Diabetes Societies for Inpatient Care. Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes. Nov 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 糖尿病团队还将能够就住院期间最合适的胰岛素方案和给药提出建议。
可变速率静脉胰岛素输注(VRIII)指征包括:[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[89]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
罹患糖尿病或医院相关性高血糖,且其无法进食或饮水,并无法调整胰岛素治疗方案的患者。例如,当:
呕吐
禁食禁饮,患者多餐不进
存在严重疾病,需要实现良好的血糖控制(例如脓毒症)。
需进行急诊手术的糖尿病患者可能需要给予 VRIII。遵循当地常规或英国围手术期诊疗中心建议。[90]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
在这些情况下,请从糖尿病团队获取专科医生建议。
若起始 VRIII:
始终持续给予基础胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果 VRIII 意外中断(例如由于导管移位或阻塞)或关闭(例如在转移病房期间),这会降低发生酮症的风险。
采用 VRIII 时让患者停用常规速效和混合胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
尽可能缩短使用 VRIII 的时间。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
遵循医院常规,执行包括停药在内的正确处理。
对于因 急性病症 入院的糖尿病患者,考虑停止或调整口服降糖药 。
以下所有患者应停用二甲双胍:[91]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
存在禁忌证,例如严重的肾脏损伤(eGRF <30 mL/[min·1.73m]),无论是慢性还是继发于急症。
伴代谢性酸中毒(包括乳酸酸中毒和糖尿病酮症酸中毒)
服用二甲双胍可能存在引发乳酸酸中毒风险。这包括与急性肾损伤、组织缺氧(包括急性心力衰竭或呼吸衰竭)有关的疾病,脱水,或已经/准长时间禁食或将要注射不透射线造影剂进行影像学检查的患者存在肾脏损伤(基于专家意见)。遵循当地常规,了解提示肾脏损伤的具体 eGFR 水平,以指导用药。
请注意,停用二甲双胍可导致高血糖。
如果您的患者正在服用其他降糖药物,这些药物可能需要增加剂量;如果没有,可能需要开处另一种降糖药(基于专家意见)。
一些患者可能需要胰岛素作为临时措施,但请寻求糖尿病住院专科医生团队的建议。
如果患者新近出现肾功能受损或恶化,或进食量比平时少,则应减少格列齐特剂量或停服一次药物,以免出现夜间低血糖。
对于所有危重症患者(包括进行大手术的患者),尤其是脱水或感染的情况下,应停用钠-葡萄糖协同转运蛋白-2(sodium-glucose cotransporter-2, SGLT-2)抑制剂并监测血酮,从而降低血糖正常的酮症酸中毒风险。[92]Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness. March 2020 [internet publication]https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness
SGLT-2 抑制剂(例如,达格列净、卡格列净、恩格列净)可减少肾脏中的血糖重吸收(与葡萄糖的胰岛素代谢无关)。[93]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Jun 15;38(9):1687-93http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com
它们可以掩盖潜在的酮症酸中毒,因为患者的血糖水平可能正常或接近正常(血糖正常的酮症酸中毒)。
检测血酮,因为尿酮体检测可能并不可靠。
如果毛细血管或血液中的酮体浓度为 >3 mmol/L ,或有 明显的酮尿(标准尿液试纸检测显示 2+ 或更多),且静脉 pH 值为 <7.3 和/或碳酸氢根浓度 <15 mmol/L ,则应治疗糖尿病酮症酸中毒 。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
针对特定患者群中所有患者的治疗建议
如同处理所有因急症而入院的患者,应对患者基线肾功能进行检查 ,如果患者具有 CKD 病史,需予以特别密切的监测。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
CKD 是急性肾损伤重要危险因素。[95]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Apr 2;74(1):101-7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
急症可增加肾功能恶化风险。
对少尿进行监测并予以处理。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
针对特定患者群中所有患者的治疗建议
对任何有卒中病史的患者,请在适当的时机尽早进行基线神经系统评估。
伴有急症(例如感染和疾病相关性低血压)的患者卒中风险升高(缺血性和出血性)。[96]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Nov 9;6(12):681-94http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com[97]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com 有卒中病史的患者风险更高。
如果在住院期间神经系统状态发生变化,应重复进行神经系统评估,从而防止再次发生卒中。
进行评估之后,应确保对患者进行适当的监护(例如需结合夜间意识模糊风险和机体脆弱相关性跌倒风险制定监护计划)。有卒中病史的患者跌倒和受伤的风险增加。[98]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 May 4;47(6):e98-e169https://www.doi.org/10.1161/STR.0000000000000098http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
尽早对具有痴呆病史的患者进行基线认知评估,并通过家人、朋友或照护者获取旁证病史。[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
使用在急性情况下可行的经过验证的评分系统,例如:[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
简化智力测试量表/10(AMTS/10)[100]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.comBritish Geriatrics Society: Abbreviated Mental Test Score. 2018
旁证病史可确定患者的认知是否稳定,或者认知和功能是逐渐下降还是急性下降。
标准化认知评估评分将有助于监测所有临床改善, 以及确定出院需求。判读该分数时,最好结合功能评估(通常由经过培训的职业治疗师进行)。
尽管由于急性疾患及其治疗的影响,该评分可能并不代表患者平时的认知基线,但当患者恢复后,记录并重复该评分仍然是很好的做法(基于专家意见)。
每当痴呆患者出现急性疾病时都要进行谵妄评估。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
伴痴呆者入院时和整个住院期间发生谵妄的风险增加。[102]National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers. Jun 2018 [internet publication].https://www.nice.org.uk/guidance/ng97[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
谵妄与痴呆不同。[104]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]http://ltctoolkit.rnao.ca/node/1774 谵妄是指精神功能出现潜在致死性的急性波动性改变,伴有注意力缺乏、思维混乱和意识水平的改变。[105]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
使用筛查工具检测可能出现的谵妄,例如:
4-AT[106]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Mar 2;43(4):496-502.https://www.doi.org/10.1093/ageing/afu021http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[107]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194https://www.doi.org/10.3310/hta23400http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
关于 4-AT 计算的更多信息已由苏格兰校际指南网络发布SIGN Decision Support: delirium - risk reduction and management.
如果患者处于危重症监护环境或术后恢复室,则使用重症监护病房意识模糊评估法(Confusion Assessment Method for the Intensive Care Unit, CAM-ICU)或重症监护谵妄筛查量表(Intensive Care Delirium Screening Checklist, ICDSC)
经英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)推荐,专为这些情况设计,但使用者需要接受培训,因此应用可能受限。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
考虑采取以下措施,作为降低痴呆患者住院期间谵妄风险的多元化干预措施的一部分:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
帮助患者定向;确保患者有自己的眼镜和/或助听器
使患者尽早活动
充分控制疼痛
监测和及时治疗术后并发症
维持充分的液体摄入,并帮助患者摄入足够食物
监测并维持正常的肠道和膀胱功能
根据指南的建议使用辅助吸氧。
安排与经验丰富的医疗卫生专业人士一起进行用药评估。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
如果患者的日常照护者愿意,考虑协助他们提供非医疗照护,例如在用餐时提供帮助(基于专家意见)。
痴呆是术后谵妄的危险因素之一
考虑与麻醉科医师联系以寻求有关疼痛管理的建议。[108]White S, Griffiths R, Baxter M, et al. Guidelines for the peri-operative care of people with dementia: guidelines from the Association of Anaesthetists. Anaesthesia. 2019 Jan 11;74(3):357-72https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14530http://www.ncbi.nlm.nih.gov/pubmed/30633822?tool=bestpractice.com
有证据表明,多元化方法可降低非 ICU 住院患者发生谵妄的风险。
2016 年关于预防医院非 ICU 患者谵妄的干预措施的 Cochrane 系统评价发现:[109]Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016 Mar 11;3:CD005563https://www.doi.org/10.1002/14651858.CD005563.pub3http://www.ncbi.nlm.nih.gov/pubmed/26967259?tool=bestpractice.com
来自七项研究的中等质量证据表明,与常规治疗相比,接受多元化风险降低干预的患者谵妄风险降低(RR 0.69,95% CI 0.59-0.81)。
这七项研究的干预措施包括多元组成部分:工作人员教育、针对特定危险因素的方案、训练有素的跨学科团队的参与、教育方面的专业护理干预、用药审评、鼓励活动和患者环境改善。
只有一项研究(低质量证据)纳入了已有痴呆的患者亚组,该研究报告称,疗效无显著差异(RR 0.90,95% CI 0.59-1.36)。这篇综述的作者得出结论,对于这一人群的疗效尚不确定。
另一项针对老年患者的系统评价发现,非药物多元化干预措施可有效预防谵妄。[110]Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2014 Nov 25;44(2):196-204https://www.doi.org/10.1093/ageing/afu173http://www.ncbi.nlm.nih.gov/pubmed/25424450?tool=bestpractice.com
对七项研究的荟萃分析发现,与常规治疗相比,谵妄的发生率显著降低(RR 0.73,95% CI 0.63-0.85;P <0.001)。
疗效不因痴呆的存在和病房类型而不同。
如果患者出现谵妄,需检查并治疗危及生命的病因:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
缺氧
低血糖
低血压
药物中毒或戒断,包括酒精戒断。
其他检查包括(基于专家意见):
全血细胞计数、电解质、肾功能、甲状腺功能检测、肝功能检测、钙、血糖、CRP、叶酸和维生素 B12
血培养(如果怀疑菌血症)
尿培养
胸部 X 线。
根据具体临床发现,可能需要进行更高级的非常规检查,例如头颅 CT。请与上级医生讨论。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
检查并治疗谵妄的所有可逆病因。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
疼痛
感染
营养不良
便秘
脱水
药物治疗
询问最近开的处方药,特别是阿片类镇痛药、抗焦虑药、镇静剂、抗精神病药物或抗胆碱作用强的药物。
考虑计算抗胆碱能总负担得分。
制动
睡眠差
感觉受损(如耵聍或眼镜丢失)
助记符PINCH ME可能有助于记住谵妄的潜在原因。“E”代表“环境改变”(Environmental change)。[111]Public Health England. Urinary tract infection: diagnostic tools for primary care. October 2020 [internet publication]https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis
首先使用非药物治疗管理谵妄患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
通过提供一个光线充足的房间,且将时钟和日历放置在显眼位置(例如挂在墙上),可减轻定向障碍。
鼓励家人、朋友和照护者探望患者。
使用语言和非语言技巧减轻冲突和苦恼。
如果非药物治疗无效,并且患者感到痛苦或可能对自己或他人构成危险,短期(通常仅需要 1-2 天)使用抗精神病药物或镇静剂可加以考虑,但只能作为最后的治疗手段。必须定期评估为此目的新给予的所有抗精神病药物,并在实际情况允许时予以停药(基于专家意见)。
NICE 推荐短期使用氟哌啶醇(通常短于一周),但这并不适合所有患者,并且坚决不能用于帕金森病或路易体痴呆患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 对所有禁忌证进行分析。
对于脆弱老年患者急性谵妄给予氟哌啶醇时,需特别注意给予密切监测和进行定期分析。此类患者使用该药物,出现神经系统和心脏不良反应的风险极高。[112]Medicines and Healthcare products Regulatory Agency. Haloperidol (haldol): reminder of risks when used in elderly patients for the acute treatment of delirium. 2021 [internet publication]https://www.gov.uk/drug-safety-update/haloperidol-haldol-reminder-of-risks-when-used-in-elderly-patients-for-the-acute-treatment-of-delirium
起始氟哌啶醇之前,推荐进行基线 ECG 检查,并纠正电解质紊乱。
尽可能以最低剂量和最短时间进行用药。
在治疗期间,建议对心脏和电解质进行监测,同时监测锥体外系不良反应 。
抗精神病药物治疗谵妄的有效性证据尚无定论,[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium 并且各医院方案可能不尽相同。遵循当地医院的方案选择药物。
始终从最低剂量开始服用抗精神病药,并依据症状谨慎地逐渐调整剂量。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 只能通过口服或肌内注射药物(绝对不可静脉注射)进行此类治疗。
向家庭/照护者提供信息,以便他们了解当前的情况以及如何与临床团队协作以帮助患者恢复正常生活。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
抗精神病药物与痴呆患者死亡率增加相关。
痴呆患者有时可能需要短期抗精神病药物以实现安全治疗护理。然而,抗精神病药物对老年人有多种不良反应,并与痴呆患者死亡风险增加相关。
一项 meta 分析发现,与服用安慰剂的人相比,服用非典型抗精神病药的痴呆患者死亡风险增加。[113]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
一项针对老年人的大型队列研究发现,更高剂量的抗精神病药通常与更高的风险相关。在所有研究的抗精神病药中,使用氟哌啶醇的风险最高。[114]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977https://www.doi.org/10.1136/bmj.e977http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
与普遍的看法相反,大多数痴呆患者的行为稳定后,就可以安全地停止长期抗精神病药处方。[115]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;3:CD007726.https://www.doi.org/10.1002/14651858.CD007726.pub3http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
如果谵妄在 48 小时内未对初步治疗产生反应,患者应转诊至接受过培训,且能熟练进行谵妄诊断的医疗卫生专业人士,从而确定诊断和确立治疗计划(基于专家意见)。
清楚记录谵妄诊断。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
针对特定患者群中所有患者的治疗建议
评估患者的衰弱症严重程度,以助于确定其是否需要进一步评估和加强护理,以及形成更优的管理计划以符合患者的价值观。[116]Hogervorst VM, Buurman BM, De Jonghe A, et al. Emergency department management of older people living with frailty: a guide for emergency practitioners. Emerg Med J. 2021 Sep;38(9):724-9http://www.ncbi.nlm.nih.gov/pubmed/33883216?tool=bestpractice.com
衰弱是与一种衰老过程相关的独特健康状态,在该状态下多身体系统逐渐发生功能衰退。[117]NHS England. Toolkit for general practice in supporting older people living with frailty. March 2017 [internet publication]https://www.england.nhs.uk/publication/toolkit-for-general-practice-in-supporting-older-people-living-with-frailty/
询问患者(以及可能的相关照护者的意见)其在急性发作前 2 周的能力情况。
如果患者的年龄 ≥65 岁,则采用临床衰弱量表。NHS Specialised Clinical Frailty Network: Clinical Frailty Scale
这是确定衰弱的实用辅助工具,但不应仅仅依赖它。
如果患者得分为 5 分或更高,临床适当情况下,在急性发病的 72 小时内进行老年综合评估。[118]Rockwood K; British Geriatrics Society. Silver book II: frailty. February 2021 [internet publication]https://www.bgs.org.uk/resources/silver-book-ii-frailty[119]Royal College of Physicians. Acute care toolkit 3. Acute care for older people living with frailty. December 2020 [internet publication]https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-3-acute-care-older-people-living-frailty 如果无法进行老年综合评估,就适当的当地转诊进行整体评估寻求上级医师建议。
较高的衰弱评分与不良结局风险增加有关。[120]Wallis SJ, Wall J, Biram RW, et al. Association of the clinical frailty scale with hospital outcomes. QJM. 2015 Dec;108(12):943-9https://www.doi.org/10.1093/qjmed/hcv066http://www.ncbi.nlm.nih.gov/pubmed/25778109?tool=bestpractice.com
查找有无非特异性症状,例如谵妄和跌倒。
老年综合评估是确定医疗、社会和功能需求并制定综合/协调诊疗计划来满足这些需求的多维度、多学科过程。[121]Conroy SP, Bardsley M, Smith P, et al. Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study. Health Services and Delivery Research. 2019 April:7(15)https://www.ncbi.nlm.nih.gov/books/NBK540056/pdf/Bookshelf_NBK540056.pdf
辅助实施多学科诊疗,并根据患者的价值观来调整管理方案。[122]Quinn TJ, Mooijaart SP, Gallacher K, et al. Acute care assessment of older adults living with frailty. BMJ. 2019 Jan 31;364:l13http://www.ncbi.nlm.nih.gov/pubmed/30705024?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
与患者协商后(如若可行,还可与其家属或照护者进行协商),尽早商定诊疗升级计划(基于专家意见)。这适用于所有患者,但可能与虚弱和/或患有某些合并症(如痴呆、卒中、心力衰竭、COPD 和晚期 CKD)的患者特别相关(基于专家意见)。
诊疗升级计划应包括:[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
复苏状态(即“不尝试心肺复苏”[Do Not Attempt Cardiopulmonary Resuscitation, DNACPR] 的决定)
干预上限(例如,是否适合气管插管或接受重症监护)。
升级计划应考虑到预立医疗照护计划,包括具有法律约束力的预立医疗指示。[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
应以您与患者有关其个人意愿的谈话为指导,包括帮助他们就较高强度干预措施的可能获益-风险平衡作出知情决策的讨论。
某些情况下,伴有痴呆或其他重大合并症的患者(特别是当其急性患病时),将缺乏就诊疗升级计划作出决策的心智能力。
评估并记录心智能力(在需要作出特定决策的特定时间作出决策的能力)。[124]The National Institute for Health and Care Excellence. Decision making and mental capacity. October 2018 [internet publication]https://www.nice.org.uk/guidance/ng108 请遵守您所在地区的相应法律。
在英格兰和威尔士,医疗卫生专业人士必须遵守《2005 年心智能力法》。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 进行评估时,应遵循该法案中的原则。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions
如果患者被评估为缺乏心智能力,应与其近亲协商符合“最大利益”的决策,同时考虑到患者自己先前所表达的偏好。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 根据英格兰和威尔士的《2005 年心智能力法》,如果患者“无亲无故”(即无人代表其最大利益,无人照顾赡养)而决策并非时间紧迫,则应寻找独立的有心智能力的权益维护人(independent mental capacity advocate, IMCA)来执行该任务。[126]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). January 2010 [internet publication]https://www.scie.org.uk/mca/imca/do
针对特定患者群中所有患者的治疗建议
对于任何突发不适的糖尿病患者,每天至少监测血糖水平四次(餐前以及睡前)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
当糖尿病患者被紧急收治入院时,其发生低血糖和高血糖风险增加(基于专家意见)。
在高血糖或低血糖发作后,以及更换降糖药物后,甚至需要更频繁的监测(基于专家意见)。
如果您的患者接受了手术,请遵循您当地的方案或指南制定组织的建议,例如英国围术期护理中心的血糖管理和血糖监测频率相关建议。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
所有采取可变速率静脉胰岛素输注(variable rate intravenous insulin infusion, VRIII)的患者,起初均应每小时检测毛细血管血糖(capillary blood glucose, CBG)。[129]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 根据医院 VRIII 常规进行调整。
在住院期间,支持您的患者自我管理糖尿病(包括监测血糖,在接受胰岛素治疗的患者中调整胰岛素剂量和给药),如果符合以下情况:[131]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
较为安全
患者愿意,且
其符合当地常规。
根据血糖水平进行决策,并对其加以监测。
指南制定组织尚未对住院糖尿病患者的目标血糖水平达成共识。
英国糖尿病联合会住院患者诊疗组建议糖尿病内科住院患者:
理想的范围是 6-10 mmol/L(108-180 mg/dL)。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
在一些情况下,4-12 mmol/L(72-216 mg/dL)是可接受的范围。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 4 mmol/L(72 mg/dL)的下限对于糖尿病控制极好且在自我管理的住院患者可能是可接受的水平(基于专家意见)
轻度衰弱的糖尿病住院患者的目标范围为 7.5-10 mmol/L(135-180 mg/dL),中度或重度衰弱患者的目标范围为不超过 12 mmol/L(216 mg/dL)。[133]Joint British Diabetes Societies for Inpatient Care. Inpatient care of the frail older adult with diabetes. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 12 mmol/L 的上限也可能适用于任何有跌倒高风险或痴呆的患者(基于专家意见)。
围手术期诊疗中心(Centre for Perioperative Care)建议围手术期患者维持于 6 至 10 mmol/L(108-180 mg/dL)范围内,可接受上限为 12 mmol/L(216 mg/dL)。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
英国国家卫生与临床优化研究所建议急症或接受手术的住院 1 型糖尿病成人目标血糖水平位于 5 至 8 mmol/L(90-144 mg/dL),但这一目标低于其他指南建议。[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
美国糖尿病学会建议,对于大多数危重患者和非危重患者,目标范围为 7.8 至 10 mmol/L(140-180 mg/dL)(一旦因持续性高血糖而起始胰岛素治疗)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
存在冲突的证据导致危重患者(有或无糖尿病史的混合人群)血糖控制严格程度建议具有差异。请遵循当地规程。
重症诊疗环境:
一项针对主要外科重症监护环境中的危重患者随机对照试验(randomised controlled trial, RCT)发现,严格控制血糖(4.4-6.1 mmol/L,即 80-110 mg/dL)的患者比“传统”宽松控制血糖的患者死亡率更低。[134]van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67https://www.doi.org/10.1056/NEJMoa011300http://www.ncbi.nlm.nih.gov/pubmed/11794168?tool=bestpractice.com
然而,随后在其他重症诊疗机构对危重内外科患者进行的一项多中心 RCT 研究发现,更严格的血糖控制却伴发了更高的死亡率,其原因可能在于低血糖发作更为频繁。[135]NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.https://www.doi.org/10.1056/NEJMoa0810625http://www.ncbi.nlm.nih.gov/pubmed/19318384?tool=bestpractice.com
一项 2010 年对 6 项 RCT 研究进行的系统评价和荟萃分析,对危重患者在重症诊疗机构进行严格控制血糖(4.4-6.1 mmol/L [80-110 mg/dL])与不甚严格的血糖控制进行比较,发现严格血糖控制并未显著改善死亡率,但与不甚严格的血糖控制相比,低血糖发作显著增多。[136]Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010 Mar;137(3):544-51https://www.doi.org/10.1378/chest.09-1737http://www.ncbi.nlm.nih.gov/pubmed/20018803?tool=bestpractice.com
无论是否已确诊糖尿病,住院患者的高血糖与不良患者结局有关,包括死亡率升高。[137]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
迅速采取行动治疗高血糖以避免糖尿病酮症酸中毒(diabetic ketoacidosis, DKA)和高渗性高血糖状态(hyperosmolar hyperglycaemic state, HHS),这两者均为医学急症。
如果患者的 CBG ≥15 mmol/L (≥270 mg/dL),请遵循当地医院的方案。
通常在达到该 CBG 水平时需要采取措施,但不同的当地规程可能会有稍不同的临界水平,并且可能会基于患者患 1 型还是 2 型糖尿病而有所不同。
排除 DKA或HHS,两者均需给予特定紧急处理。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
通常使用钠-葡萄糖协同转运蛋白 2(sodium-glucose co-transporter-2, SGLT2)抑制剂治疗的患者应进行血酮检测以排除血糖正常的酮症酸中毒(血糖浓度正常时的酮症酸中毒),即使已停止使用 SGLT2 抑制剂(基于专家意见)。
如果患者存在 DKA 或 HHS,向糖尿病住院患者专科医生团队寻求建议,并遵循当地医院指南,或遵循英国糖尿病住院患者联合治疗协会(British Diabetes Society for Inpatient Care, JBDS-IP)指南。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
务必尽早由熟悉 HHS 管理的临床医生对 HHS 患者进行高级检查。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 对伴其他合并症的患者,可能需要收住高依赖病房(high-dependency unit)。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
请参阅“糖尿病酮症酸中毒” 或“高渗性高血糖状态” 。
需注意,以下药物可能与高血糖具有相关性,因此需进行评估:[140]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-Induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8http://spectrum.diabetesjournals.org/content/24/4/234
皮质类固醇
部分 β 受体阻滞剂(如普萘洛尔、阿替洛尔)
噻嗪类利尿剂(例如氢氯噻嗪)
部分第二代抗精神病药物(如奥氮平、氯氮平)
某些氟喹诺酮类抗生素(如环丙沙星)
钙调磷酸酶抑制剂(如环孢素、他克莫司)
蛋白酶抑制剂(例如,作为抗逆转录病毒治疗的成分,如利托那韦)。
对于复杂型患者或高血糖难以控制的患者,可向糖尿病团队寻求专家建议。
监测血糖并根据病情和住院就餐时间调整用药,从而降低低血糖发作风险。
大约 1/5 英格兰和威尔士糖尿病住院患者被发现曾在住院期间发生过低血糖。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
病因包括:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
急性疾病痊愈
胰岛素或口服降糖药用药错误
就餐相关胰岛素治疗的给药时间错误
患者进食少,但服用相同量的糖尿病药物
睡前不食用零食
食欲减退或呕吐
若在应用胰岛素或磺脲类药物情况下,血糖降至 6 mmol/L 以下(108 mg/dL)(濒临低血糖),应考虑进行干预。
此类患者进展为低血糖的风险较高。
按照低血糖指南建议,并遵循当地规程,给予碳水化合物(参阅下文)。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果血糖低于 4 mmol/L(72 mg/dL),则应积极治疗低血糖。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 请遵循医院规程或 JBDS-IP 的低血糖管理流程。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group JBDS-IP 指南也推荐:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
10-15 分钟后重新检测血糖,以确定治疗疗效
如果已经纠正低血糖,切勿停止下一次计划的胰岛素给药。否则会导致 1 型糖尿病患者出现反弹性高血糖和 DKA。
就是否需要对患者的胰岛素治疗方案进行审查,寻求糖尿病住院专家团队的建议。
采取措施降低夜间低血糖风险。假设患者可以吞咽,他们在医院所进晚餐可能比在家进食更少。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
在没有明显高血糖的情况下,考虑入院时将晚间基础胰岛素降低 20%(基于专家意见)。
请注意,如果患者错过进餐或用药剂量过大,则低血糖更可能是磺脲类药物治疗的不良反应(例如格列本脲、格列齐特、格列美脲、格列吡嗪)。
在急症医院环境中,餐时有可能被打乱,或无法每天同一时间进餐。
应在进食前或进食时给予磺脲类药物。查看当地药物处方集获取更为具体的指导信息,了解特定磺脲类药物给药时间与进食时间的关系。
切勿在睡前服用磺脲类药物,如果患者要在晚餐时服用一次,应考虑减少晚间剂量,以降低夜间低血糖发生风险(基于专家意见)。
睡前加餐可以降低清晨低血糖的风险。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
若糖尿病患者正在接受临终关怀:
将可致低血糖药物用量减至最少,但使患者不出现有症状高血糖,其可能导致:[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
脱水
酮症
高渗性高血糖。
1 型糖尿病患者切勿停用基础胰岛素
请参阅当地常规或来自英国 TREND Diabetes 等糖尿病组织的指南。[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
针对特定患者群中所有患者的治疗建议
患者可能会忘记告诉您他们常用的吸入器。记得检查并酌情开处吸入器。
哮喘患者应继续其惯常的吸入皮质类固醇药物治疗。没有明确的医学原因,不得停止治疗。
许多吸入器含有多种药物,因此请确保不要重复开药。
对于有急性肾损伤的 COPD 或哮喘患者,如果估算 GFR <50 mL/(min·1.73 mm),可能需要暂时停用其常用的吸入性长效毒蕈碱受体拮抗剂,具体取决于其使用的特定药物。
查阅当地处方集或寻求药师建议。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能提示合并哮喘的患者发生哮喘急性发作。
根据指南建议评估严重程度和管理成人哮喘的急性加重。[144]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. July 2019 [internet publication].https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/[145]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]https://ginasthma.org/2023-gina-main-report/
请参阅“成人哮喘急性发作” 专题。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理哮喘可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com
尽管有这方面的证据,但如果合并有哮喘的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能表明合并 COPD 的患者出现急性加重。[148]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2023 [internet publication]https://goldcopd.org/2023-gold-report-2/
与其他疾患进行鉴别,如急性冠脉综合征、急性心力衰竭和肺炎。
请遵循指南建议。请参阅 “COPD 急性加重” 专题。
支气管舒张剂雾化吸入疗法应仅持续 24 至 48 小时,然后患者应换回他们常用的吸入剂(基于专家意见)。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理 COPD 可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com
尽管有这方面的证据,但如果合并有 COPD 的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
一项系统评价发现,对于 COPD 急性加重的患者,皮质类固醇的短期疗程(7 天或更短)与更长时间的传统疗程(长于 7 天)之间的结局(治疗失败、至下一次加重时间、住院时间、肺功能、不良反应、死亡率)没有差异。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
此 Cochrane 评价中包括的随机对照试验均在医院环境内进行,且仅涉及重度至极重度 COPD 患者。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
该评价的作者得出结论,由于增加了一项新的试验,他们更加确信大约 5 天的皮质类固醇疗程可能足以治疗 COPD 急性加重。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
同样,在 2019 年对证据进行了一次评价后,英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)建议在 COPD 加重期间提供泼尼松龙治疗 5 天。[150]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication]https://www.nice.org.uk/guidance/ng115
针对特定患者群中所有患者的治疗建议
在临床情况允许以及患者有反应的情况下进行精神状态检查(基于专家意见)。
精神状态检查是精神病学临床实践中常规使用的主要临床工具之一,有助于诊断并指导进一步的管理。情绪是其中一项评估内容。
考虑使用 PHQ-9 问卷评估抑郁。[151]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
这是一份自测问卷,仅需不到 3 分钟即可完成。
结果可提示抑郁症状的严重程度。
应将得分为 5 分或以上的患者转诊至接受联络精神病学服务(基于专家意见)。
考虑可能影响患者精神状态的其他因素(例如,非法成瘾物质或酒精的作用)。[152]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14.http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
如果紧急临床情况允许,询问患者正在服用哪些药物治疗抑郁。或查看其初级卫生保健记录,获取相关信息(若可获取)。
为患者开具其常用的抗抑郁药,除非有充分的理由不得这样做(基于专家意见)。
如果突然停用抗抑郁药,患者可能会出现停药症状。[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
停药症状的严重程度可能不一,但可能令人不快,并使急性疾病的管理复杂化。[154]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91
审评当前药物时,需注意以下情况:
当前和既往不良反应
近期用药剂量改变
最近换了一种不同类别的药物
特定抑郁症亚型的药物细微差别(例如,精神病性抑郁症患者很可能会同时服用抗精神病处方药)
治疗难治性抑郁症时可能使用的增强策略(如锂剂或喹硫平加选择性 5-羟色胺再摄取抑制剂 [selective serotonin-reuptake inhibitor, SSRI])。
考虑药物相互作用。
抗抑郁药可能会与用于其他疾病的药物发生药代动力学(通过抑制 CYP450 通路)和药效动力学相互作用。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
开具非精神类药物时,应考虑精神并发症。
开具抗惊厥药物、抗帕金森病药物和皮质类固醇时,应格外小心。
考虑不良反应,具体可能包括以下不良反应。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021
低钠血症,由抗抑郁药(尤其是 SSRI)引起,会因使用同时开具的其他药物(例如利尿药)而加重。请检查患者的血清电解质。
5-羟色胺综合征(精神状态改变、激越、震颤、反射亢进、阵挛、肌强直、大量出汗、心动过速、肠鸣音增加、体温 >38℃),尤其是在多重用药和/或 5-羟色胺能药物过量时。[156]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com[157]Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014 Feb 19;348:g1626http://www.ncbi.nlm.nih.gov/pubmed/24554467?tool=bestpractice.com
特别要注意的是,服用 SSRI 的终末期肾病患者 5-羟色胺综合征的风险增加。治疗肾脏损伤患者的抑郁需要采取多学科方法,并需要格外谨慎。
肝毒性。必要时调整肝功能受损患者的抗抑郁药物剂量,避免使用已知具有肝毒性的药物。
与三环类抗抑郁药相关的 QTc 延长、心律失常、心率加快、体位性低血压。查看 ECG,特别是有心律失常风险的人群。
消化道出血。SSRI 与消化道出血风险增加相关。[158]Dalton SO, Sørensen HT, Johansen C. SSRIs and upper gastrointestinal bleeding: what is known and how should it influence prescribing? CNS Drugs. 2006;20(2):143-51http://www.ncbi.nlm.nih.gov/pubmed/16478289?tool=bestpractice.com[159]Dalton SO, Johansen C, Mellemkjaer L, et al. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study. Arch Intern Med. 2003 Jan 13;163(1):59-64https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/214901http://www.ncbi.nlm.nih.gov/pubmed/12523917?tool=bestpractice.com[160]Cheng YL, Hu HY, Lin XH, et al. Use of SSRI, but not SNRI, increased upper and lower gastrointestinal bleeding: a nationwide population-based cohort study in Taiwan. Medicine (Baltimore). 2015 Nov;94(46):e2022https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652818/http://www.ncbi.nlm.nih.gov/pubmed/26579809?tool=bestpractice.com与阿司匹林、非甾体抗炎药(non-steroidal anti-inflammatory drugs, NSAID)或口服抗凝剂联用时,风险尤其增加。[161]Loke YK, Trivedi AN, Singh S. Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther. 2008 Jan 1;27(1):31-40https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2007.03541.xhttp://www.ncbi.nlm.nih.gov/pubmed/17919277?tool=bestpractice.com
此清单并未详尽列出全部不良反应——请参阅当地处方集以获取更多信息。请咨询您联络的精神病学同事和/或药剂师以获取建议。
请询问患者通过哪些非药物治疗方法管理抑郁,并核实其目前在社区获得的支持情况。
这可能包括参与其护理的其他医疗卫生专业人士、慈善机构、家庭和社会网络以及心理治疗。
请注意,戒烟或从吸烟转为其他替代方案(包括尼古丁替代疗法)可能导致患者服用的精神类药物(例如,治疗抑郁的药物)血浆浓度发生变化。这是因为尼古丁替代治疗并不会像吸烟那样影响肝酶活性。[162]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid. 2016 Jun;11(6)4-7https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602[163]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com[164]Oliveira P, Ribeiro J, Donato H, Madeira N. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017;16:17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com[165]National Centre for Smoking Cessation and Training. Smoking cessation and mental health. 2014 [internet publication]https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf寻求相关建议,确认精神类药物剂量调整是否适当。
针对特定患者群中所有患者的治疗建议
考虑将任何因急性疾病入院且伴有抑郁的患者转诊至联络精神病学团队/服务机构。[166]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. March 2018 [internet publication]https://www.nice.org.uk/guidance/ng94[167]National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Treat as one. Bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
如果不存在抑郁和/或其管理可能影响急性病情的顾虑,则可能不需要转诊(基于专家意见)。
对于情况不明的事故、自伤行为和/或自杀企图,都应临床怀疑共病精神障碍(基于专家意见)。
合并抑郁症与对推荐的躯体健康治疗(从药物治疗到康复治疗)的依从性差有关。[168]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
这可能导致更差的临床结局,包括更高的再入院风险。[169]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(S7):S54-60http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com[170]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91[171]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33https://www.sciencedirect.com/science/article/pii/S0022399914003821http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com
最为重要的是,包括抑郁在内的情感症状与高死亡率有关,但其因果关系仍有待证实。[172]Archer G, Kuh D, Hotopf M, et al. Association between lifetime affective symptoms and premature mortality. JAMA Psychiatry. 2020 Aug 1;77(8):806-13https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2763796http://www.ncbi.nlm.nih.gov/pubmed/32267482?tool=bestpractice.com[173]Machado MO, Veronese N, Sanches M, et al. The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses. BMC Med. 2018 Jul 20;16(1):112https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1101-zhttp://www.ncbi.nlm.nih.gov/pubmed/30025524?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
对所有糖尿病患者在入院时和不适加重时进行足部检查。[174]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. October 2019 [internet publication]https://www.nice.org.uk/guidance/ng19
这是为了发现新的溃疡或感染,这些溃疡或感染可能被患者忽视,甚至可能是引发其急性病的原因(例如,出现脓毒症或心内膜炎的患者,其感染的原发灶是足部病变)。
检查足部有无病损,并检查保护性感觉是否丧失。
遵循当地指南,但有一个快速简单的试验:Ipswich Touch Test©(伊普斯威奇触摸试验),即将食指指尖轻轻触摸/放置在第一、第三和第五个足趾趾尖上 1 到 2 秒。[175]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 May 18;34(7):1517-8https://www.doi.org/10.2337/dc11-0156http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
如果患者在这六个部位中的两个或以上没有感觉,则代表其保护性感觉减退。
如果患者有感觉减退,则其有较高的压疮风险。告知其护理人员并提供减压装置。
护理人员或医疗人员应每日进行踝部检查,注意压力性创伤征象。
对于糖尿病患者是否应该使用弹力袜存在争议——如果有血管疾病,请勿使用。
针对特定患者群中所有患者的治疗建议
如果患者为当前吸烟者,请提供戒烟支持途径。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209 恰当的时机取决于具体的临床情况。一般情况下,英国国家卫生与临床优化研究所建议应立刻或在 24 小时内提供戒烟途径。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
对于所有吸烟的住院患者,如果没有禁忌证,应提供尼古丁替代疗法(nicotine replacement therapy, NRT)和其他戒烟药物疗法。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
建议:[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
尼古丁很容易使人成瘾,但这不是吸烟相关危害的原因。
NRT 可防止入院期间快速戒断,快速戒断可能会导致痛苦和不适。
当与专科支持相结合时,有数种高效的治疗选择能提供最大的戒烟可能性。
由于联合 NRT 比单一 NRT 有效,应将长效制剂 NRT(例如,透皮贴剂)与短效制剂 NRT(例如,咀嚼胶、锭剂、舌下片剂、吸入剂、口腔黏膜或鼻喷雾剂)联用来实施 NRT。 [177]Theodoulou A, Chepkin SC, Ye W, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2023 Jun 19;6(6):CD013308https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/37335995?tool=bestpractice.com[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
询问醒后至吸第一根烟的时间。短于 30 分钟的答案可提示这些患者可能有更多的尼古丁依赖问题,从而能指导选择尼古丁透皮贴剂的剂量。
查阅当地的处方集,以了解各种注意事项,尤其当患者有一种或多种合并症和/或血流动力学不稳定时。
对于任何有意戒烟的患者,可考虑 联合使用伐尼克兰和 NRT ,因为这是一种对成人戒烟非常有效的组合。 [179]Thomas KH, Dalili MN, López-López JA, et al. Comparative clinical effectiveness and safety of tobacco cessation pharmacotherapies and electronic cigarettes: a systematic review and network meta-analysis of randomized controlled trials. Addiction. 2022 Apr;117(4):861-76.https://onlinelibrary.wiley.com/doi/10.1111/add.15675http://www.ncbi.nlm.nih.gov/pubmed/34636108?tool=bestpractice.com 对于烟草依赖,联合治疗比使用单一药物更有效。[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
一项 Cochrane 评价发现,有高确定性证据表明伐尼克兰是烟草依赖的有效治疗方法。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 该评价还发现,伐尼克兰使用者出现导致住院的严重不良反应(例如心脏问题)几率可能会增加;但这种情况仍属罕见(伐尼克兰使用者中有 2.7%-4.0% 出现这种情况,而未使用伐尼克兰者中仅 2.7% 出现这种情况),并且其中可能包括与伐尼克兰无关的不良反应。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 查阅当地处方集,以获取关于禁忌证/注意事项的完整清单,或者寻求药师建议。
心理卫生疾病不是开具伐尼克兰的禁忌证。然而,对于已患精神疾病的患者,应谨慎使用伐尼克兰,因为该药可能加重症状。
对于戒烟,安非他酮是另一种选择,但是取得成功的可能性更低。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 应考虑药物相互作用的可能性。
完成到烟草依赖执业医师/服务机构的转诊。
如果发生梗阻,应将患者转诊立即接受泌尿科会诊。
引流的方式有两种。泌尿科医生可在梗阻部位放置一根输尿管支架,实现引流。另外还可通过影像学介入技术进行经皮肾造瘘置管。
引流数日之后再实施确定性取石术。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/ 然后根据结石部位和大小处理结石(见下文)。
针对特定患者群中所有患者的治疗建议
在患者入院时检查其血糖水平和 HbA1c。
排除低血糖、糖尿病酮症酸中毒(diabetic ketoacidosis, DKA),以及高渗性高血糖状态,这些均为医学急症。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[84]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
入院 HbA1c 可能会提示您患者既往糖尿病控制情况,并可能影响出院时的治疗(基于专家意见)。
对于患急性疾病或发生损伤的 1 型糖尿病患者,切勿停止使用基础胰岛素(长效/背景胰岛素 [例如,地特胰岛素、甘精胰岛素或德谷胰岛素])。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
胰岛素缺乏(例如由于用药延迟或漏用)会迅速引起酮症酸中毒。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
将任何使用胰岛素泵入院的糖尿病患者转诊至糖尿病专家团队。[86]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
一般情况下,所有接受基础胰岛素治疗的 2 型糖尿病患者均应继续接受治疗,但情况可能并非总是如此,因此应咨询您上级医生和/或糖尿病专科医生团队意见(基于专家意见)。
在患者入院时,考虑是否需要调整其胰岛素剂量。
如果 1 型或 2 型糖尿病患者正在使用胰岛素,血糖控制良好,入院时未出现严重的高血糖,则可能适当将基础胰岛素剂量减少 20%,尤其是当他们的进食量不及平时在家中时。需要考虑到的另一个因素是医院的膳食通常比患者在家的膳食含有更少的碳水化合物。
相反,危重症感染患者有时需要更高剂量的胰岛素。
定期监测血糖(每日至少 4 次)有助于指导合理调整胰岛素剂量。如有疑问,应寻求专家意见。
应尽早向糖尿病住院团队寻求专家建议,尤其是当诊疗较为复杂(例如,存在代谢紊乱、复发性或重度低血糖、持续高血糖),或者患者需要接受一段时间的肠内喂饲时。[87]Joint British Diabetes Societies for Inpatient Care. Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes. Nov 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 糖尿病团队还将能够就住院期间最合适的胰岛素方案和给药提出建议。
可变速率静脉胰岛素输注(VRIII)指征包括:[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[89]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
罹患糖尿病或医院相关性高血糖,且其无法进食或饮水,并无法调整胰岛素治疗方案的患者。例如,当:
呕吐
禁食禁饮,患者多餐不进
存在严重疾病,需要实现良好的血糖控制(例如脓毒症)。
需进行急诊手术的糖尿病患者可能需要给予 VRIII。遵循当地常规或英国围手术期诊疗中心建议。[90]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
在这些情况下,请从糖尿病团队获取专科医生建议。
若起始 VRIII:
始终持续给予基础胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果 VRIII 意外中断(例如由于导管移位或阻塞)或关闭(例如在转移病房期间),这会降低发生酮症的风险。
采用 VRIII 时让患者停用常规速效和混合胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
尽可能缩短使用 VRIII 的时间。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
遵循医院常规,执行包括停药在内的正确处理。
对于因 急性病症 入院的糖尿病患者,考虑停止或调整口服降糖药 。
以下所有患者应停用二甲双胍:[91]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
存在禁忌证,例如严重的肾脏损伤(eGRF <30 mL/[min·1.73m]),无论是慢性还是继发于急症。
伴代谢性酸中毒(包括乳酸酸中毒和糖尿病酮症酸中毒)
服用二甲双胍可能存在引发乳酸酸中毒风险。这包括与急性肾损伤、组织缺氧(包括急性心力衰竭或呼吸衰竭)有关的疾病,脱水,或已经/准长时间禁食或将要注射不透射线造影剂进行影像学检查的患者存在肾脏损伤(基于专家意见)。遵循当地常规,了解提示肾脏损伤的具体 eGFR 水平,以指导用药。
请注意,停用二甲双胍可导致高血糖。
如果您的患者正在服用其他降糖药物,这些药物可能需要增加剂量;如果没有,可能需要开处另一种降糖药(基于专家意见)。
一些患者可能需要胰岛素作为临时措施,但请寻求糖尿病住院专科医生团队的建议。
如果患者新近出现肾功能受损或恶化,或进食量比平时少,则应减少格列齐特剂量或停服一次药物,以免出现夜间低血糖。
对于所有危重症患者(包括进行大手术的患者),尤其是脱水或感染的情况下,应停用钠-葡萄糖协同转运蛋白-2(sodium-glucose cotransporter-2, SGLT-2)抑制剂并监测血酮,从而降低血糖正常的酮症酸中毒风险。[92]Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness. March 2020 [internet publication]https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness
SGLT-2 抑制剂(例如,达格列净、卡格列净、恩格列净)可减少肾脏中的血糖重吸收(与葡萄糖的胰岛素代谢无关)。[93]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Jun 15;38(9):1687-93http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com
它们可以掩盖潜在的酮症酸中毒,因为患者的血糖水平可能正常或接近正常(血糖正常的酮症酸中毒)。
检测血酮,因为尿酮体检测可能并不可靠。
如果毛细血管或血液中的酮体浓度为 >3 mmol/L ,或有 明显的酮尿(标准尿液试纸检测显示 2+ 或更多),且静脉 pH 值为 <7.3 和/或碳酸氢根浓度 <15 mmol/L ,则应治疗糖尿病酮症酸中毒 。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
针对特定患者群中所有患者的治疗建议
如同处理所有因急症而入院的患者,应对患者基线肾功能进行检查 ,如果患者具有 CKD 病史,需予以特别密切的监测。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
CKD 是急性肾损伤重要危险因素。[95]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Apr 2;74(1):101-7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
急症可增加肾功能恶化风险。
对少尿进行监测并予以处理。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
针对特定患者群中所有患者的治疗建议
对任何有卒中病史的患者,请在适当的时机尽早进行基线神经系统评估。
伴有急症(例如感染和疾病相关性低血压)的患者卒中风险升高(缺血性和出血性)。[96]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Nov 9;6(12):681-94http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com[97]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com 有卒中病史的患者风险更高。
如果在住院期间神经系统状态发生变化,应重复进行神经系统评估,从而防止再次发生卒中。
进行评估之后,应确保对患者进行适当的监护(例如需结合夜间意识模糊风险和机体脆弱相关性跌倒风险制定监护计划)。有卒中病史的患者跌倒和受伤的风险增加。[98]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 May 4;47(6):e98-e169https://www.doi.org/10.1161/STR.0000000000000098http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
尽早对具有痴呆病史的患者进行基线认知评估,并通过家人、朋友或照护者获取旁证病史。[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
使用在急性情况下可行的经过验证的评分系统,例如:[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
简化智力测试量表/10(AMTS/10)[100]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.comBritish Geriatrics Society: Abbreviated Mental Test Score. 2018
旁证病史可确定患者的认知是否稳定,或者认知和功能是逐渐下降还是急性下降。
标准化认知评估评分将有助于监测所有临床改善, 以及确定出院需求。判读该分数时,最好结合功能评估(通常由经过培训的职业治疗师进行)。
尽管由于急性疾患及其治疗的影响,该评分可能并不代表患者平时的认知基线,但当患者恢复后,记录并重复该评分仍然是很好的做法(基于专家意见)。
每当痴呆患者出现急性疾病时都要进行谵妄评估。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
伴痴呆者入院时和整个住院期间发生谵妄的风险增加。[102]National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers. Jun 2018 [internet publication].https://www.nice.org.uk/guidance/ng97[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
谵妄与痴呆不同。[104]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]http://ltctoolkit.rnao.ca/node/1774 谵妄是指精神功能出现潜在致死性的急性波动性改变,伴有注意力缺乏、思维混乱和意识水平的改变。[105]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
使用筛查工具检测可能出现的谵妄,例如:
4-AT[106]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Mar 2;43(4):496-502.https://www.doi.org/10.1093/ageing/afu021http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[107]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194https://www.doi.org/10.3310/hta23400http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
关于 4-AT 计算的更多信息已由苏格兰校际指南网络发布SIGN Decision Support: delirium - risk reduction and management.
如果患者处于危重症监护环境或术后恢复室,则使用重症监护病房意识模糊评估法(Confusion Assessment Method for the Intensive Care Unit, CAM-ICU)或重症监护谵妄筛查量表(Intensive Care Delirium Screening Checklist, ICDSC)
经英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)推荐,专为这些情况设计,但使用者需要接受培训,因此应用可能受限。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
考虑采取以下措施,作为降低痴呆患者住院期间谵妄风险的多元化干预措施的一部分:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
帮助患者定向;确保患者有自己的眼镜和/或助听器
使患者尽早活动
充分控制疼痛
监测和及时治疗术后并发症
维持充分的液体摄入,并帮助患者摄入足够食物
监测并维持正常的肠道和膀胱功能
根据指南的建议使用辅助吸氧。
安排与经验丰富的医疗卫生专业人士一起进行用药评估。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
如果患者的日常照护者愿意,考虑协助他们提供非医疗照护,例如在用餐时提供帮助(基于专家意见)。
痴呆是术后谵妄的危险因素之一
考虑与麻醉科医师联系以寻求有关疼痛管理的建议。[108]White S, Griffiths R, Baxter M, et al. Guidelines for the peri-operative care of people with dementia: guidelines from the Association of Anaesthetists. Anaesthesia. 2019 Jan 11;74(3):357-72https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14530http://www.ncbi.nlm.nih.gov/pubmed/30633822?tool=bestpractice.com
有证据表明,多元化方法可降低非 ICU 住院患者发生谵妄的风险。
2016 年关于预防医院非 ICU 患者谵妄的干预措施的 Cochrane 系统评价发现:[109]Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016 Mar 11;3:CD005563https://www.doi.org/10.1002/14651858.CD005563.pub3http://www.ncbi.nlm.nih.gov/pubmed/26967259?tool=bestpractice.com
来自七项研究的中等质量证据表明,与常规治疗相比,接受多元化风险降低干预的患者谵妄风险降低(RR 0.69,95% CI 0.59-0.81)。
这七项研究的干预措施包括多元组成部分:工作人员教育、针对特定危险因素的方案、训练有素的跨学科团队的参与、教育方面的专业护理干预、用药审评、鼓励活动和患者环境改善。
只有一项研究(低质量证据)纳入了已有痴呆的患者亚组,该研究报告称,疗效无显著差异(RR 0.90,95% CI 0.59-1.36)。这篇综述的作者得出结论,对于这一人群的疗效尚不确定。
另一项针对老年患者的系统评价发现,非药物多元化干预措施可有效预防谵妄。[110]Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2014 Nov 25;44(2):196-204https://www.doi.org/10.1093/ageing/afu173http://www.ncbi.nlm.nih.gov/pubmed/25424450?tool=bestpractice.com
对七项研究的荟萃分析发现,与常规治疗相比,谵妄的发生率显著降低(RR 0.73,95% CI 0.63-0.85;P <0.001)。
疗效不因痴呆的存在和病房类型而不同。
如果患者出现谵妄,需检查并治疗危及生命的病因:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
缺氧
低血糖
低血压
药物中毒或戒断,包括酒精戒断。
其他检查包括(基于专家意见):
全血细胞计数、电解质、肾功能、甲状腺功能检测、肝功能检测、钙、血糖、CRP、叶酸和维生素 B12
血培养(如果怀疑菌血症)
尿培养
胸部 X 线。
根据具体临床发现,可能需要进行更高级的非常规检查,例如头颅 CT。请与上级医生讨论。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
检查并治疗谵妄的所有可逆病因。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
疼痛
感染
营养不良
便秘
脱水
药物治疗
询问最近开的处方药,特别是阿片类镇痛药、抗焦虑药、镇静剂、抗精神病药物或抗胆碱作用强的药物。
考虑计算抗胆碱能总负担得分。
制动
睡眠差
感觉受损(如耵聍或眼镜丢失)
助记符PINCH ME可能有助于记住谵妄的潜在原因。“E”代表“环境改变”(Environmental change)。[111]Public Health England. Urinary tract infection: diagnostic tools for primary care. October 2020 [internet publication]https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis
首先使用非药物治疗管理谵妄患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
通过提供一个光线充足的房间,且将时钟和日历放置在显眼位置(例如挂在墙上),可减轻定向障碍。
鼓励家人、朋友和照护者探望患者。
使用语言和非语言技巧减轻冲突和苦恼。
如果非药物治疗无效,并且患者感到痛苦或可能对自己或他人构成危险,短期(通常仅需要 1-2 天)使用抗精神病药物或镇静剂可加以考虑,但只能作为最后的治疗手段。必须定期评估为此目的新给予的所有抗精神病药物,并在实际情况允许时予以停药(基于专家意见)。
NICE 推荐短期使用氟哌啶醇(通常短于一周),但这并不适合所有患者,并且坚决不能用于帕金森病或路易体痴呆患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 对所有禁忌证进行分析。
对于脆弱老年患者急性谵妄给予氟哌啶醇时,需特别注意给予密切监测和进行定期分析。此类患者使用该药物,出现神经系统和心脏不良反应的风险极高。[112]Medicines and Healthcare products Regulatory Agency. Haloperidol (haldol): reminder of risks when used in elderly patients for the acute treatment of delirium. 2021 [internet publication]https://www.gov.uk/drug-safety-update/haloperidol-haldol-reminder-of-risks-when-used-in-elderly-patients-for-the-acute-treatment-of-delirium
起始氟哌啶醇之前,推荐进行基线 ECG 检查,并纠正电解质紊乱。
尽可能以最低剂量和最短时间进行用药。
在治疗期间,建议对心脏和电解质进行监测,同时监测锥体外系不良反应 。
抗精神病药物治疗谵妄的有效性证据尚无定论,[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium 并且各医院方案可能不尽相同。遵循当地医院的方案选择药物。
始终从最低剂量开始服用抗精神病药,并依据症状谨慎地逐渐调整剂量。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 只能通过口服或肌内注射药物(绝对不可静脉注射)进行此类治疗。
向家庭/照护者提供信息,以便他们了解当前的情况以及如何与临床团队协作以帮助患者恢复正常生活。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
抗精神病药物与痴呆患者死亡率增加相关。
痴呆患者有时可能需要短期抗精神病药物以实现安全治疗护理。然而,抗精神病药物对老年人有多种不良反应,并与痴呆患者死亡风险增加相关。
一项 meta 分析发现,与服用安慰剂的人相比,服用非典型抗精神病药的痴呆患者死亡风险增加。[113]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
一项针对老年人的大型队列研究发现,更高剂量的抗精神病药通常与更高的风险相关。在所有研究的抗精神病药中,使用氟哌啶醇的风险最高。[114]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977https://www.doi.org/10.1136/bmj.e977http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
与普遍的看法相反,大多数痴呆患者的行为稳定后,就可以安全地停止长期抗精神病药处方。[115]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;3:CD007726.https://www.doi.org/10.1002/14651858.CD007726.pub3http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
如果谵妄在 48 小时内未对初步治疗产生反应,患者应转诊至接受过培训,且能熟练进行谵妄诊断的医疗卫生专业人士,从而确定诊断和确立治疗计划(基于专家意见)。
清楚记录谵妄诊断。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
针对特定患者群中所有患者的治疗建议
评估患者的衰弱症严重程度,以助于确定其是否需要进一步评估和加强护理,以及形成更优的管理计划以符合患者的价值观。[116]Hogervorst VM, Buurman BM, De Jonghe A, et al. Emergency department management of older people living with frailty: a guide for emergency practitioners. Emerg Med J. 2021 Sep;38(9):724-9http://www.ncbi.nlm.nih.gov/pubmed/33883216?tool=bestpractice.com
衰弱是与一种衰老过程相关的独特健康状态,在该状态下多身体系统逐渐发生功能衰退。[117]NHS England. Toolkit for general practice in supporting older people living with frailty. March 2017 [internet publication]https://www.england.nhs.uk/publication/toolkit-for-general-practice-in-supporting-older-people-living-with-frailty/
询问患者(以及可能的相关照护者的意见)其在急性发作前 2 周的能力情况。
如果患者的年龄 ≥65 岁,则采用临床衰弱量表。NHS Specialised Clinical Frailty Network: Clinical Frailty Scale
这是确定衰弱的实用辅助工具,但不应仅仅依赖它。
如果患者得分为 5 分或更高,临床适当情况下,在急性发病的 72 小时内进行老年综合评估。[118]Rockwood K; British Geriatrics Society. Silver book II: frailty. February 2021 [internet publication]https://www.bgs.org.uk/resources/silver-book-ii-frailty[119]Royal College of Physicians. Acute care toolkit 3. Acute care for older people living with frailty. December 2020 [internet publication]https://www.rcplondon.ac.uk/guidelines-policy/acute-care-toolkit-3-acute-care-older-people-living-frailty 如果无法进行老年综合评估,就适当的当地转诊进行整体评估寻求上级医师建议。
较高的衰弱评分与不良结局风险增加有关。[120]Wallis SJ, Wall J, Biram RW, et al. Association of the clinical frailty scale with hospital outcomes. QJM. 2015 Dec;108(12):943-9https://www.doi.org/10.1093/qjmed/hcv066http://www.ncbi.nlm.nih.gov/pubmed/25778109?tool=bestpractice.com
查找有无非特异性症状,例如谵妄和跌倒。
老年综合评估是确定医疗、社会和功能需求并制定综合/协调诊疗计划来满足这些需求的多维度、多学科过程。[121]Conroy SP, Bardsley M, Smith P, et al. Comprehensive geriatric assessment for frail older people in acute hospitals: the HoW-CGA mixed-methods study. Health Services and Delivery Research. 2019 April:7(15)https://www.ncbi.nlm.nih.gov/books/NBK540056/pdf/Bookshelf_NBK540056.pdf
辅助实施多学科诊疗,并根据患者的价值观来调整管理方案。[122]Quinn TJ, Mooijaart SP, Gallacher K, et al. Acute care assessment of older adults living with frailty. BMJ. 2019 Jan 31;364:l13http://www.ncbi.nlm.nih.gov/pubmed/30705024?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
与患者协商后(如若可行,还可与其家属或照护者进行协商),尽早商定诊疗升级计划(基于专家意见)。这适用于所有患者,但可能与虚弱和/或患有某些合并症(如痴呆、卒中、心力衰竭、COPD 和晚期 CKD)的患者特别相关(基于专家意见)。
诊疗升级计划应包括:[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
复苏状态(即“不尝试心肺复苏”[Do Not Attempt Cardiopulmonary Resuscitation, DNACPR] 的决定)
干预上限(例如,是否适合气管插管或接受重症监护)。
升级计划应考虑到预立医疗照护计划,包括具有法律约束力的预立医疗指示。[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
应以您与患者有关其个人意愿的谈话为指导,包括帮助他们就较高强度干预措施的可能获益-风险平衡作出知情决策的讨论。
某些情况下,伴有痴呆或其他重大合并症的患者(特别是当其急性患病时),将缺乏就诊疗升级计划作出决策的心智能力。
评估并记录心智能力(在需要作出特定决策的特定时间作出决策的能力)。[124]The National Institute for Health and Care Excellence. Decision making and mental capacity. October 2018 [internet publication]https://www.nice.org.uk/guidance/ng108 请遵守您所在地区的相应法律。
在英格兰和威尔士,医疗卫生专业人士必须遵守《2005 年心智能力法》。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 进行评估时,应遵循该法案中的原则。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions
如果患者被评估为缺乏心智能力,应与其近亲协商符合“最大利益”的决策,同时考虑到患者自己先前所表达的偏好。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 根据英格兰和威尔士的《2005 年心智能力法》,如果患者“无亲无故”(即无人代表其最大利益,无人照顾赡养)而决策并非时间紧迫,则应寻找独立的有心智能力的权益维护人(independent mental capacity advocate, IMCA)来执行该任务。[126]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). January 2010 [internet publication]https://www.scie.org.uk/mca/imca/do
针对特定患者群中所有患者的治疗建议
对于任何突发不适的糖尿病患者,每天至少监测血糖水平四次(餐前以及睡前)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
当糖尿病患者被紧急收治入院时,其发生低血糖和高血糖风险增加(基于专家意见)。
在高血糖或低血糖发作后,以及更换降糖药物后,甚至需要更频繁的监测(基于专家意见)。
如果您的患者接受了手术,请遵循您当地的方案或指南制定组织的建议,例如英国围术期护理中心的血糖管理和血糖监测频率相关建议。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
所有采取可变速率静脉胰岛素输注(variable rate intravenous insulin infusion, VRIII)的患者,起初均应每小时检测毛细血管血糖(capillary blood glucose, CBG)。[129]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 根据医院 VRIII 常规进行调整。
在住院期间,支持您的患者自我管理糖尿病(包括监测血糖,在接受胰岛素治疗的患者中调整胰岛素剂量和给药),如果符合以下情况:[131]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
较为安全
患者愿意,且
其符合当地常规。
根据血糖水平进行决策,并对其加以监测。
指南制定组织尚未对住院糖尿病患者的目标血糖水平达成共识。
英国糖尿病联合会住院患者诊疗组建议糖尿病内科住院患者:
理想的范围是 6-10 mmol/L(108-180 mg/dL)。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
在一些情况下,4-12 mmol/L(72-216 mg/dL)是可接受的范围。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 4 mmol/L(72 mg/dL)的下限对于糖尿病控制极好且在自我管理的住院患者可能是可接受的水平(基于专家意见)
轻度衰弱的糖尿病住院患者的目标范围为 7.5-10 mmol/L(135-180 mg/dL),中度或重度衰弱患者的目标范围为不超过 12 mmol/L(216 mg/dL)。[133]Joint British Diabetes Societies for Inpatient Care. Inpatient care of the frail older adult with diabetes. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 12 mmol/L 的上限也可能适用于任何有跌倒高风险或痴呆的患者(基于专家意见)。
围手术期诊疗中心(Centre for Perioperative Care)建议围手术期患者维持于 6 至 10 mmol/L(108-180 mg/dL)范围内,可接受上限为 12 mmol/L(216 mg/dL)。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
英国国家卫生与临床优化研究所建议急症或接受手术的住院 1 型糖尿病成人目标血糖水平位于 5 至 8 mmol/L(90-144 mg/dL),但这一目标低于其他指南建议。[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
美国糖尿病学会建议,对于大多数危重患者和非危重患者,目标范围为 7.8 至 10 mmol/L(140-180 mg/dL)(一旦因持续性高血糖而起始胰岛素治疗)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
存在冲突的证据导致危重患者(有或无糖尿病史的混合人群)血糖控制严格程度建议具有差异。请遵循当地规程。
重症诊疗环境:
一项针对主要外科重症监护环境中的危重患者随机对照试验(randomised controlled trial, RCT)发现,严格控制血糖(4.4-6.1 mmol/L,即 80-110 mg/dL)的患者比“传统”宽松控制血糖的患者死亡率更低。[134]van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67https://www.doi.org/10.1056/NEJMoa011300http://www.ncbi.nlm.nih.gov/pubmed/11794168?tool=bestpractice.com
然而,随后在其他重症诊疗机构对危重内外科患者进行的一项多中心 RCT 研究发现,更严格的血糖控制却伴发了更高的死亡率,其原因可能在于低血糖发作更为频繁。[135]NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.https://www.doi.org/10.1056/NEJMoa0810625http://www.ncbi.nlm.nih.gov/pubmed/19318384?tool=bestpractice.com
一项 2010 年对 6 项 RCT 研究进行的系统评价和荟萃分析,对危重患者在重症诊疗机构进行严格控制血糖(4.4-6.1 mmol/L [80-110 mg/dL])与不甚严格的血糖控制进行比较,发现严格血糖控制并未显著改善死亡率,但与不甚严格的血糖控制相比,低血糖发作显著增多。[136]Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010 Mar;137(3):544-51https://www.doi.org/10.1378/chest.09-1737http://www.ncbi.nlm.nih.gov/pubmed/20018803?tool=bestpractice.com
无论是否已确诊糖尿病,住院患者的高血糖与不良患者结局有关,包括死亡率升高。[137]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
迅速采取行动治疗高血糖以避免糖尿病酮症酸中毒(diabetic ketoacidosis, DKA)和高渗性高血糖状态(hyperosmolar hyperglycaemic state, HHS),这两者均为医学急症。
如果患者的 CBG ≥15 mmol/L (≥270 mg/dL),请遵循当地医院的方案。
通常在达到该 CBG 水平时需要采取措施,但不同的当地规程可能会有稍不同的临界水平,并且可能会基于患者患 1 型还是 2 型糖尿病而有所不同。
排除 DKA或HHS,两者均需给予特定紧急处理。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
通常使用钠-葡萄糖协同转运蛋白 2(sodium-glucose co-transporter-2, SGLT2)抑制剂治疗的患者应进行血酮检测以排除血糖正常的酮症酸中毒(血糖浓度正常时的酮症酸中毒),即使已停止使用 SGLT2 抑制剂(基于专家意见)。
如果患者存在 DKA 或 HHS,向糖尿病住院患者专科医生团队寻求建议,并遵循当地医院指南,或遵循英国糖尿病住院患者联合治疗协会(British Diabetes Society for Inpatient Care, JBDS-IP)指南。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
务必尽早由熟悉 HHS 管理的临床医生对 HHS 患者进行高级检查。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 对伴其他合并症的患者,可能需要收住高依赖病房(high-dependency unit)。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
请参阅“糖尿病酮症酸中毒” 或“高渗性高血糖状态” 。
需注意,以下药物可能与高血糖具有相关性,因此需进行评估:[140]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-Induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8http://spectrum.diabetesjournals.org/content/24/4/234
皮质类固醇
部分 β 受体阻滞剂(如普萘洛尔、阿替洛尔)
噻嗪类利尿剂(例如氢氯噻嗪)
部分第二代抗精神病药物(如奥氮平、氯氮平)
某些氟喹诺酮类抗生素(如环丙沙星)
钙调磷酸酶抑制剂(如环孢素、他克莫司)
蛋白酶抑制剂(例如,作为抗逆转录病毒治疗的成分,如利托那韦)。
对于复杂型患者或高血糖难以控制的患者,可向糖尿病团队寻求专家建议。
监测血糖并根据病情和住院就餐时间调整用药,从而降低低血糖发作风险。
大约 1/5 英格兰和威尔士糖尿病住院患者被发现曾在住院期间发生过低血糖。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
病因包括:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
急性疾病痊愈
胰岛素或口服降糖药用药错误
就餐相关胰岛素治疗的给药时间错误
患者进食少,但服用相同量的糖尿病药物
睡前不食用零食
食欲减退或呕吐
若在应用胰岛素或磺脲类药物情况下,血糖降至 6 mmol/L 以下(108 mg/dL)(濒临低血糖),应考虑进行干预。
此类患者进展为低血糖的风险较高。
按照低血糖指南建议,并遵循当地规程,给予碳水化合物(参阅下文)。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果血糖低于 4 mmol/L(72 mg/dL),则应积极治疗低血糖。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 请遵循医院规程或 JBDS-IP 的低血糖管理流程。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group JBDS-IP 指南也推荐:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
10-15 分钟后重新检测血糖,以确定治疗疗效
如果已经纠正低血糖,切勿停止下一次计划的胰岛素给药。否则会导致 1 型糖尿病患者出现反弹性高血糖和 DKA。
就是否需要对患者的胰岛素治疗方案进行审查,寻求糖尿病住院专家团队的建议。
采取措施降低夜间低血糖风险。假设患者可以吞咽,他们在医院所进晚餐可能比在家进食更少。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
在没有明显高血糖的情况下,考虑入院时将晚间基础胰岛素降低 20%(基于专家意见)。
请注意,如果患者错过进餐或用药剂量过大,则低血糖更可能是磺脲类药物治疗的不良反应(例如格列本脲、格列齐特、格列美脲、格列吡嗪)。
在急症医院环境中,餐时有可能被打乱,或无法每天同一时间进餐。
应在进食前或进食时给予磺脲类药物。查看当地药物处方集获取更为具体的指导信息,了解特定磺脲类药物给药时间与进食时间的关系。
切勿在睡前服用磺脲类药物,如果患者要在晚餐时服用一次,应考虑减少晚间剂量,以降低夜间低血糖发生风险(基于专家意见)。
睡前加餐可以降低清晨低血糖的风险。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
若糖尿病患者正在接受临终关怀:
将可致低血糖药物用量减至最少,但使患者不出现有症状高血糖,其可能导致:[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
脱水
酮症
高渗性高血糖。
1 型糖尿病患者切勿停用基础胰岛素
请参阅当地常规或来自英国 TREND Diabetes 等糖尿病组织的指南。[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
针对特定患者群中所有患者的治疗建议
患者可能会忘记告诉您他们常用的吸入器。记得检查并酌情开处吸入器。
哮喘患者应继续其惯常的吸入皮质类固醇药物治疗。没有明确的医学原因,不得停止治疗。
许多吸入器含有多种药物,因此请确保不要重复开药。
对于有急性肾损伤的 COPD 或哮喘患者,如果估算 GFR <50 mL/(min·1.73 mm),可能需要暂时停用其常用的吸入性长效毒蕈碱受体拮抗剂,具体取决于其使用的特定药物。
查阅当地处方集或寻求药师建议。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能提示合并哮喘的患者发生哮喘急性发作。
根据指南建议评估严重程度和管理成人哮喘的急性加重。[144]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. July 2019 [internet publication].https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/[145]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]https://ginasthma.org/2023-gina-main-report/
请参阅“成人哮喘急性发作” 专题。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理哮喘可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com
尽管有这方面的证据,但如果合并有哮喘的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能表明合并 COPD 的患者出现急性加重。[148]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2023 [internet publication]https://goldcopd.org/2023-gold-report-2/
与其他疾患进行鉴别,如急性冠脉综合征、急性心力衰竭和肺炎。
请遵循指南建议。请参阅 “COPD 急性加重” 专题。
支气管舒张剂雾化吸入疗法应仅持续 24 至 48 小时,然后患者应换回他们常用的吸入剂(基于专家意见)。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理 COPD 可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com
尽管有这方面的证据,但如果合并有 COPD 的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
一项系统评价发现,对于 COPD 急性加重的患者,皮质类固醇的短期疗程(7 天或更短)与更长时间的传统疗程(长于 7 天)之间的结局(治疗失败、至下一次加重时间、住院时间、肺功能、不良反应、死亡率)没有差异。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
此 Cochrane 评价中包括的随机对照试验均在医院环境内进行,且仅涉及重度至极重度 COPD 患者。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
该评价的作者得出结论,由于增加了一项新的试验,他们更加确信大约 5 天的皮质类固醇疗程可能足以治疗 COPD 急性加重。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
同样,在 2019 年对证据进行了一次评价后,英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)建议在 COPD 加重期间提供泼尼松龙治疗 5 天。[150]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication]https://www.nice.org.uk/guidance/ng115
针对特定患者群中所有患者的治疗建议
在临床情况允许以及患者有反应的情况下进行精神状态检查(基于专家意见)。
精神状态检查是精神病学临床实践中常规使用的主要临床工具之一,有助于诊断并指导进一步的管理。情绪是其中一项评估内容。
考虑使用 PHQ-9 问卷评估抑郁。[151]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
这是一份自测问卷,仅需不到 3 分钟即可完成。
结果可提示抑郁症状的严重程度。
应将得分为 5 分或以上的患者转诊至接受联络精神病学服务(基于专家意见)。
考虑可能影响患者精神状态的其他因素(例如,非法成瘾物质或酒精的作用)。[152]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14.http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
如果紧急临床情况允许,询问患者正在服用哪些药物治疗抑郁。或查看其初级卫生保健记录,获取相关信息(若可获取)。
为患者开具其常用的抗抑郁药,除非有充分的理由不得这样做(基于专家意见)。
如果突然停用抗抑郁药,患者可能会出现停药症状。[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
停药症状的严重程度可能不一,但可能令人不快,并使急性疾病的管理复杂化。[154]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91
审评当前药物时,需注意以下情况:
当前和既往不良反应
近期用药剂量改变
最近换了一种不同类别的药物
特定抑郁症亚型的药物细微差别(例如,精神病性抑郁症患者很可能会同时服用抗精神病处方药)
治疗难治性抑郁症时可能使用的增强策略(如锂剂或喹硫平加选择性 5-羟色胺再摄取抑制剂 [selective serotonin-reuptake inhibitor, SSRI])。
考虑药物相互作用。
抗抑郁药可能会与用于其他疾病的药物发生药代动力学(通过抑制 CYP450 通路)和药效动力学相互作用。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
开具非精神类药物时,应考虑精神并发症。
开具抗惊厥药物、抗帕金森病药物和皮质类固醇时,应格外小心。
考虑不良反应,具体可能包括以下不良反应。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021
低钠血症,由抗抑郁药(尤其是 SSRI)引起,会因使用同时开具的其他药物(例如利尿药)而加重。请检查患者的血清电解质。
5-羟色胺综合征(精神状态改变、激越、震颤、反射亢进、阵挛、肌强直、大量出汗、心动过速、肠鸣音增加、体温 >38℃),尤其是在多重用药和/或 5-羟色胺能药物过量时。[156]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com[157]Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014 Feb 19;348:g1626http://www.ncbi.nlm.nih.gov/pubmed/24554467?tool=bestpractice.com
特别要注意的是,服用 SSRI 的终末期肾病患者 5-羟色胺综合征的风险增加。治疗肾脏损伤患者的抑郁需要采取多学科方法,并需要格外谨慎。
肝毒性。必要时调整肝功能受损患者的抗抑郁药物剂量,避免使用已知具有肝毒性的药物。
与三环类抗抑郁药相关的 QTc 延长、心律失常、心率加快、体位性低血压。查看 ECG,特别是有心律失常风险的人群。
消化道出血。SSRI 与消化道出血风险增加相关。[158]Dalton SO, Sørensen HT, Johansen C. SSRIs and upper gastrointestinal bleeding: what is known and how should it influence prescribing? CNS Drugs. 2006;20(2):143-51http://www.ncbi.nlm.nih.gov/pubmed/16478289?tool=bestpractice.com[159]Dalton SO, Johansen C, Mellemkjaer L, et al. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study. Arch Intern Med. 2003 Jan 13;163(1):59-64https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/214901http://www.ncbi.nlm.nih.gov/pubmed/12523917?tool=bestpractice.com[160]Cheng YL, Hu HY, Lin XH, et al. Use of SSRI, but not SNRI, increased upper and lower gastrointestinal bleeding: a nationwide population-based cohort study in Taiwan. Medicine (Baltimore). 2015 Nov;94(46):e2022https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652818/http://www.ncbi.nlm.nih.gov/pubmed/26579809?tool=bestpractice.com与阿司匹林、非甾体抗炎药(non-steroidal anti-inflammatory drugs, NSAID)或口服抗凝剂联用时,风险尤其增加。[161]Loke YK, Trivedi AN, Singh S. Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther. 2008 Jan 1;27(1):31-40https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2007.03541.xhttp://www.ncbi.nlm.nih.gov/pubmed/17919277?tool=bestpractice.com
此清单并未详尽列出全部不良反应——请参阅当地处方集以获取更多信息。请咨询您联络的精神病学同事和/或药剂师以获取建议。
请询问患者通过哪些非药物治疗方法管理抑郁,并核实其目前在社区获得的支持情况。
这可能包括参与其护理的其他医疗卫生专业人士、慈善机构、家庭和社会网络以及心理治疗。
请注意,戒烟或从吸烟转为其他替代方案(包括尼古丁替代疗法)可能导致患者服用的精神类药物(例如,治疗抑郁的药物)血浆浓度发生变化。这是因为尼古丁替代治疗并不会像吸烟那样影响肝酶活性。[162]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid. 2016 Jun;11(6)4-7https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602[163]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com[164]Oliveira P, Ribeiro J, Donato H, Madeira N. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017;16:17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com[165]National Centre for Smoking Cessation and Training. Smoking cessation and mental health. 2014 [internet publication]https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf寻求相关建议,确认精神类药物剂量调整是否适当。
针对特定患者群中所有患者的治疗建议
考虑将任何因急性疾病入院且伴有抑郁的患者转诊至联络精神病学团队/服务机构。[166]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. March 2018 [internet publication]https://www.nice.org.uk/guidance/ng94[167]National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Treat as one. Bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
如果不存在抑郁和/或其管理可能影响急性病情的顾虑,则可能不需要转诊(基于专家意见)。
对于情况不明的事故、自伤行为和/或自杀企图,都应临床怀疑共病精神障碍(基于专家意见)。
合并抑郁症与对推荐的躯体健康治疗(从药物治疗到康复治疗)的依从性差有关。[168]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
这可能导致更差的临床结局,包括更高的再入院风险。[169]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(S7):S54-60http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com[170]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91[171]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33https://www.sciencedirect.com/science/article/pii/S0022399914003821http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com
最为重要的是,包括抑郁在内的情感症状与高死亡率有关,但其因果关系仍有待证实。[172]Archer G, Kuh D, Hotopf M, et al. Association between lifetime affective symptoms and premature mortality. JAMA Psychiatry. 2020 Aug 1;77(8):806-13https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2763796http://www.ncbi.nlm.nih.gov/pubmed/32267482?tool=bestpractice.com[173]Machado MO, Veronese N, Sanches M, et al. The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses. BMC Med. 2018 Jul 20;16(1):112https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1101-zhttp://www.ncbi.nlm.nih.gov/pubmed/30025524?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
对所有糖尿病患者在入院时和不适加重时进行足部检查。[174]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. October 2019 [internet publication]https://www.nice.org.uk/guidance/ng19
这是为了发现新的溃疡或感染,这些溃疡或感染可能被患者忽视,甚至可能是引发其急性病的原因(例如,出现脓毒症或心内膜炎的患者,其感染的原发灶是足部病变)。
检查足部有无病损,并检查保护性感觉是否丧失。
遵循当地指南,但有一个快速简单的试验:Ipswich Touch Test©(伊普斯威奇触摸试验),即将食指指尖轻轻触摸/放置在第一、第三和第五个足趾趾尖上 1 到 2 秒。[175]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 May 18;34(7):1517-8https://www.doi.org/10.2337/dc11-0156http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
如果患者在这六个部位中的两个或以上没有感觉,则代表其保护性感觉减退。
如果患者有感觉减退,则其有较高的压疮风险。告知其护理人员并提供减压装置。
护理人员或医疗人员应每日进行踝部检查,注意压力性创伤征象。
对于糖尿病患者是否应该使用弹力袜存在争议——如果有血管疾病,请勿使用。
针对特定患者群中所有患者的治疗建议
如果患者为当前吸烟者,请提供戒烟支持途径。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209 恰当的时机取决于具体的临床情况。一般情况下,英国国家卫生与临床优化研究所建议应立刻或在 24 小时内提供戒烟途径。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
对于所有吸烟的住院患者,如果没有禁忌证,应提供尼古丁替代疗法(nicotine replacement therapy, NRT)和其他戒烟药物疗法。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
建议:[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
尼古丁很容易使人成瘾,但这不是吸烟相关危害的原因。
NRT 可防止入院期间快速戒断,快速戒断可能会导致痛苦和不适。
当与专科支持相结合时,有数种高效的治疗选择能提供最大的戒烟可能性。
由于联合 NRT 比单一 NRT 有效,应将长效制剂 NRT(例如,透皮贴剂)与短效制剂 NRT(例如,咀嚼胶、锭剂、舌下片剂、吸入剂、口腔黏膜或鼻喷雾剂)联用来实施 NRT。 [177]Theodoulou A, Chepkin SC, Ye W, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2023 Jun 19;6(6):CD013308https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/37335995?tool=bestpractice.com[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
询问醒后至吸第一根烟的时间。短于 30 分钟的答案可提示这些患者可能有更多的尼古丁依赖问题,从而能指导选择尼古丁透皮贴剂的剂量。
查阅当地的处方集,以了解各种注意事项,尤其当患者有一种或多种合并症和/或血流动力学不稳定时。
对于任何有意戒烟的患者,可考虑 联合使用伐尼克兰和 NRT ,因为这是一种对成人戒烟非常有效的组合。 [179]Thomas KH, Dalili MN, López-López JA, et al. Comparative clinical effectiveness and safety of tobacco cessation pharmacotherapies and electronic cigarettes: a systematic review and network meta-analysis of randomized controlled trials. Addiction. 2022 Apr;117(4):861-76.https://onlinelibrary.wiley.com/doi/10.1111/add.15675http://www.ncbi.nlm.nih.gov/pubmed/34636108?tool=bestpractice.com 对于烟草依赖,联合治疗比使用单一药物更有效。[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
一项 Cochrane 评价发现,有高确定性证据表明伐尼克兰是烟草依赖的有效治疗方法。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 该评价还发现,伐尼克兰使用者出现导致住院的严重不良反应(例如心脏问题)几率可能会增加;但这种情况仍属罕见(伐尼克兰使用者中有 2.7%-4.0% 出现这种情况,而未使用伐尼克兰者中仅 2.7% 出现这种情况),并且其中可能包括与伐尼克兰无关的不良反应。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 查阅当地处方集,以获取关于禁忌证/注意事项的完整清单,或者寻求药师建议。
心理卫生疾病不是开具伐尼克兰的禁忌证。然而,对于已患精神疾病的患者,应谨慎使用伐尼克兰,因为该药可能加重症状。
对于戒烟,安非他酮是另一种选择,但是取得成功的可能性更低。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 应考虑药物相互作用的可能性。
完成到烟草依赖执业医师/服务机构的转诊。
若无紧急考量因素,对急性结石事件初步治疗的主要目标是缓解症状,并根据需要进行补液和镇痛。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com[46]Afshar K, Jafari S, Marks AJ, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. Cochrane Database Syst Rev. 2015 Jun 29;(6):CD006027.https://www.doi.org/10.1002/14651858.CD006027.pub2http://www.ncbi.nlm.nih.gov/pubmed/26120804?tool=bestpractice.com [ ]Is there randomized controlled trial evidence to support the use of nonsteroidal anti-inflammatory drugs (NSAIDS) compare with other analgesics and each other in people with acute renal colic?https://cochranelibrary.com/cca/doi/10.1002/cca.920/full展示答案
在疼痛管理方面,请给予:
使用一种非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)作为一线治疗,任何给药途径均可[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118[47]Davenport K, Waine E. The role of non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals (Basel). 2010 Apr 28;3(5):1304-10.https://www.mdpi.com/1424-8247/3/5/1304/htmhttp://www.ncbi.nlm.nih.gov/pubmed/27713303?tool=bestpractice.com[证据 C]f4ca9417-e30c-45fd-adf3-eddc765b257bguidelineC对于有症状肾结石或输尿管结石患者,非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)对于急性疼痛管理的临床有效性如何?[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
非甾体抗炎药已被证实能够有效缓解急性肾结石相关的疼痛,并且其副作用少于阿片类药物和对乙酰氨基酚。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com
肠外 NSAID 疼痛缓解作用最为持久,且与阿片类药物相比不良反应更少。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com[49]Gu HY, Luo J, Wu JY, et al. Increasing nonsteroidal anti-inflammatory drugs and reducing opioids or paracetamol in the management of acute renal colic: based on three-stage study design of network meta-analysis of randomized controlled trials. Front Pharmacol. 2019;10:96.https://www.doi.org/10.3389/fphar.2019.00096http://www.ncbi.nlm.nih.gov/pubmed/30853910?tool=bestpractice.com
如果禁忌使用 NSAID 或该药对患者的镇痛效果不足,应静脉使用对乙酰氨基酚。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
只有在禁忌使用 NSAID 和静脉对乙酰氨基酚或这两种药物对患者的镇痛效果不足时,才可考虑阿片类药物。[47]Davenport K, Waine E. The role of non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals (Basel). 2010 Apr 28;3(5):1304-10.https://www.mdpi.com/1424-8247/3/5/1304/htmhttp://www.ncbi.nlm.nih.gov/pubmed/27713303?tool=bestpractice.com 如果给予阿片类药物,应同时开具止吐药控制阿片类药物引起的恶心。
请勿对疑似肾绞痛患者使用解痉药。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
心衰 慢性肾脏病 (CKD) 哮喘
选择最为合适的镇痛治疗和给药方案时,需对患者合并症加以考量。
避免将非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)用于心力衰竭患者(基于专家意见)。
对于肾功能减退患者, 调整阿片类药物剂量非常重要。
如果肾脏无法排泄,包括吗啡在内的数种阿片类药物活性代谢物就会出现积聚。[80]Davison SN. Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol. 2019 Jun 7;14(6):917-31https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556722/http://www.ncbi.nlm.nih.gov/pubmed/30833302?tool=bestpractice.com
避免将 NSADI 用于 CKD 患者。[81]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
糖尿病 痴呆 COPD 卒中 心衰 Frailty 高血压 冠状动脉病 慢性肾脏病 (CKD) 抑郁
在决定患者是居家治疗,还是需要入院治疗和/或专家评估时,患者的合并症是一项重要的考虑因素。
需考虑患者临床疾病总体严重性和稳定性,及其在家中进行自我照护的能力。
即使是虚弱患者或慢性疾病患者的轻度疾病也可能导致其身体机能下降,以致其无法居家进行安全地自理,而且可能无法立即获得照护者的支持。
若患者年龄 ≥65 岁,则在适当的时候应用临床衰弱量表(Clinical Frailty Scale, CFS)评估患者的衰弱程度,作为整体评估的一部分。[82]NHS Specialised Clinical Frailty Network. Clinical frailty scale. 2018 [internet publication]https://www.scfn.org.uk/clinical-frailty-scale
请勿使用 CFS 评估较年轻患者或者存在长期稳定残疾(例如脑性瘫痪)、学习障碍或孤独症的患者。[82]NHS Specialised Clinical Frailty Network. Clinical frailty scale. 2018 [internet publication]https://www.scfn.org.uk/clinical-frailty-scale
如果患者可以居家安全继续接受治疗,确保为其提供充分随访服务,并给予安全保障建议。建议患者在病情未改善或者出现恶化时寻求医疗建议或返院接受再评估。
必要时咨询专家意见。
布洛芬 : 儿童:咨询专科医生,获取剂量指导;成人:300-600 mg,口服(速释型),根据需要每 6-8 小时一次,每日最多 2400 mg
或
双氯芬酸钠 : 儿童:咨询专科医生,获得剂量指导;成人:75 mg,肌内注射,需要时每日一次或两次
或
双氯芬酸钾 : 儿童:咨询专科医生,获得剂量指导;成人:75-150 mg/d,口服(速释型),需要时分 2-3 次给药
对乙酰氨基酚 : 儿童:咨询专科医生,获得剂量指导;成人:15 mg/kg(每剂最大剂量为 1000 mg),静脉使用,需要时每 4-6 小时一次,每日最大剂量为 4000 mg
硫酸吗啡 : 儿童:咨询专科医生,获取剂量指导;成人:5-10mg,口服(速释型)/皮下/静脉/肌内注射,最初每 4 小时一次,根据疗效调整剂量
布洛芬 : 儿童:咨询专科医生,获取剂量指导;成人:300-600 mg,口服(速释型),根据需要每 6-8 小时一次,每日最多 2400 mg
或
双氯芬酸钠 : 儿童:咨询专科医生,获得剂量指导;成人:75 mg,肌内注射,需要时每日一次或两次
或
双氯芬酸钾 : 儿童:咨询专科医生,获得剂量指导;成人:75-150 mg/d,口服(速释型),需要时分 2-3 次给药
对乙酰氨基酚 : 儿童:咨询专科医生,获得剂量指导;成人:15 mg/kg(每剂最大剂量为 1000 mg),静脉使用,需要时每 4-6 小时一次,每日最大剂量为 4000 mg
硫酸吗啡 : 儿童:咨询专科医生,获取剂量指导;成人:5-10mg,口服(速释型)/皮下/静脉/肌内注射,最初每 4 小时一次,根据疗效调整剂量
针对特定患者群中所有患者的治疗建议
如同处理所有因急症而入院的患者,应对患者基线肾功能进行检查 ,如果患者具有 CKD 病史,需予以特别密切的监测。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
CKD 是急性肾损伤重要危险因素。[95]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Apr 2;74(1):101-7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
急症可增加肾功能恶化风险。
对少尿进行监测并予以处理。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
针对特定患者群中部分患者治疗的附加建议
如果患者有症状并被确诊为菌尿,但无梗阻或脓毒症征象,则应在获得基于尿液分析培养的药敏结果之前启动经验性抗生素治疗。然后根据结石大小予以相应治疗(见下文)。
经验性方案取决于多种因素,包括感染类型、患者因素和当地抗生素耐药性模式;关于抗生素的选择,查阅当地指南,了解更多信息。
如果患者被确诊为菌尿但无症状,则在抗感染治疗之前先治疗结石可能更恰当;请咨询专科医生。
针对特定患者群中所有患者的治疗建议
衰弱是与一种衰老过程相关的独特健康状态,在该状态下多身体系统逐渐发生功能衰退。[117]NHS England. Toolkit for general practice in supporting older people living with frailty. March 2017 [internet publication]https://www.england.nhs.uk/publication/toolkit-for-general-practice-in-supporting-older-people-living-with-frailty/
询问患者其在急性发作前 2 周的能力情况(以及可能的相关照护者的意见)。
如果患者的年龄 ≥65 岁,则采用临床衰弱量表。NHS Specialised Clinical Frailty Network: Clinical Frailty Scale
这是确定衰弱的实用辅助工具,但不应仅仅依赖它。
较高的衰弱评分与不良结局风险增加有关。[120]Wallis SJ, Wall J, Biram RW, et al. Association of the clinical frailty scale with hospital outcomes. QJM. 2015 Dec;108(12):943-9https://www.doi.org/10.1093/qjmed/hcv066http://www.ncbi.nlm.nih.gov/pubmed/25778109?tool=bestpractice.com
辅助实施多学科诊疗,并根据患者的价值观来调整管理方案。[122]Quinn TJ, Mooijaart SP, Gallacher K, et al. Acute care assessment of older adults living with frailty. BMJ. 2019 Jan 31;364:l13http://www.ncbi.nlm.nih.gov/pubmed/30705024?tool=bestpractice.com
针对特定患者群中部分患者治疗的附加建议
对存在以下情况的患者考虑采取观察等待策略:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
肾结石 <5 mm 且无症状
肾结石为 5-10 mm、无症状并且在对观察等待策略的潜在风险获益开展知情讨论后,患者(或其家人或照护者,视情况而定)同意采取该治疗策略。
针对特定患者群中部分患者治疗的附加建议
对于较大结石(≥10 mm)以及经保守治疗后仍未清除的较小结石,可能需要外科干预,推荐手术方法取决于结石大小。
过去,开放性手术是清除结石的唯一方法。然而,随着腔内泌尿外科学(endourology;此术语已被用于描述在内窥镜的辅助下、于闭合尿道内进行操作的微创手术技术)的发展和成功,目前已很少进行开放性手术。
冲击波碎石术(shock wave lithotripsy, SWL)是在所有确定性结石治疗中创伤性最小的疗法,适合大多数单纯性结石病患者。在 SWL 过程中,患者体外的波源会产生冲击波,然后传播进入体内,聚焦于结石。冲击波会通过压缩力和拉力击碎结石。然后结石碎片通过尿液排出。SWL 的应用受限于结石的大小和部位。然而,SWL 一般无需全身麻醉,所以通常可在门诊进行。坦索罗辛治疗似乎可有效促进肾或输尿管结石患者清除结石。[58]Zhu Y, Duijvesz D, Rovers MM, et al. Alpha-blockers to assist stone clearance after extracorporeal shock wave lithotripsy: a meta-analysis. BJU Int. 2010 Jul;106(2):256-61.http://www.ncbi.nlm.nih.gov/pubmed/19889063?tool=bestpractice.com 虽然 SWL 治疗肾下极结石的成功率有限,但有证据表明 SWL 联合辅助方法(例如体外敲打、利尿和倒立)可以提高净石率。[59]Liu LR, Li QJ, Wei Q, et al. Percussion, diuresis, and inversion therapy for the passage of lower pole kidney stones following shock wave lithotripsy. Cochrane Database Syst Rev. 2013;(12):CD008569.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008569.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/24318643?tool=bestpractice.com SWL 治疗的禁忌证包括妊娠、严重骨骼畸形、严重肥胖、主动脉和/或肾动脉瘤、未控制高血压、凝血功能障碍和泌尿道感染控制不良。[60]Loughlin KR. Management of urologic problems during pregnancy. Urology. 1994 Aug;44(2):159-69.http://www.ncbi.nlm.nih.gov/pubmed/8048189?tool=bestpractice.com[61]Ignatoff JM, Nelson JB. Use of extracorporeal shock wave lithotripsy in a solitary kidney with renal artery aneurysm. J Urol. 1993 Feb;149(2):359-60.http://www.ncbi.nlm.nih.gov/pubmed/8426419?tool=bestpractice.com
输尿管镜治疗是将一条纤细的半硬性或软性内镜经尿道置入输尿管和/或肾脏。一旦发现结石,可用激光将其击碎,然后用取石装置抓取碎片并移除。这种治疗的创伤性大于 SWL,但普遍认为其结石清除率更高。[62]Wang H, Man L, Li G, et al. Meta-analysis of stenting versus non-stenting for the treatment of ureteral stones. PLoS One. 2017 Jan 9;12(1):e0167670.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221881/http://www.ncbi.nlm.nih.gov/pubmed/28068364?tool=bestpractice.com [ ]For adults undergoing ureteroscopy for ureteral calculi clearance, how does placement of a ureteral stent affect outcomes?https://www.cochranelibrary.com/cca/doi/10.1002/cca.2494/full展示答案该操作通常作为日间手术进行。手术使用钬激光,可安全用于凝血功能异常的患者。一次性软式输尿管肾盂镜(FURS)治疗肾结石的有效性与可重复使用 FURS 相当。[63]Davis NF, Quinlan MR, Browne C, et al. Single-use flexible ureteropyeloscopy: a systematic review. World J Urol. 2018 Apr;36(4):529-36.http://www.ncbi.nlm.nih.gov/pubmed/29177820?tool=bestpractice.com 对于远端输尿管结石(无论其大小如何)和>10 mm 的近段输尿管结石,输尿管镜的净石率要优于 SWL。[64]Dell'Atti L, Papa S. Ten-year experience in the management of distal ureteral stones greater than 10 mm in size. G Chir. 2016 Jan-Feb;37(1):27-30.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859772/http://www.ncbi.nlm.nih.gov/pubmed/27142822?tool=bestpractice.com[65]Cui X, Ji F, Yan H, et al. Comparison between extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy for treating large proximal ureteral stones: a meta-analysis. Urology. 2015 Apr;85(4):748-56.http://www.ncbi.nlm.nih.gov/pubmed/25681251?tool=bestpractice.com 但是,输尿管镜取石的并发症发生率较高,住院时间较长。[66]Drake T, Grivas N, Dabestani S, et al. What are the benefits and harms of ureteroscopy compared with shock-wave lithotripsy in the treatment of upper ureteral stones? A systematic review. Eur Urol. 2017 Nov;72(5):772-86.http://www.ncbi.nlm.nih.gov/pubmed/28456350?tool=bestpractice.com[67]Aboumarzouk OM, Kata SG, Keeley FX, et al. Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev. 2012;(5):CD006029.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006029.pub4/fullhttp://www.ncbi.nlm.nih.gov/pubmed/22592707?tool=bestpractice.com 输尿管支架是从肾脏延伸至膀胱的内置导管,通常在输尿管镜治疗后临时留置,以促进集合系统引流,同时消退结石或操作造成的任何水肿。建议将支架用于功能性或解剖性孤立肾、输尿管狭窄、发现输尿管损伤的患者,或计划接受二期手术的患者。对于 <20 mm 的输尿管结石,请勿在输尿管镜治疗后无并发症的情况下常规置入支架。
经皮肾镜取石术(percutaneous nephrolithotomy, PCNL)是一种微创治疗,通常仅用于肾结石(尤其是肾下极结石)、较大结石(>20 mm)、SWL 和输尿管镜治疗失败的结石或者所在部位肾解剖结构复杂的结石。[68]Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016 [internet publication].http://www.auanet.org/education/guidelines/surgical-management-of-stones.cfm 建立入路时,从腰部经皮进入肾脏。当前证据表明,在荧光透视和超声引导下,均可成功建立经皮肾脏入路。联合使用超声和荧光透视似乎可以改善结局,包括提高入路建立成功率和减少并发症。[69]Breda A, Territo A, Scoffone C, et al. The evaluation of radiologic methods for access guidance in percutaneous nephrolithotomy: a systematic review of the literature. Scand J Urol. 2018 Apr;52(2):81-6.http://www.ncbi.nlm.nih.gov/pubmed/29130789?tool=bestpractice.com 建立入路后,将镜鞘送入肾脏,并使用肾镜取出结石。对于较大结石,通常使用超声碎石技术将结石击碎,然后进行清除。PCNL 通常需要住院,而且与 SWL 或输尿管镜相比,其潜在并发症更多。对于 20-30 mm 的结石,SWL 结石清除率(34%)低于 PCNL(90%)。[70]Lingeman JE, Coury TA, Newman DM, et al. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol. 1987 Sep;138(3):485-90.http://www.ncbi.nlm.nih.gov/pubmed/3625845?tool=bestpractice.com
腹腔镜取石是清除输尿管或肾结石的另一种微创治疗方式。然而,其创伤性仍然较大,需要较长时间的住院,而且掌握这项技术所需的时间要远长于输尿管镜和 SWL。在过去 20 年中,随着 SWL 和腔内泌尿外科技术(即输尿管镜和 PCNL)的发展,开放性取石手术的适应证范围已显著缩小。下列罕见情况下可使用腹腔镜或开放性手术取石:SWL、输尿管镜和经皮输尿管镜治疗失败或者不太可能成功的患者;解剖结构畸形(妨碍微创手术的使用)的患者;需要同时接受开放手术、肾盂成形或部分肾切除术的患者;或者结石负担较大,需要一次性清除的患者。[68]Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016 [internet publication].http://www.auanet.org/education/guidelines/surgical-management-of-stones.cfm[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
如果患者是成年人:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
实施冲击波碎石术(shock wave lithotripsy, SWL)
请勿对准备接受 SWL 的成人患者实施治疗前支架置入术
如果患者有 SWL 禁忌证、SWL 治疗失败或因解剖原因而不适合接受该治疗,应考虑输尿管镜治疗
如果 SWL 和输尿管镜治疗均不适合或均已失败,应考虑经皮肾镜取石术(percutaneous nephrolithotomy, PCNL)。
如果患者年龄小于 16 岁:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
考虑输尿管镜治疗或 SWL
如果 SWL 和输尿管镜治疗均不适合或均已失败,应考虑进行 PCNL。
如果患者是成年人:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
考虑输尿管镜治疗或 SWL
请勿对准备接受 SWL 的成人患者实施治疗前支架置入术
如果 SWL 和输尿管镜治疗均不适合或均已失败,应考虑进行 PCNL。
如果患者年龄小于 16 岁,应考虑输尿管镜治疗、SWL 或 PCNL。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
如果患者是成年人:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
提供 PCNL
如果 PCNL 不适合,应考虑输尿管镜治疗。
如果患者是年龄小于 16 岁的未成年人,应考虑输尿管镜治疗、SWL 或 PCNL。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
考虑对准备接受 SWL 治疗肾鹿角状结石的儿童和青少年患者进行治疗前支架置入术。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
针对特定患者群中所有患者的治疗建议
对任何有卒中病史的患者,请在适当的时机尽早进行基线神经系统评估。
伴有急症(例如感染和疾病相关性低血压)的患者卒中风险升高(缺血性和出血性)。[96]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Nov 9;6(12):681-94http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com[97]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com 有卒中病史的患者风险更高。
如果在住院期间神经系统状态发生变化,应重复进行神经系统评估,从而防止再次发生卒中。
进行评估之后,应确保对患者进行适当的监护(例如需结合夜间意识模糊风险和机体脆弱相关性跌倒风险制定监护计划)。有卒中病史的患者跌倒和受伤的风险增加。[98]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 May 4;47(6):e98-e169https://www.doi.org/10.1161/STR.0000000000000098http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
尽早对具有痴呆病史的患者进行基线认知评估,并通过家人、朋友或照护者获取旁证病史。[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
使用在急性情况下可行的经过验证的评分系统,例如:[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
简化智力测试量表/10(AMTS/10)[100]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.comBritish Geriatrics Society: Abbreviated Mental Test Score. 2018
旁证病史可确定患者的认知是否稳定,或者认知和功能是逐渐下降还是急性下降。
标准化认知评估评分将有助于监测所有临床改善, 以及确定出院需求。判读该分数时,最好结合功能评估(通常由经过培训的职业治疗师进行)。
尽管由于急性疾患及其治疗的影响,该评分可能并不代表患者平时的认知基线,但当患者恢复后,记录并重复该评分仍然是很好的做法(基于专家意见)。
每当痴呆患者出现急性疾病时都要进行谵妄评估。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
伴痴呆者入院时和整个住院期间发生谵妄的风险增加。[102]National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers. Jun 2018 [internet publication].https://www.nice.org.uk/guidance/ng97[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
谵妄与痴呆不同。[104]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]http://ltctoolkit.rnao.ca/node/1774 谵妄是指精神功能出现潜在致死性的急性波动性改变,伴有注意力缺乏、思维混乱和意识水平的改变。[105]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
使用筛查工具检测可能出现的谵妄,例如:
4-AT[106]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Mar 2;43(4):496-502.https://www.doi.org/10.1093/ageing/afu021http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[107]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194https://www.doi.org/10.3310/hta23400http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
关于 4-AT 计算的更多信息已由苏格兰校际指南网络发布SIGN Decision Support: delirium - risk reduction and management.
如果患者处于危重症监护环境或术后恢复室,则使用重症监护病房意识模糊评估法(Confusion Assessment Method for the Intensive Care Unit, CAM-ICU)或重症监护谵妄筛查量表(Intensive Care Delirium Screening Checklist, ICDSC)
经英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)推荐,专为这些情况设计,但使用者需要接受培训,因此应用可能受限。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
考虑采取以下措施,作为降低痴呆患者住院期间谵妄风险的多元化干预措施的一部分:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
帮助患者定向;确保患者有自己的眼镜和/或助听器
使患者尽早活动
充分控制疼痛
监测和及时治疗术后并发症
维持充分的液体摄入,并帮助患者摄入足够食物
监测并维持正常的肠道和膀胱功能
根据指南的建议使用辅助吸氧。
安排与经验丰富的医疗卫生专业人士一起进行用药评估。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
如果患者的日常照护者愿意,考虑协助他们提供非医疗照护,例如在用餐时提供帮助(基于专家意见)。
痴呆是术后谵妄的危险因素之一
考虑与麻醉科医师联系以寻求有关疼痛管理的建议。[108]White S, Griffiths R, Baxter M, et al. Guidelines for the peri-operative care of people with dementia: guidelines from the Association of Anaesthetists. Anaesthesia. 2019 Jan 11;74(3):357-72https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14530http://www.ncbi.nlm.nih.gov/pubmed/30633822?tool=bestpractice.com
有证据表明,多元化方法可降低非 ICU 住院患者发生谵妄的风险。
2016 年关于预防医院非 ICU 患者谵妄的干预措施的 Cochrane 系统评价发现:[109]Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016 Mar 11;3:CD005563https://www.doi.org/10.1002/14651858.CD005563.pub3http://www.ncbi.nlm.nih.gov/pubmed/26967259?tool=bestpractice.com
来自七项研究的中等质量证据表明,与常规治疗相比,接受多元化风险降低干预的患者谵妄风险降低(RR 0.69,95% CI 0.59-0.81)。
这七项研究的干预措施包括多元组成部分:工作人员教育、针对特定危险因素的方案、训练有素的跨学科团队的参与、教育方面的专业护理干预、用药审评、鼓励活动和患者环境改善。
只有一项研究(低质量证据)纳入了已有痴呆的患者亚组,该研究报告称,疗效无显著差异(RR 0.90,95% CI 0.59-1.36)。这篇综述的作者得出结论,对于这一人群的疗效尚不确定。
另一项针对老年患者的系统评价发现,非药物多元化干预措施可有效预防谵妄。[110]Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2014 Nov 25;44(2):196-204https://www.doi.org/10.1093/ageing/afu173http://www.ncbi.nlm.nih.gov/pubmed/25424450?tool=bestpractice.com
对七项研究的荟萃分析发现,与常规治疗相比,谵妄的发生率显著降低(RR 0.73,95% CI 0.63-0.85;P <0.001)。
疗效不因痴呆的存在和病房类型而不同。
如果患者出现谵妄,需检查并治疗危及生命的病因:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
缺氧
低血糖
低血压
药物中毒或戒断,包括酒精戒断。
其他检查包括(基于专家意见):
全血细胞计数、电解质、肾功能、甲状腺功能检测、肝功能检测、钙、血糖、CRP、叶酸和维生素 B12
血培养(如果怀疑菌血症)
尿培养
胸部 X 线。
根据具体临床发现,可能需要进行更高级的非常规检查,例如头颅 CT。请与上级医生讨论。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
检查并治疗谵妄的所有可逆病因。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
疼痛
感染
营养不良
便秘
脱水
药物治疗
询问最近开的处方药,特别是阿片类镇痛药、抗焦虑药、镇静剂、抗精神病药物或抗胆碱作用强的药物。
考虑计算抗胆碱能总负担得分。
制动
睡眠差
感觉受损(如耵聍或眼镜丢失)
助记符PINCH ME可能有助于记住谵妄的潜在原因。“E”代表“环境改变”(Environmental change)。[111]Public Health England. Urinary tract infection: diagnostic tools for primary care. October 2020 [internet publication]https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis
首先使用非药物治疗管理谵妄患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
通过提供一个光线充足的房间,且将时钟和日历放置在显眼位置(例如挂在墙上),可减轻定向障碍。
鼓励家人、朋友和照护者探望患者。
使用语言和非语言技巧减轻冲突和苦恼。
如果非药物治疗无效,并且患者感到痛苦或可能对自己或他人构成危险,短期(通常仅需要 1-2 天)使用抗精神病药物或镇静剂可加以考虑,但只能作为最后的治疗手段。必须定期评估为此目的新给予的所有抗精神病药物,并在实际情况允许时予以停药(基于专家意见)。
NICE 推荐短期使用氟哌啶醇(通常短于一周),但这并不适合所有患者,并且坚决不能用于帕金森病或路易体痴呆患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 对所有禁忌证进行分析。
对于脆弱老年患者急性谵妄给予氟哌啶醇时,需特别注意给予密切监测和进行定期分析。此类患者使用该药物,出现神经系统和心脏不良反应的风险极高。[112]Medicines and Healthcare products Regulatory Agency. Haloperidol (haldol): reminder of risks when used in elderly patients for the acute treatment of delirium. 2021 [internet publication]https://www.gov.uk/drug-safety-update/haloperidol-haldol-reminder-of-risks-when-used-in-elderly-patients-for-the-acute-treatment-of-delirium
起始氟哌啶醇之前,推荐进行基线 ECG 检查,并纠正电解质紊乱。
尽可能以最低剂量和最短时间进行用药。
在治疗期间,建议对心脏和电解质进行监测,同时监测锥体外系不良反应 。
抗精神病药物治疗谵妄的有效性证据尚无定论,[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium 并且各医院方案可能不尽相同。遵循当地医院的方案选择药物。
始终从最低剂量开始服用抗精神病药,并依据症状谨慎地逐渐调整剂量。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 只能通过口服或肌内注射药物(绝对不可静脉注射)进行此类治疗。
向家庭/照护者提供信息,以便他们了解当前的情况以及如何与临床团队协作以帮助患者恢复正常生活。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
抗精神病药物与痴呆患者死亡率增加相关。
痴呆患者有时可能需要短期抗精神病药物以实现安全治疗护理。然而,抗精神病药物对老年人有多种不良反应,并与痴呆患者死亡风险增加相关。
一项 meta 分析发现,与服用安慰剂的人相比,服用非典型抗精神病药的痴呆患者死亡风险增加。[113]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
一项针对老年人的大型队列研究发现,更高剂量的抗精神病药通常与更高的风险相关。在所有研究的抗精神病药中,使用氟哌啶醇的风险最高。[114]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977https://www.doi.org/10.1136/bmj.e977http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
与普遍的看法相反,大多数痴呆患者的行为稳定后,就可以安全地停止长期抗精神病药处方。[115]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;3:CD007726.https://www.doi.org/10.1002/14651858.CD007726.pub3http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
如果谵妄在 48 小时内未对初步治疗产生反应,患者应转诊至接受过培训,且能熟练进行谵妄诊断的医疗卫生专业人士,从而确定诊断和确立治疗计划(基于专家意见)。
清楚记录谵妄诊断。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
针对特定患者群中所有患者的治疗建议
与患者协商后(如若可行,还可与其家属或照护者进行协商),尽早商定诊疗升级计划(基于专家意见)。这适用于所有患者,但可能与虚弱和/或患有某些合并症(如痴呆、卒中、心力衰竭、COPD 和晚期 CKD)的患者特别相关(基于专家意见)。
诊疗升级计划应包括:[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
复苏状态(即“不尝试心肺复苏”[Do Not Attempt Cardiopulmonary Resuscitation, DNACPR] 的决定)
干预上限(例如,是否适合气管插管或接受重症监护)。
升级计划应考虑到预立医疗照护计划,包括具有法律约束力的预立医疗指示。[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
应以您与患者有关其个人意愿的谈话为指导,包括帮助他们就较高强度干预措施的可能获益-风险平衡作出知情决策的讨论。
某些情况下,伴有痴呆或其他重大合并症的患者(特别是当其急性患病时),将缺乏就诊疗升级计划作出决策的心智能力。
评估并记录心智能力(在需要作出特定决策的特定时间作出决策的能力)。[124]The National Institute for Health and Care Excellence. Decision making and mental capacity. October 2018 [internet publication]https://www.nice.org.uk/guidance/ng108 请遵守您所在地区的相应法律。
在英格兰和威尔士,医疗卫生专业人士必须遵守《2005 年心智能力法》。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 进行评估时,应遵循该法案中的原则。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions
如果患者被评估为缺乏心智能力,应与其近亲协商符合“最大利益”的决策,同时考虑到患者自己先前所表达的偏好。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 根据英格兰和威尔士的《2005 年心智能力法》,如果患者“无亲无故”(即无人代表其最大利益,无人照顾赡养)而决策并非时间紧迫,则应寻找独立的有心智能力的权益维护人(independent mental capacity advocate, IMCA)来执行该任务。[126]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). January 2010 [internet publication]https://www.scie.org.uk/mca/imca/do
针对特定患者群中所有患者的治疗建议
在患者入院时检查其血糖水平和 HbA1c。
排除低血糖、糖尿病酮症酸中毒(diabetic ketoacidosis, DKA),以及高渗性高血糖状态,这些均为医学急症。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[84]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
入院 HbA1c 可能会提示您患者既往糖尿病控制情况,并可能影响出院时的治疗(基于专家意见)。
对于患急性疾病或发生损伤的 1 型糖尿病患者,切勿停止使用基础胰岛素(长效/背景胰岛素 [例如,地特胰岛素、甘精胰岛素或德谷胰岛素])。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
胰岛素缺乏(例如由于用药延迟或漏用)会迅速引起酮症酸中毒。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
将任何使用胰岛素泵入院的糖尿病患者转诊至糖尿病专家团队。[86]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
一般情况下,所有接受基础胰岛素治疗的 2 型糖尿病患者均应继续接受治疗,但情况可能并非总是如此,因此应咨询您上级医生和/或糖尿病专科医生团队意见(基于专家意见)。
在患者入院时,考虑是否需要调整其胰岛素剂量。
如果 1 型或 2 型糖尿病患者正在使用胰岛素,血糖控制良好,入院时未出现严重的高血糖,则可能适当将基础胰岛素剂量减少 20%,尤其是当他们的进食量不及平时在家中时。需要考虑到的另一个因素是医院的膳食通常比患者在家的膳食含有更少的碳水化合物。
相反,危重症感染患者有时需要更高剂量的胰岛素。
定期监测血糖(每日至少 4 次)有助于指导合理调整胰岛素剂量。如有疑问,应寻求专家意见。
应尽早向糖尿病住院团队寻求专家建议,尤其是当诊疗较为复杂(例如,存在代谢紊乱、复发性或重度低血糖、持续高血糖),或者患者需要接受一段时间的肠内喂饲时。[87]Joint British Diabetes Societies for Inpatient Care. Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes. Nov 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 糖尿病团队还将能够就住院期间最合适的胰岛素方案和给药提出建议。
可变速率静脉胰岛素输注(VRIII)指征包括:[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[89]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
罹患糖尿病或医院相关性高血糖,且其无法进食或饮水,并无法调整胰岛素治疗方案的患者。例如,当:
呕吐
禁食禁饮,患者多餐不进
存在严重疾病,需要实现良好的血糖控制(例如脓毒症)。
需进行急诊手术的糖尿病患者可能需要给予 VRIII。遵循当地常规或英国围手术期诊疗中心建议。[90]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
在这些情况下,请从糖尿病团队获取专科医生建议。
若起始 VRIII:
始终持续给予基础胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果 VRIII 意外中断(例如由于导管移位或阻塞)或关闭(例如在转移病房期间),这会降低发生酮症的风险。
采用 VRIII 时让患者停用常规速效和混合胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
尽可能缩短使用 VRIII 的时间。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
遵循医院常规,执行包括停药在内的正确处理。
对于因 急性病症 入院的糖尿病患者,考虑停止或调整口服降糖药 。
以下所有患者应停用二甲双胍:[91]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
存在禁忌证,例如严重的肾脏损伤(eGRF <30 mL/[min·1.73m]),无论是慢性还是继发于急症。
伴代谢性酸中毒(包括乳酸酸中毒和糖尿病酮症酸中毒)
服用二甲双胍可能存在引发乳酸酸中毒风险。这包括与急性肾损伤、组织缺氧(包括急性心力衰竭或呼吸衰竭)有关的疾病,脱水,或已经/准长时间禁食或将要注射不透射线造影剂进行影像学检查的患者存在肾脏损伤(基于专家意见)。遵循当地常规,了解提示肾脏损伤的具体 eGFR 水平,以指导用药。
请注意,停用二甲双胍可导致高血糖。
如果您的患者正在服用其他降糖药物,这些药物可能需要增加剂量;如果没有,可能需要开处另一种降糖药(基于专家意见)。
一些患者可能需要胰岛素作为临时措施,但请寻求糖尿病住院专科医生团队的建议。
如果患者新近出现肾功能受损或恶化,或进食量比平时少,则应减少格列齐特剂量或停服一次药物,以免出现夜间低血糖。
对于所有危重症患者(包括进行大手术的患者),尤其是脱水或感染的情况下,应停用钠-葡萄糖协同转运蛋白-2(sodium-glucose cotransporter-2, SGLT-2)抑制剂并监测血酮,从而降低血糖正常的酮症酸中毒风险。[92]Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness. March 2020 [internet publication]https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness
SGLT-2 抑制剂(例如,达格列净、卡格列净、恩格列净)可减少肾脏中的血糖重吸收(与葡萄糖的胰岛素代谢无关)。[93]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Jun 15;38(9):1687-93http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com
它们可以掩盖潜在的酮症酸中毒,因为患者的血糖水平可能正常或接近正常(血糖正常的酮症酸中毒)。
检测血酮,因为尿酮体检测可能并不可靠。
如果毛细血管或血液中的酮体浓度为 >3 mmol/L ,或有 明显的酮尿(标准尿液试纸检测显示 2+ 或更多),且静脉 pH 值为 <7.3 和/或碳酸氢根浓度 <15 mmol/L ,则应治疗糖尿病酮症酸中毒 。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
针对特定患者群中所有患者的治疗建议
对于任何突发不适的糖尿病患者,每天至少监测血糖水平四次(餐前以及睡前)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
当糖尿病患者被紧急收治入院时,其发生低血糖和高血糖风险增加(基于专家意见)。
在高血糖或低血糖发作后,以及更换降糖药物后,甚至需要更频繁的监测(基于专家意见)。
如果您的患者接受了手术,请遵循您当地的方案或指南制定组织的建议,例如英国围术期护理中心的血糖管理和血糖监测频率相关建议。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
所有采取可变速率静脉胰岛素输注(variable rate intravenous insulin infusion, VRIII)的患者,起初均应每小时检测毛细血管血糖(capillary blood glucose, CBG)。[129]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 根据医院 VRIII 常规进行调整。
在住院期间,支持您的患者自我管理糖尿病(包括监测血糖,在接受胰岛素治疗的患者中调整胰岛素剂量和给药),如果符合以下情况:[131]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
较为安全
患者愿意,且
其符合当地常规。
根据血糖水平进行决策,并对其加以监测。
指南制定组织尚未对住院糖尿病患者的目标血糖水平达成共识。
英国糖尿病联合会住院患者诊疗组建议糖尿病内科住院患者:
理想的范围是 6-10 mmol/L(108-180 mg/dL)。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
在一些情况下,4-12 mmol/L(72-216 mg/dL)是可接受的范围。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 4 mmol/L(72 mg/dL)的下限对于糖尿病控制极好且在自我管理的住院患者可能是可接受的水平(基于专家意见)
轻度衰弱的糖尿病住院患者的目标范围为 7.5-10 mmol/L(135-180 mg/dL),中度或重度衰弱患者的目标范围为不超过 12 mmol/L(216 mg/dL)。[133]Joint British Diabetes Societies for Inpatient Care. Inpatient care of the frail older adult with diabetes. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 12 mmol/L 的上限也可能适用于任何有跌倒高风险或痴呆的患者(基于专家意见)。
围手术期诊疗中心(Centre for Perioperative Care)建议围手术期患者维持于 6 至 10 mmol/L(108-180 mg/dL)范围内,可接受上限为 12 mmol/L(216 mg/dL)。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
英国国家卫生与临床优化研究所建议急症或接受手术的住院 1 型糖尿病成人目标血糖水平位于 5 至 8 mmol/L(90-144 mg/dL),但这一目标低于其他指南建议。[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
美国糖尿病学会建议,对于大多数危重患者和非危重患者,目标范围为 7.8 至 10 mmol/L(140-180 mg/dL)(一旦因持续性高血糖而起始胰岛素治疗)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
存在冲突的证据导致危重患者(有或无糖尿病史的混合人群)血糖控制严格程度建议具有差异。请遵循当地规程。
重症诊疗环境:
一项针对主要外科重症监护环境中的危重患者随机对照试验(randomised controlled trial, RCT)发现,严格控制血糖(4.4-6.1 mmol/L,即 80-110 mg/dL)的患者比“传统”宽松控制血糖的患者死亡率更低。[134]van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67https://www.doi.org/10.1056/NEJMoa011300http://www.ncbi.nlm.nih.gov/pubmed/11794168?tool=bestpractice.com
然而,随后在其他重症诊疗机构对危重内外科患者进行的一项多中心 RCT 研究发现,更严格的血糖控制却伴发了更高的死亡率,其原因可能在于低血糖发作更为频繁。[135]NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.https://www.doi.org/10.1056/NEJMoa0810625http://www.ncbi.nlm.nih.gov/pubmed/19318384?tool=bestpractice.com
一项 2010 年对 6 项 RCT 研究进行的系统评价和荟萃分析,对危重患者在重症诊疗机构进行严格控制血糖(4.4-6.1 mmol/L [80-110 mg/dL])与不甚严格的血糖控制进行比较,发现严格血糖控制并未显著改善死亡率,但与不甚严格的血糖控制相比,低血糖发作显著增多。[136]Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010 Mar;137(3):544-51https://www.doi.org/10.1378/chest.09-1737http://www.ncbi.nlm.nih.gov/pubmed/20018803?tool=bestpractice.com
无论是否已确诊糖尿病,住院患者的高血糖与不良患者结局有关,包括死亡率升高。[137]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
迅速采取行动治疗高血糖以避免糖尿病酮症酸中毒(diabetic ketoacidosis, DKA)和高渗性高血糖状态(hyperosmolar hyperglycaemic state, HHS),这两者均为医学急症。
如果患者的 CBG ≥15 mmol/L (≥270 mg/dL),请遵循当地医院的方案。
通常在达到该 CBG 水平时需要采取措施,但不同的当地规程可能会有稍不同的临界水平,并且可能会基于患者患 1 型还是 2 型糖尿病而有所不同。
排除 DKA或HHS,两者均需给予特定紧急处理。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
通常使用钠-葡萄糖协同转运蛋白 2(sodium-glucose co-transporter-2, SGLT2)抑制剂治疗的患者应进行血酮检测以排除血糖正常的酮症酸中毒(血糖浓度正常时的酮症酸中毒),即使已停止使用 SGLT2 抑制剂(基于专家意见)。
如果患者存在 DKA 或 HHS,向糖尿病住院患者专科医生团队寻求建议,并遵循当地医院指南,或遵循英国糖尿病住院患者联合治疗协会(British Diabetes Society for Inpatient Care, JBDS-IP)指南。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
务必尽早由熟悉 HHS 管理的临床医生对 HHS 患者进行高级检查。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 对伴其他合并症的患者,可能需要收住高依赖病房(high-dependency unit)。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
请参阅“糖尿病酮症酸中毒” 或“高渗性高血糖状态” 。
需注意,以下药物可能与高血糖具有相关性,因此需进行评估:[140]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-Induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8http://spectrum.diabetesjournals.org/content/24/4/234
皮质类固醇
部分 β 受体阻滞剂(如普萘洛尔、阿替洛尔)
噻嗪类利尿剂(例如氢氯噻嗪)
部分第二代抗精神病药物(如奥氮平、氯氮平)
某些氟喹诺酮类抗生素(如环丙沙星)
钙调磷酸酶抑制剂(如环孢素、他克莫司)
蛋白酶抑制剂(例如,作为抗逆转录病毒治疗的成分,如利托那韦)。
对于复杂型患者或高血糖难以控制的患者,可向糖尿病团队寻求专家建议。
监测血糖并根据病情和住院就餐时间调整用药,从而降低低血糖发作风险。
大约 1/5 英格兰和威尔士糖尿病住院患者被发现曾在住院期间发生过低血糖。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
病因包括:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
急性疾病痊愈
胰岛素或口服降糖药用药错误
就餐相关胰岛素治疗的给药时间错误
患者进食少,但服用相同量的糖尿病药物
睡前不食用零食
食欲减退或呕吐
若在应用胰岛素或磺脲类药物情况下,血糖降至 6 mmol/L 以下(108 mg/dL)(濒临低血糖),应考虑进行干预。
此类患者进展为低血糖的风险较高。
按照低血糖指南建议,并遵循当地规程,给予碳水化合物(参阅下文)。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果血糖低于 4 mmol/L(72 mg/dL),则应积极治疗低血糖。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 请遵循医院规程或 JBDS-IP 的低血糖管理流程。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group JBDS-IP 指南也推荐:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
10-15 分钟后重新检测血糖,以确定治疗疗效
如果已经纠正低血糖,切勿停止下一次计划的胰岛素给药。否则会导致 1 型糖尿病患者出现反弹性高血糖和 DKA。
就是否需要对患者的胰岛素治疗方案进行审查,寻求糖尿病住院专家团队的建议。
采取措施降低夜间低血糖风险。假设患者可以吞咽,他们在医院所进晚餐可能比在家进食更少。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
在没有明显高血糖的情况下,考虑入院时将晚间基础胰岛素降低 20%(基于专家意见)。
请注意,如果患者错过进餐或用药剂量过大,则低血糖更可能是磺脲类药物治疗的不良反应(例如格列本脲、格列齐特、格列美脲、格列吡嗪)。
在急症医院环境中,餐时有可能被打乱,或无法每天同一时间进餐。
应在进食前或进食时给予磺脲类药物。查看当地药物处方集获取更为具体的指导信息,了解特定磺脲类药物给药时间与进食时间的关系。
切勿在睡前服用磺脲类药物,如果患者要在晚餐时服用一次,应考虑减少晚间剂量,以降低夜间低血糖发生风险(基于专家意见)。
睡前加餐可以降低清晨低血糖的风险。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
若糖尿病患者正在接受临终关怀:
将可致低血糖药物用量减至最少,但使患者不出现有症状高血糖,其可能导致:[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
脱水
酮症
高渗性高血糖。
1 型糖尿病患者切勿停用基础胰岛素
请参阅当地常规或来自英国 TREND Diabetes 等糖尿病组织的指南。[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
针对特定患者群中所有患者的治疗建议
患者可能会忘记告诉您他们常用的吸入器。记得检查并酌情开处吸入器。
哮喘患者应继续其惯常的吸入皮质类固醇药物治疗。没有明确的医学原因,不得停止治疗。
许多吸入器含有多种药物,因此请确保不要重复开药。
对于有急性肾损伤的 COPD 或哮喘患者,如果估算 GFR <50 mL/(min·1.73 mm),可能需要暂时停用其常用的吸入性长效毒蕈碱受体拮抗剂,具体取决于其使用的特定药物。
查阅当地处方集或寻求药师建议。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能提示合并哮喘的患者发生哮喘急性发作。
根据指南建议评估严重程度和管理成人哮喘的急性加重。[144]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. July 2019 [internet publication].https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/[145]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]https://ginasthma.org/2023-gina-main-report/
请参阅“成人哮喘急性发作” 专题。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理哮喘可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com
尽管有这方面的证据,但如果合并有哮喘的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能表明合并 COPD 的患者出现急性加重。[148]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2023 [internet publication]https://goldcopd.org/2023-gold-report-2/
与其他疾患进行鉴别,如急性冠脉综合征、急性心力衰竭和肺炎。
请遵循指南建议。请参阅 “COPD 急性加重” 专题。
支气管舒张剂雾化吸入疗法应仅持续 24 至 48 小时,然后患者应换回他们常用的吸入剂(基于专家意见)。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理 COPD 可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com
尽管有这方面的证据,但如果合并有 COPD 的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
一项系统评价发现,对于 COPD 急性加重的患者,皮质类固醇的短期疗程(7 天或更短)与更长时间的传统疗程(长于 7 天)之间的结局(治疗失败、至下一次加重时间、住院时间、肺功能、不良反应、死亡率)没有差异。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
此 Cochrane 评价中包括的随机对照试验均在医院环境内进行,且仅涉及重度至极重度 COPD 患者。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
该评价的作者得出结论,由于增加了一项新的试验,他们更加确信大约 5 天的皮质类固醇疗程可能足以治疗 COPD 急性加重。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
同样,在 2019 年对证据进行了一次评价后,英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)建议在 COPD 加重期间提供泼尼松龙治疗 5 天。[150]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication]https://www.nice.org.uk/guidance/ng115
针对特定患者群中所有患者的治疗建议
在临床情况允许以及患者有反应的情况下进行精神状态检查(基于专家意见)。
精神状态检查是精神病学临床实践中常规使用的主要临床工具之一,有助于诊断并指导进一步的管理。情绪是其中一项评估内容。
考虑使用 PHQ-9 问卷评估抑郁。[151]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
这是一份自测问卷,仅需不到 3 分钟即可完成。
结果可提示抑郁症状的严重程度。
应将得分为 5 分或以上的患者转诊至接受联络精神病学服务(基于专家意见)。
考虑可能影响患者精神状态的其他因素(例如,非法成瘾物质或酒精的作用)。[152]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14.http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
如果紧急临床情况允许,询问患者正在服用哪些药物治疗抑郁。或查看其初级卫生保健记录,获取相关信息(若可获取)。
为患者开具其常用的抗抑郁药,除非有充分的理由不得这样做(基于专家意见)。
如果突然停用抗抑郁药,患者可能会出现停药症状。[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
停药症状的严重程度可能不一,但可能令人不快,并使急性疾病的管理复杂化。[154]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91
审评当前药物时,需注意以下情况:
当前和既往不良反应
近期用药剂量改变
最近换了一种不同类别的药物
特定抑郁症亚型的药物细微差别(例如,精神病性抑郁症患者很可能会同时服用抗精神病处方药)
治疗难治性抑郁症时可能使用的增强策略(如锂剂或喹硫平加选择性 5-羟色胺再摄取抑制剂 [selective serotonin-reuptake inhibitor, SSRI])。
考虑药物相互作用。
抗抑郁药可能会与用于其他疾病的药物发生药代动力学(通过抑制 CYP450 通路)和药效动力学相互作用。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
开具非精神类药物时,应考虑精神并发症。
开具抗惊厥药物、抗帕金森病药物和皮质类固醇时,应格外小心。
考虑不良反应,具体可能包括以下不良反应。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021
低钠血症,由抗抑郁药(尤其是 SSRI)引起,会因使用同时开具的其他药物(例如利尿药)而加重。请检查患者的血清电解质。
5-羟色胺综合征(精神状态改变、激越、震颤、反射亢进、阵挛、肌强直、大量出汗、心动过速、肠鸣音增加、体温 >38℃),尤其是在多重用药和/或 5-羟色胺能药物过量时。[156]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com[157]Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014 Feb 19;348:g1626http://www.ncbi.nlm.nih.gov/pubmed/24554467?tool=bestpractice.com
特别要注意的是,服用 SSRI 的终末期肾病患者 5-羟色胺综合征的风险增加。治疗肾脏损伤患者的抑郁需要采取多学科方法,并需要格外谨慎。
肝毒性。必要时调整肝功能受损患者的抗抑郁药物剂量,避免使用已知具有肝毒性的药物。
与三环类抗抑郁药相关的 QTc 延长、心律失常、心率加快、体位性低血压。查看 ECG,特别是有心律失常风险的人群。
消化道出血。SSRI 与消化道出血风险增加相关。[158]Dalton SO, Sørensen HT, Johansen C. SSRIs and upper gastrointestinal bleeding: what is known and how should it influence prescribing? CNS Drugs. 2006;20(2):143-51http://www.ncbi.nlm.nih.gov/pubmed/16478289?tool=bestpractice.com[159]Dalton SO, Johansen C, Mellemkjaer L, et al. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study. Arch Intern Med. 2003 Jan 13;163(1):59-64https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/214901http://www.ncbi.nlm.nih.gov/pubmed/12523917?tool=bestpractice.com[160]Cheng YL, Hu HY, Lin XH, et al. Use of SSRI, but not SNRI, increased upper and lower gastrointestinal bleeding: a nationwide population-based cohort study in Taiwan. Medicine (Baltimore). 2015 Nov;94(46):e2022https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652818/http://www.ncbi.nlm.nih.gov/pubmed/26579809?tool=bestpractice.com与阿司匹林、非甾体抗炎药(non-steroidal anti-inflammatory drugs, NSAID)或口服抗凝剂联用时,风险尤其增加。[161]Loke YK, Trivedi AN, Singh S. Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther. 2008 Jan 1;27(1):31-40https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2007.03541.xhttp://www.ncbi.nlm.nih.gov/pubmed/17919277?tool=bestpractice.com
此清单并未详尽列出全部不良反应——请参阅当地处方集以获取更多信息。请咨询您联络的精神病学同事和/或药剂师以获取建议。
请询问患者通过哪些非药物治疗方法管理抑郁,并核实其目前在社区获得的支持情况。
这可能包括参与其护理的其他医疗卫生专业人士、慈善机构、家庭和社会网络以及心理治疗。
请注意,戒烟或从吸烟转为其他替代方案(包括尼古丁替代疗法)可能导致患者服用的精神类药物(例如,治疗抑郁的药物)血浆浓度发生变化。这是因为尼古丁替代治疗并不会像吸烟那样影响肝酶活性。[162]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid. 2016 Jun;11(6)4-7https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602[163]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com[164]Oliveira P, Ribeiro J, Donato H, Madeira N. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017;16:17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com[165]National Centre for Smoking Cessation and Training. Smoking cessation and mental health. 2014 [internet publication]https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf寻求相关建议,确认精神类药物剂量调整是否适当。
针对特定患者群中所有患者的治疗建议
考虑将任何因急性疾病入院且伴有抑郁的患者转诊至联络精神病学团队/服务机构。[166]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. March 2018 [internet publication]https://www.nice.org.uk/guidance/ng94[167]National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Treat as one. Bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
如果不存在抑郁和/或其管理可能影响急性病情的顾虑,则可能不需要转诊(基于专家意见)。
对于情况不明的事故、自伤行为和/或自杀企图,都应临床怀疑共病精神障碍(基于专家意见)。
合并抑郁症与对推荐的躯体健康治疗(从药物治疗到康复治疗)的依从性差有关。[168]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
这可能导致更差的临床结局,包括更高的再入院风险。[169]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(S7):S54-60http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com[170]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91[171]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33https://www.sciencedirect.com/science/article/pii/S0022399914003821http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com
最为重要的是,包括抑郁在内的情感症状与高死亡率有关,但其因果关系仍有待证实。[172]Archer G, Kuh D, Hotopf M, et al. Association between lifetime affective symptoms and premature mortality. JAMA Psychiatry. 2020 Aug 1;77(8):806-13https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2763796http://www.ncbi.nlm.nih.gov/pubmed/32267482?tool=bestpractice.com[173]Machado MO, Veronese N, Sanches M, et al. The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses. BMC Med. 2018 Jul 20;16(1):112https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1101-zhttp://www.ncbi.nlm.nih.gov/pubmed/30025524?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
对所有糖尿病患者在入院时和不适加重时进行足部检查。[174]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. October 2019 [internet publication]https://www.nice.org.uk/guidance/ng19
这是为了发现新的溃疡或感染,这些溃疡或感染可能被患者忽视,甚至可能是引发其急性病的原因(例如,出现脓毒症或心内膜炎的患者,其感染的原发灶是足部病变)。
检查足部有无病损,并检查保护性感觉是否丧失。
遵循当地指南,但有一个快速简单的试验:Ipswich Touch Test©(伊普斯威奇触摸试验),即将食指指尖轻轻触摸/放置在第一、第三和第五个足趾趾尖上 1 到 2 秒。[175]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 May 18;34(7):1517-8https://www.doi.org/10.2337/dc11-0156http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
如果患者在这六个部位中的两个或以上没有感觉,则代表其保护性感觉减退。
如果患者有感觉减退,则其有较高的压疮风险。告知其护理人员并提供减压装置。
护理人员或医疗人员应每日进行踝部检查,注意压力性创伤征象。
对于糖尿病患者是否应该使用弹力袜存在争议——如果有血管疾病,请勿使用。
针对特定患者群中所有患者的治疗建议
如果患者为当前吸烟者,请提供戒烟支持途径。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209 恰当的时机取决于具体的临床情况。一般情况下,英国国家卫生与临床优化研究所建议应立刻或在 24 小时内提供戒烟途径。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
对于所有吸烟的住院患者,如果没有禁忌证,应提供尼古丁替代疗法(nicotine replacement therapy, NRT)和其他戒烟药物疗法。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
建议:[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
尼古丁很容易使人成瘾,但这不是吸烟相关危害的原因。
NRT 可防止入院期间快速戒断,快速戒断可能会导致痛苦和不适。
当与专科支持相结合时,有数种高效的治疗选择能提供最大的戒烟可能性。
由于联合 NRT 比单一 NRT 有效,应将长效制剂 NRT(例如,透皮贴剂)与短效制剂 NRT(例如,咀嚼胶、锭剂、舌下片剂、吸入剂、口腔黏膜或鼻喷雾剂)联用来实施 NRT。 [177]Theodoulou A, Chepkin SC, Ye W, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2023 Jun 19;6(6):CD013308https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/37335995?tool=bestpractice.com[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
询问醒后至吸第一根烟的时间。短于 30 分钟的答案可提示这些患者可能有更多的尼古丁依赖问题,从而能指导选择尼古丁透皮贴剂的剂量。
查阅当地的处方集,以了解各种注意事项,尤其当患者有一种或多种合并症和/或血流动力学不稳定时。
对于任何有意戒烟的患者,可考虑 联合使用伐尼克兰和 NRT ,因为这是一种对成人戒烟非常有效的组合。 [179]Thomas KH, Dalili MN, López-López JA, et al. Comparative clinical effectiveness and safety of tobacco cessation pharmacotherapies and electronic cigarettes: a systematic review and network meta-analysis of randomized controlled trials. Addiction. 2022 Apr;117(4):861-76.https://onlinelibrary.wiley.com/doi/10.1111/add.15675http://www.ncbi.nlm.nih.gov/pubmed/34636108?tool=bestpractice.com 对于烟草依赖,联合治疗比使用单一药物更有效。[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
一项 Cochrane 评价发现,有高确定性证据表明伐尼克兰是烟草依赖的有效治疗方法。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 该评价还发现,伐尼克兰使用者出现导致住院的严重不良反应(例如心脏问题)几率可能会增加;但这种情况仍属罕见(伐尼克兰使用者中有 2.7%-4.0% 出现这种情况,而未使用伐尼克兰者中仅 2.7% 出现这种情况),并且其中可能包括与伐尼克兰无关的不良反应。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 查阅当地处方集,以获取关于禁忌证/注意事项的完整清单,或者寻求药师建议。
心理卫生疾病不是开具伐尼克兰的禁忌证。然而,对于已患精神疾病的患者,应谨慎使用伐尼克兰,因为该药可能加重症状。
对于戒烟,安非他酮是另一种选择,但是取得成功的可能性更低。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 应考虑药物相互作用的可能性。
完成到烟草依赖执业医师/服务机构的转诊。
若无紧急考量因素,对急性结石事件初步治疗的主要目标是缓解症状,并根据需要进行补液和镇痛。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com[46]Afshar K, Jafari S, Marks AJ, et al. Nonsteroidal anti-inflammatory drugs (NSAIDs) and non-opioids for acute renal colic. Cochrane Database Syst Rev. 2015 Jun 29;(6):CD006027.https://www.doi.org/10.1002/14651858.CD006027.pub2http://www.ncbi.nlm.nih.gov/pubmed/26120804?tool=bestpractice.com [ ]Is there randomized controlled trial evidence to support the use of nonsteroidal anti-inflammatory drugs (NSAIDS) compare with other analgesics and each other in people with acute renal colic?https://cochranelibrary.com/cca/doi/10.1002/cca.920/full展示答案
在疼痛管理方面,请给予:
使用一种非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)作为一线治疗,任何给药途径均可[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118[47]Davenport K, Waine E. The role of non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals (Basel). 2010 Apr 28;3(5):1304-10.https://www.mdpi.com/1424-8247/3/5/1304/htmhttp://www.ncbi.nlm.nih.gov/pubmed/27713303?tool=bestpractice.com[证据 C]f4ca9417-e30c-45fd-adf3-eddc765b257bguidelineC对于有症状肾结石或输尿管结石患者,非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)对于急性疼痛管理的临床有效性如何?[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
非甾体抗炎药已被证实能够有效缓解急性肾结石相关的疼痛,并且其副作用少于阿片类药物和对乙酰氨基酚。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com
肠外 NSAID 疼痛缓解作用最为持久,且与阿片类药物相比不良反应更少。[45]Pathan SA, Mitra B, Cameron PA. A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic. Eur Urol. 2018 Apr;73(4):583-95.http://www.ncbi.nlm.nih.gov/pubmed/29174580?tool=bestpractice.com[49]Gu HY, Luo J, Wu JY, et al. Increasing nonsteroidal anti-inflammatory drugs and reducing opioids or paracetamol in the management of acute renal colic: based on three-stage study design of network meta-analysis of randomized controlled trials. Front Pharmacol. 2019;10:96.https://www.doi.org/10.3389/fphar.2019.00096http://www.ncbi.nlm.nih.gov/pubmed/30853910?tool=bestpractice.com
如果禁忌使用 NSAID 或该药对患者的镇痛效果不足,应静脉使用对乙酰氨基酚。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
只有在禁忌使用 NSAID 和静脉对乙酰氨基酚或这两种药物对患者的镇痛效果不足时,才可考虑阿片类药物。[47]Davenport K, Waine E. The role of non-steroidal anti-inflammatory drugs in renal colic. Pharmaceuticals (Basel). 2010 Apr 28;3(5):1304-10.https://www.mdpi.com/1424-8247/3/5/1304/htmhttp://www.ncbi.nlm.nih.gov/pubmed/27713303?tool=bestpractice.com 如果给予阿片类药物,应同时开具止吐药控制阿片类药物引起的恶心。
请勿对疑似肾绞痛患者使用解痉药。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
心衰 慢性肾脏病 (CKD) 哮喘
选择最为合适的镇痛治疗和给药方案时,需对患者合并症加以考量。
避免将非甾体抗炎药(non-steroidal anti-inflammatory drug, NSAID)用于心力衰竭患者(基于专家意见)。
对于肾功能减退患者, 调整阿片类药物剂量非常重要。
如果肾脏无法排泄,包括吗啡在内的数种阿片类药物活性代谢物就会出现积聚。[80]Davison SN. Clinical pharmacology considerations in pain management in patients with advanced kidney failure. Clin J Am Soc Nephrol. 2019 Jun 7;14(6):917-31https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6556722/http://www.ncbi.nlm.nih.gov/pubmed/30833302?tool=bestpractice.com
避免将 NSADI 用于 CKD 患者。[81]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
糖尿病 痴呆 COPD 卒中 心衰 Frailty 高血压 冠状动脉病 慢性肾脏病 (CKD) 抑郁
在决定患者是居家治疗,还是需要入院治疗和/或专家评估时,患者的合并症是一项重要的考虑因素。
需考虑患者临床疾病总体严重性和稳定性,及其在家中进行自我照护的能力。
即使是虚弱患者或慢性疾病患者的轻度疾病也可能导致其身体机能下降,以致其无法居家进行安全地自理,而且可能无法立即获得照护者的支持。
若患者年龄 ≥65 岁,则在适当的时候应用临床衰弱量表(Clinical Frailty Scale, CFS)评估患者的衰弱程度,作为整体评估的一部分。[82]NHS Specialised Clinical Frailty Network. Clinical frailty scale. 2018 [internet publication]https://www.scfn.org.uk/clinical-frailty-scale
请勿使用 CFS 评估较年轻患者或者存在长期稳定残疾(例如脑性瘫痪)、学习障碍或孤独症的患者。[82]NHS Specialised Clinical Frailty Network. Clinical frailty scale. 2018 [internet publication]https://www.scfn.org.uk/clinical-frailty-scale
如果患者可以居家安全继续接受治疗,确保为其提供充分随访服务,并给予安全保障建议。建议患者在病情未改善或者出现恶化时寻求医疗建议或返院接受再评估。
必要时咨询专家意见。
布洛芬 : 儿童:咨询专科医生,获取剂量指导;成人:300-600 mg,口服(速释型),根据需要每 6-8 小时一次,每日最多 2400 mg
或
双氯芬酸钠 : 儿童:咨询专科医生,获得剂量指导;成人:75 mg,肌内注射,需要时每日一次或两次
或
双氯芬酸钾 : 儿童:咨询专科医生,获得剂量指导;成人:75-150 mg/d,口服(速释型),需要时分 2-3 次给药
对乙酰氨基酚 : 儿童:咨询专科医生,获得剂量指导;成人:15 mg/kg(每剂最大剂量为 1000 mg),静脉使用,需要时每 4-6 小时一次,每日最大剂量为 4000 mg
硫酸吗啡 : 儿童:咨询专科医生,获取剂量指导;成人:5-10mg,口服(速释型)/皮下/静脉/肌内注射,最初每 4 小时一次,根据疗效调整剂量
布洛芬 : 儿童:咨询专科医生,获取剂量指导;成人:300-600 mg,口服(速释型),根据需要每 6-8 小时一次,每日最多 2400 mg
或
双氯芬酸钠 : 儿童:咨询专科医生,获得剂量指导;成人:75 mg,肌内注射,需要时每日一次或两次
或
双氯芬酸钾 : 儿童:咨询专科医生,获得剂量指导;成人:75-150 mg/d,口服(速释型),需要时分 2-3 次给药
对乙酰氨基酚 : 儿童:咨询专科医生,获得剂量指导;成人:15 mg/kg(每剂最大剂量为 1000 mg),静脉使用,需要时每 4-6 小时一次,每日最大剂量为 4000 mg
硫酸吗啡 : 儿童:咨询专科医生,获取剂量指导;成人:5-10mg,口服(速释型)/皮下/静脉/肌内注射,最初每 4 小时一次,根据疗效调整剂量
针对特定患者群中所有患者的治疗建议
如同处理所有因急症而入院的患者,应对患者基线肾功能进行检查 ,如果患者具有 CKD 病史,需予以特别密切的监测。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
CKD 是急性肾损伤重要危险因素。[95]Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int. 2008 Apr 2;74(1):101-7https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2673528/http://www.ncbi.nlm.nih.gov/pubmed/18385668?tool=bestpractice.com
急症可增加肾功能恶化风险。
对少尿进行监测并予以处理。[94]National Institute for Health and Care Excellence. Acute kidney injury: prevention, detection and management. December 2019 [internet publication]https://www.nice.org.uk/guidance/ng148
针对特定患者群中部分患者治疗的附加建议
如果患者有症状并被确诊为菌尿,但无梗阻或脓毒症征象,则应在获得基于尿液分析培养的药敏结果之前启动经验性抗生素治疗。然后根据结石大小予以相应治疗(见下文)。
经验性方案取决于多种因素,包括感染类型、患者因素和当地抗生素耐药性模式;关于抗生素的选择,查阅当地指南,了解更多信息。
如果患者被确诊为菌尿但无症状,则在抗感染治疗之前先治疗结石可能更恰当;请咨询专科医生。
针对特定患者群中部分患者治疗的附加建议
衰弱是与一种衰老过程相关的独特健康状态,在该状态下多身体系统逐渐发生功能衰退。[117]NHS England. Toolkit for general practice in supporting older people living with frailty. March 2017 [internet publication]https://www.england.nhs.uk/publication/toolkit-for-general-practice-in-supporting-older-people-living-with-frailty/
询问患者其在急性发作前 2 周的能力情况(以及可能的相关照护者的意见)。
如果患者的年龄 ≥65 岁,则采用临床衰弱量表。NHS Specialised Clinical Frailty Network: Clinical Frailty Scale
这是确定衰弱的实用辅助工具,但不应仅仅依赖它。
较高的衰弱评分与不良结局风险增加有关。[120]Wallis SJ, Wall J, Biram RW, et al. Association of the clinical frailty scale with hospital outcomes. QJM. 2015 Dec;108(12):943-9https://www.doi.org/10.1093/qjmed/hcv066http://www.ncbi.nlm.nih.gov/pubmed/25778109?tool=bestpractice.com
辅助实施多学科诊疗,并根据患者的价值观来调整管理方案。[122]Quinn TJ, Mooijaart SP, Gallacher K, et al. Acute care assessment of older adults living with frailty. BMJ. 2019 Jan 31;364:l13http://www.ncbi.nlm.nih.gov/pubmed/30705024?tool=bestpractice.com
针对特定患者群中部分患者治疗的附加建议
及时治疗输尿管结石很重要,否则可能引起梗阻和肾损伤。
对于成人和儿童 <10 mm 的输尿管远端结石,可以选用 α 受体阻滞剂进行药物排石治疗(medical expulsive therapy, MET)。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
使用 α 受体阻滞剂(例如坦索罗辛或阿夫唑嗪)进行 MET 可能对促进输尿管远端较大结石(仍 <10 mm)排出有益;但其有效性存疑。[50]Sridharan K, Sivaramakrishnan G. Efficacy and safety of alpha blockers in medical expulsive therapy for ureteral stones: a mixed treatment network meta-analysis and trial sequential analysis of randomized controlled clinical trials. Expert Rev Clin Pharmacol. 2018 Mar;11(3):291-307.http://www.ncbi.nlm.nih.gov/pubmed/29334287?tool=bestpractice.com[51]Meltzer AC, Burrows PK, Wolfson AB, et al. Effect of tamsulosin on passage of symptomatic ureteral stones: a randomized clinical trial. JAMA Intern Med. 2018 Aug 1;178(8):1051-7.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082698/http://www.ncbi.nlm.nih.gov/pubmed/29913020?tool=bestpractice.com[52]Hollingsworth JM, Canales BK, Rogers MA, et al. Alpha blockers for treatment of ureteric stones: systematic review and meta-analysis. BMJ. 2016 Dec 1;355:i6112.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5131734/http://www.ncbi.nlm.nih.gov/pubmed/27908918?tool=bestpractice.com[53]Wang RC, Smith-Bindman R, Whitaker E, et al. Effect of tamsulosin on stone passage for ureteral stones: a systematic review and meta-analysis. Ann Emerg Med. 2017 Mar;69(3):353-61.e3.http://www.ncbi.nlm.nih.gov/pubmed/27616037?tool=bestpractice.com[54]Aboumarzouk OM, Jones P, Amer T, et al. What is the role of α-blockers for medical expulsive therapy? Results from a meta-analysis of 60 randomized trials and over 9500 patients. Urology. 2018 Sep;119:5-16.http://www.ncbi.nlm.nih.gov/pubmed/29626570?tool=bestpractice.com[55]Hsu YP, Hsu CW, Bai CH, et al. Silodosin versus tamsulosin for medical expulsive treatment of ureteral stones: A systematic review and meta-analysis. PLoS One. 2018;13(8):e0203035.https://www.doi.org/10.1371/journal.pone.0203035http://www.ncbi.nlm.nih.gov/pubmed/30153301?tool=bestpractice.com[56]Oestreich MC, Vernooij RW, Sathianathen NJ, et al. Alpha-blockers after shock wave lithotripsy for renal or ureteral stones in adults. Cochrane Database Syst Rev. 2020 Nov 12;11:CD013393.https://www.doi.org/10.1002/14651858.CD013393.pub2http://www.ncbi.nlm.nih.gov/pubmed/33179245?tool=bestpractice.com 在英国的临床实践中,坦索罗辛最常用。
这些药物可使输尿管平滑肌松弛,并具有抗输尿管痉挛的作用,因此可促进排石。[57]Micali S, Grande M, Sighinolfi MC, et al. Medical therapy of urolithiasis. J Endourol. 2006 Nov;20(11):841-7.http://www.ncbi.nlm.nih.gov/pubmed/17144848?tool=bestpractice.com
如果出现并发症(感染、难治性疼痛或肾功能恶化),请停止治疗。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
患者应注意针对此适应证开具的 α 受体阻滞剂属于超说明书用药。此外,坦索罗辛的使用已被证实与术中虹膜松弛综合征相关,因此如果患者已有白内障手术的计划应禁止开具此药物。
大多数能够自发性排石的病例在 4-6 周内完成排石。结石越大,自发性排石的可能性越小。据有限数据估计,95% 不超过 4 mm 的结石可在 40 天内排出。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
一般来说,此类患者均应采用 KUB 加肾脏超声或腹部和盆腔计算机体层成像平扫(non-contrast computed tomography, NCCT)等影像学手段进行定期随访,以监测结石的位置和肾盂积水的程度。
手术干预的适应证为:存在持续梗阻、排石失败、脓毒症、肾绞痛持续或加重。
如果成人患者有输尿管结石且疼痛持续、难忍,或者该输尿管结石不太可能排出,则务必在作出诊断或患者再入院后 48 小时内实施手术治疗。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118请参阅下文外科干预章节。
坦索罗辛 : 儿童:咨询专科医生,获得剂量指导;成人:0.4 mg,口服,每日一次
或
阿夫唑嗪 : 儿童:咨询专科医生,获得剂量指导;成人:10 mg,口服(控释型),每日一次
坦索罗辛 : 儿童:咨询专科医生,获得剂量指导;成人:0.4 mg,口服,每日一次
或
阿夫唑嗪 : 儿童:咨询专科医生,获得剂量指导;成人:10 mg,口服(控释型),每日一次
针对特定患者群中部分患者治疗的附加建议
对于较大结石(≥10 mm)、经保守治疗后仍未清除的较小结石以及引起持续不可耐受性疼痛的结石,需要外科干预。
如果成人患者有输尿管结石且疼痛持续、难忍,或者该输尿管结石不太可能排出,则务必在作出诊断或患者再入院后 48 小时内实施手术治疗。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
过去,开放性手术是清除结石的唯一方法。然而,随着腔内泌尿外科学(endourology;此术语已被用于描述在内窥镜的辅助下、于闭合尿道内进行操作的微创手术技术)的发展和成功,目前已很少进行开放性手术。
冲击波碎石术(shock wave lithotripsy, SWL)是所有确定性结石治疗中创伤性最小的疗法,适合大多数单纯性结石病患者。在 SWL 过程中,位于患者体外的波源会产生冲击波,然后传播进入体内,聚焦于结石。冲击波会通过压力和拉力击碎结石。结石碎片则会通过尿液排出。SWL 的应用会受限于结石的大小和部位。然而,SWL 一般无需全身麻醉,所以通常可在门诊进行。使用坦索罗辛进行治疗可有效地帮助肾脏和输尿管结石患者清除结石。[58]Zhu Y, Duijvesz D, Rovers MM, et al. Alpha-blockers to assist stone clearance after extracorporeal shock wave lithotripsy: a meta-analysis. BJU Int. 2010 Jul;106(2):256-61.http://www.ncbi.nlm.nih.gov/pubmed/19889063?tool=bestpractice.com 虽然 SWL 治疗肾下极结石的成功率有限,但有证据表明 SWL 联合辅助方法(例如体外敲打、利尿和倒立)可以提高净石率。[59]Liu LR, Li QJ, Wei Q, et al. Percussion, diuresis, and inversion therapy for the passage of lower pole kidney stones following shock wave lithotripsy. Cochrane Database Syst Rev. 2013;(12):CD008569.http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008569.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/24318643?tool=bestpractice.com SWL 治疗的禁忌证包括妊娠、严重骨骼畸形、严重肥胖、主动脉和/或肾动脉瘤、未控制高血压、凝血功能障碍和泌尿道感染控制不良。[60]Loughlin KR. Management of urologic problems during pregnancy. Urology. 1994 Aug;44(2):159-69.http://www.ncbi.nlm.nih.gov/pubmed/8048189?tool=bestpractice.com[61]Ignatoff JM, Nelson JB. Use of extracorporeal shock wave lithotripsy in a solitary kidney with renal artery aneurysm. J Urol. 1993 Feb;149(2):359-60.http://www.ncbi.nlm.nih.gov/pubmed/8426419?tool=bestpractice.com
输尿管镜治疗是将一条纤细的半硬性或软性内镜经尿道置入输尿管和/或肾脏。一旦发现结石,可用激光将其击碎,然后用取石装置抓取碎片并移除。这种治疗的创伤性大于 SWL,但普遍认为其结石清除率更高。[62]Wang H, Man L, Li G, et al. Meta-analysis of stenting versus non-stenting for the treatment of ureteral stones. PLoS One. 2017 Jan 9;12(1):e0167670.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5221881/http://www.ncbi.nlm.nih.gov/pubmed/28068364?tool=bestpractice.com [ ]For adults undergoing ureteroscopy for ureteral calculi clearance, how does placement of a ureteral stent affect outcomes?https://www.cochranelibrary.com/cca/doi/10.1002/cca.2494/full展示答案该操作通常作为日间手术进行。手术使用钬激光,可安全用于凝血功能异常的患者。一次性软式输尿管肾盂镜(FURS)治疗肾结石的有效性与可重复使用 FURS 相当。[63]Davis NF, Quinlan MR, Browne C, et al. Single-use flexible ureteropyeloscopy: a systematic review. World J Urol. 2018 Apr;36(4):529-36.http://www.ncbi.nlm.nih.gov/pubmed/29177820?tool=bestpractice.com 对于远端输尿管结石(无论其大小如何)和>10 mm 的近段输尿管结石,输尿管镜的净石率要优于 SWL。[64]Dell'Atti L, Papa S. Ten-year experience in the management of distal ureteral stones greater than 10 mm in size. G Chir. 2016 Jan-Feb;37(1):27-30.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859772/http://www.ncbi.nlm.nih.gov/pubmed/27142822?tool=bestpractice.com[65]Cui X, Ji F, Yan H, et al. Comparison between extracorporeal shock wave lithotripsy and ureteroscopic lithotripsy for treating large proximal ureteral stones: a meta-analysis. Urology. 2015 Apr;85(4):748-56.http://www.ncbi.nlm.nih.gov/pubmed/25681251?tool=bestpractice.com 但是,输尿管镜取石的并发症发生率较高,住院时间较长。[66]Drake T, Grivas N, Dabestani S, et al. What are the benefits and harms of ureteroscopy compared with shock-wave lithotripsy in the treatment of upper ureteral stones? A systematic review. Eur Urol. 2017 Nov;72(5):772-86.http://www.ncbi.nlm.nih.gov/pubmed/28456350?tool=bestpractice.com[67]Aboumarzouk OM, Kata SG, Keeley FX, et al. Extracorporeal shock wave lithotripsy (ESWL) versus ureteroscopic management for ureteric calculi. Cochrane Database Syst Rev. 2012;(5):CD006029.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006029.pub4/fullhttp://www.ncbi.nlm.nih.gov/pubmed/22592707?tool=bestpractice.com 输尿管支架是从肾脏延伸至膀胱的内置导管,通常在输尿管镜治疗后临时留置,以促进集合系统引流,同时消退结石或操作造成的任何水肿。建议将支架用于功能性或解剖性孤立肾、输尿管狭窄、发现输尿管损伤的患者,或计划接受二期手术的患者。对于 <20 mm 的输尿管结石,请勿在输尿管镜治疗后无并发症的情况下常规置入支架。
经皮肾镜取石术(percutaneous nephrolithotomy, PCNL)是一种微创治疗,通常仅用于肾结石(尤其是肾下极结石)、较大结石(>20 mm)、SWL 和输尿管镜治疗失败的结石或者所在部位肾解剖结构复杂的结石。[68]Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016 [internet publication].http://www.auanet.org/education/guidelines/surgical-management-of-stones.cfm 建立入路时,从腰部经皮进入肾脏。当前证据表明,在荧光透视和超声引导下,均可成功建立经皮肾脏入路。联合使用超声和荧光透视似乎可以改善结局,包括提高入路建立成功率和减少并发症。[69]Breda A, Territo A, Scoffone C, et al. The evaluation of radiologic methods for access guidance in percutaneous nephrolithotomy: a systematic review of the literature. Scand J Urol. 2018 Apr;52(2):81-6.http://www.ncbi.nlm.nih.gov/pubmed/29130789?tool=bestpractice.com 建立入路后,将镜鞘送入肾脏,并使用肾镜取出结石。对于较大结石,通常使用超声碎石技术将结石击碎,然后进行清除。PCNL 通常需要住院,而且与 SWL 或输尿管镜相比,其潜在并发症更多。对于 20-30 mm 的结石,SWL 结石清除率(34%)低于 PCNL(90%)。[70]Lingeman JE, Coury TA, Newman DM, et al. Comparison of results and morbidity of percutaneous nephrostolithotomy and extracorporeal shock wave lithotripsy. J Urol. 1987 Sep;138(3):485-90.http://www.ncbi.nlm.nih.gov/pubmed/3625845?tool=bestpractice.com
腹腔镜取石是清除输尿管或肾结石的另一种微创治疗方式。然而,其创伤性仍然较大,需要较长时间的住院,而且掌握这项技术所需的时间要远长于输尿管镜和 SWL。在过去 20 年中,随着 SWL 和腔内泌尿外科技术(即输尿管镜和 PCNL)的发展,开放性取石手术的适应证范围已显著缩小。下列罕见情况下可使用腹腔镜或开放性手术取石:SWL、输尿管镜和经皮输尿管镜治疗失败或者不太可能成功的患者;解剖结构畸形(妨碍微创手术的使用)的患者;需要同时接受开放手术、肾盂成形或部分肾切除术的患者;或者结石负担较大,需要一次性清除的患者。[68]Assimos D, Krambeck A, Miller NL, et al. Surgical management of stones: American Urological Association/Endourological Society Guideline. 2016 [internet publication].http://www.auanet.org/education/guidelines/surgical-management-of-stones.cfm[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
如果患者是成年人:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
实施冲击波碎石术(shock wave lithotripsy, SWL)
请勿对准备接受 SWL 的成人患者实施治疗前支架置入术
如果不可能在 SWL 术后 4 周内清除结石、患者有 SWL 禁忌证、SWL 治疗失败或无法靶向碎石,应考虑输尿管镜治疗
对于输尿管结石 <20 mm 的成人患者,请勿在输尿管镜治疗后常规采用治疗后支架置入术。
如果患者年龄小于 16 岁:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
考虑输尿管镜治疗或 SWL
如果患者是成年人:[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
提供输尿管镜治疗
对于输尿管结石 <20 mm 的成人患者,请勿在输尿管镜治疗后常规采用治疗后支架置入术。
如果当地医疗设施允许在 4 周内清除结石,应考虑 SWL
请勿对准备接受 SWL 的成人患者实施治疗前支架置入术。
如果输尿管镜治疗失败,应考虑使用 PCNL 清除嵌入的近端结石。
如果患者年龄小于 16 岁,应考虑输尿管镜治疗或 SWL。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
这种较大的输尿管结石在临床实践中很少见。因此,应根据患者实际病情制定结石治疗方案,具体取决于当地的可用疗法以及相关专业技术水平。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
针对特定患者群中所有患者的治疗建议
对任何有卒中病史的患者,请在适当的时机尽早进行基线神经系统评估。
伴有急症(例如感染和疾病相关性低血压)的患者卒中风险升高(缺血性和出血性)。[96]Grau AJ, Urbanek C, Palm F. Common infections and the risk of stroke. Nat Rev Neurol. 2010 Nov 9;6(12):681-94http://www.ncbi.nlm.nih.gov/pubmed/21060340?tool=bestpractice.com[97]Eigenbrodt ML, Rose KM, Couper DJ, et al. Orthostatic hypotension as a risk factor for stroke: the atherosclerosis risk in communities (ARIC) study, 1987-1996. Stroke. 2000 Oct;31(10):2307-13http://www.ncbi.nlm.nih.gov/pubmed/11022055?tool=bestpractice.com 有卒中病史的患者风险更高。
如果在住院期间神经系统状态发生变化,应重复进行神经系统评估,从而防止再次发生卒中。
进行评估之后,应确保对患者进行适当的监护(例如需结合夜间意识模糊风险和机体脆弱相关性跌倒风险制定监护计划)。有卒中病史的患者跌倒和受伤的风险增加。[98]Winstein CJ, Stein J, Arena R, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 May 4;47(6):e98-e169https://www.doi.org/10.1161/STR.0000000000000098http://www.ncbi.nlm.nih.gov/pubmed/27145936?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
尽早对具有痴呆病史的患者进行基线认知评估,并通过家人、朋友或照护者获取旁证病史。[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
使用在急性情况下可行的经过验证的评分系统,例如:[99]Pendlebury ST, Klaus SP, Mather M, et al. Routine cognitive screening in older patients admitted to acute medicine: abbreviated mental test score (AMTS) and subjective memory complaint versus Montreal Cognitive Assessment and IQCODE. Age Ageing. 2015 Oct 13;44(6):1000-5https://www.doi.org/10.1093/ageing/afv134http://www.ncbi.nlm.nih.gov/pubmed/26464420?tool=bestpractice.com
简化智力测试量表/10(AMTS/10)[100]Hodkinson HM. Evaluation of a mental test score for assessment of mental impairment in the elderly. Age Ageing. 1972 Nov;1(4):233-8http://www.ncbi.nlm.nih.gov/pubmed/4669880?tool=bestpractice.comBritish Geriatrics Society: Abbreviated Mental Test Score. 2018
旁证病史可确定患者的认知是否稳定,或者认知和功能是逐渐下降还是急性下降。
标准化认知评估评分将有助于监测所有临床改善, 以及确定出院需求。判读该分数时,最好结合功能评估(通常由经过培训的职业治疗师进行)。
尽管由于急性疾患及其治疗的影响,该评分可能并不代表患者平时的认知基线,但当患者恢复后,记录并重复该评分仍然是很好的做法(基于专家意见)。
每当痴呆患者出现急性疾病时都要进行谵妄评估。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
伴痴呆者入院时和整个住院期间发生谵妄的风险增加。[102]National Institute for Health and Care Excellence. Dementia: assessment, management and support for people living with dementia and their carers. Jun 2018 [internet publication].https://www.nice.org.uk/guidance/ng97[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
谵妄与痴呆不同。[104]Nova Scotia Health Authority. This is not my Mom. 2012 [internet publication]http://ltctoolkit.rnao.ca/node/1774 谵妄是指精神功能出现潜在致死性的急性波动性改变,伴有注意力缺乏、思维混乱和意识水平的改变。[105]Inouye SK, Schlesinger MJ, Lydon TJ. Delirium: a symptom of how hospital care is failing older persons and a window to improve quality of hospital care. Am J Med. 1999 May;106(5):565-73http://www.ncbi.nlm.nih.gov/pubmed/10335730?tool=bestpractice.com
使用筛查工具检测可能出现的谵妄,例如:
4-AT[106]Bellelli G, Morandi A, Davis DH, et al. Validation of the 4AT, a new instrument for rapid delirium screening: a study in 234 hospitalised older people. Age Ageing. 2014 Mar 2;43(4):496-502.https://www.doi.org/10.1093/ageing/afu021http://www.ncbi.nlm.nih.gov/pubmed/24590568?tool=bestpractice.com[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[107]MacLullich AM, Shenkin SD, Goodacre S, et al. The 4 'A's test for detecting delirium in acute medical patients: a diagnostic accuracy study. Health Technol Assess. 2019 Aug;23(40):1-194https://www.doi.org/10.3310/hta23400http://www.ncbi.nlm.nih.gov/pubmed/31397263?tool=bestpractice.com[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
关于 4-AT 计算的更多信息已由苏格兰校际指南网络发布SIGN Decision Support: delirium - risk reduction and management.
如果患者处于危重症监护环境或术后恢复室,则使用重症监护病房意识模糊评估法(Confusion Assessment Method for the Intensive Care Unit, CAM-ICU)或重症监护谵妄筛查量表(Intensive Care Delirium Screening Checklist, ICDSC)
经英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)推荐,专为这些情况设计,但使用者需要接受培训,因此应用可能受限。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
考虑采取以下措施,作为降低痴呆患者住院期间谵妄风险的多元化干预措施的一部分:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
帮助患者定向;确保患者有自己的眼镜和/或助听器
使患者尽早活动
充分控制疼痛
监测和及时治疗术后并发症
维持充分的液体摄入,并帮助患者摄入足够食物
监测并维持正常的肠道和膀胱功能
根据指南的建议使用辅助吸氧。
安排与经验丰富的医疗卫生专业人士一起进行用药评估。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
如果患者的日常照护者愿意,考虑协助他们提供非医疗照护,例如在用餐时提供帮助(基于专家意见)。
痴呆是术后谵妄的危险因素之一
考虑与麻醉科医师联系以寻求有关疼痛管理的建议。[108]White S, Griffiths R, Baxter M, et al. Guidelines for the peri-operative care of people with dementia: guidelines from the Association of Anaesthetists. Anaesthesia. 2019 Jan 11;74(3):357-72https://onlinelibrary.wiley.com/doi/full/10.1111/anae.14530http://www.ncbi.nlm.nih.gov/pubmed/30633822?tool=bestpractice.com
有证据表明,多元化方法可降低非 ICU 住院患者发生谵妄的风险。
2016 年关于预防医院非 ICU 患者谵妄的干预措施的 Cochrane 系统评价发现:[109]Siddiqi N, Harrison JK, Clegg A, et al. Interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database Syst Rev. 2016 Mar 11;3:CD005563https://www.doi.org/10.1002/14651858.CD005563.pub3http://www.ncbi.nlm.nih.gov/pubmed/26967259?tool=bestpractice.com
来自七项研究的中等质量证据表明,与常规治疗相比,接受多元化风险降低干预的患者谵妄风险降低(RR 0.69,95% CI 0.59-0.81)。
这七项研究的干预措施包括多元组成部分:工作人员教育、针对特定危险因素的方案、训练有素的跨学科团队的参与、教育方面的专业护理干预、用药审评、鼓励活动和患者环境改善。
只有一项研究(低质量证据)纳入了已有痴呆的患者亚组,该研究报告称,疗效无显著差异(RR 0.90,95% CI 0.59-1.36)。这篇综述的作者得出结论,对于这一人群的疗效尚不确定。
另一项针对老年患者的系统评价发现,非药物多元化干预措施可有效预防谵妄。[110]Martinez F, Tobar C, Hill N. Preventing delirium: should non-pharmacological, multicomponent interventions be used? A systematic review and meta-analysis of the literature. Age Ageing. 2014 Nov 25;44(2):196-204https://www.doi.org/10.1093/ageing/afu173http://www.ncbi.nlm.nih.gov/pubmed/25424450?tool=bestpractice.com
对七项研究的荟萃分析发现,与常规治疗相比,谵妄的发生率显著降低(RR 0.73,95% CI 0.63-0.85;P <0.001)。
疗效不因痴呆的存在和病房类型而不同。
如果患者出现谵妄,需检查并治疗危及生命的病因:[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
缺氧
低血糖
低血压
药物中毒或戒断,包括酒精戒断。
其他检查包括(基于专家意见):
全血细胞计数、电解质、肾功能、甲状腺功能检测、肝功能检测、钙、血糖、CRP、叶酸和维生素 B12
血培养(如果怀疑菌血症)
尿培养
胸部 X 线。
根据具体临床发现,可能需要进行更高级的非常规检查,例如头颅 CT。请与上级医生讨论。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
检查并治疗谵妄的所有可逆病因。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
疼痛
感染
营养不良
便秘
脱水
药物治疗
询问最近开的处方药,特别是阿片类镇痛药、抗焦虑药、镇静剂、抗精神病药物或抗胆碱作用强的药物。
考虑计算抗胆碱能总负担得分。
制动
睡眠差
感觉受损(如耵聍或眼镜丢失)
助记符PINCH ME可能有助于记住谵妄的潜在原因。“E”代表“环境改变”(Environmental change)。[111]Public Health England. Urinary tract infection: diagnostic tools for primary care. October 2020 [internet publication]https://www.gov.uk/government/publications/urinary-tract-infection-diagnosis
首先使用非药物治疗管理谵妄患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
通过提供一个光线充足的房间,且将时钟和日历放置在显眼位置(例如挂在墙上),可减轻定向障碍。
鼓励家人、朋友和照护者探望患者。
使用语言和非语言技巧减轻冲突和苦恼。
如果非药物治疗无效,并且患者感到痛苦或可能对自己或他人构成危险,短期(通常仅需要 1-2 天)使用抗精神病药物或镇静剂可加以考虑,但只能作为最后的治疗手段。必须定期评估为此目的新给予的所有抗精神病药物,并在实际情况允许时予以停药(基于专家意见)。
NICE 推荐短期使用氟哌啶醇(通常短于一周),但这并不适合所有患者,并且坚决不能用于帕金森病或路易体痴呆患者。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 对所有禁忌证进行分析。
对于脆弱老年患者急性谵妄给予氟哌啶醇时,需特别注意给予密切监测和进行定期分析。此类患者使用该药物,出现神经系统和心脏不良反应的风险极高。[112]Medicines and Healthcare products Regulatory Agency. Haloperidol (haldol): reminder of risks when used in elderly patients for the acute treatment of delirium. 2021 [internet publication]https://www.gov.uk/drug-safety-update/haloperidol-haldol-reminder-of-risks-when-used-in-elderly-patients-for-the-acute-treatment-of-delirium
起始氟哌啶醇之前,推荐进行基线 ECG 检查,并纠正电解质紊乱。
尽可能以最低剂量和最短时间进行用药。
在治疗期间,建议对心脏和电解质进行监测,同时监测锥体外系不良反应 。
抗精神病药物治疗谵妄的有效性证据尚无定论,[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium 并且各医院方案可能不尽相同。遵循当地医院的方案选择药物。
始终从最低剂量开始服用抗精神病药,并依据症状谨慎地逐渐调整剂量。[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103 只能通过口服或肌内注射药物(绝对不可静脉注射)进行此类治疗。
向家庭/照护者提供信息,以便他们了解当前的情况以及如何与临床团队协作以帮助患者恢复正常生活。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium
抗精神病药物与痴呆患者死亡率增加相关。
痴呆患者有时可能需要短期抗精神病药物以实现安全治疗护理。然而,抗精神病药物对老年人有多种不良反应,并与痴呆患者死亡风险增加相关。
一项 meta 分析发现,与服用安慰剂的人相比,服用非典型抗精神病药的痴呆患者死亡风险增加。[113]Ma H, Huang Y, Cong Z, et al. The efficacy and safety of atypical antipsychotics for the treatment of dementia: a meta-analysis of randomized placebo-controlled trials. J Alzheimers Dis. 2014;42(3):915-37http://www.ncbi.nlm.nih.gov/pubmed/25024323?tool=bestpractice.com
一项针对老年人的大型队列研究发现,更高剂量的抗精神病药通常与更高的风险相关。在所有研究的抗精神病药中,使用氟哌啶醇的风险最高。[114]Huybrechts KF, Gerhard T, Crystal S, et al. Differential risk of death in older residents in nursing homes prescribed specific antipsychotic drugs: population based cohort study. BMJ. 2012 Feb 23;344:e977https://www.doi.org/10.1136/bmj.e977http://www.ncbi.nlm.nih.gov/pubmed/22362541?tool=bestpractice.com
与普遍的看法相反,大多数痴呆患者的行为稳定后,就可以安全地停止长期抗精神病药处方。[115]Van Leeuwen E, Petrovic M, van Driel ML, et al. Withdrawal versus continuation of long-term antipsychotic drug use for behavioural and psychological symptoms in older people with dementia. Cochrane Database Syst Rev. 2018 Mar 30;3:CD007726.https://www.doi.org/10.1002/14651858.CD007726.pub3http://www.ncbi.nlm.nih.gov/pubmed/29605970?tool=bestpractice.com
如果谵妄在 48 小时内未对初步治疗产生反应,患者应转诊至接受过培训,且能熟练进行谵妄诊断的医疗卫生专业人士,从而确定诊断和确立治疗计划(基于专家意见)。
清楚记录谵妄诊断。[103]Scottish Intercollegiate Guidelines Network. Risk reduction and management of delirium. Mar 2019 [internet publication].https://www.sign.ac.uk/our-guidelines/risk-reduction-and-management-of-delirium[101]National Institute for Health and Care Excellence. Delirium: prevention, diagnosis and management in hospital and long-term care. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/cg103
针对特定患者群中所有患者的治疗建议
与患者协商后(如若可行,还可与其家属或照护者进行协商),尽早商定诊疗升级计划(基于专家意见)。这适用于所有患者,但可能与虚弱和/或患有某些合并症(如痴呆、卒中、心力衰竭、COPD 和晚期 CKD)的患者特别相关(基于专家意见)。
诊疗升级计划应包括:[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
复苏状态(即“不尝试心肺复苏”[Do Not Attempt Cardiopulmonary Resuscitation, DNACPR] 的决定)
干预上限(例如,是否适合气管插管或接受重症监护)。
升级计划应考虑到预立医疗照护计划,包括具有法律约束力的预立医疗指示。[123]Fritz Z, Slowther AM, Perkins GD. Resuscitation policy should focus on the patient, not the decision. BMJ. 2017 Feb 28;356:j813https://www.doi.org/10.1136/bmj.j813http://www.ncbi.nlm.nih.gov/pubmed/28246084?tool=bestpractice.com
应以您与患者有关其个人意愿的谈话为指导,包括帮助他们就较高强度干预措施的可能获益-风险平衡作出知情决策的讨论。
某些情况下,伴有痴呆或其他重大合并症的患者(特别是当其急性患病时),将缺乏就诊疗升级计划作出决策的心智能力。
评估并记录心智能力(在需要作出特定决策的特定时间作出决策的能力)。[124]The National Institute for Health and Care Excellence. Decision making and mental capacity. October 2018 [internet publication]https://www.nice.org.uk/guidance/ng108 请遵守您所在地区的相应法律。
在英格兰和威尔士,医疗卫生专业人士必须遵守《2005 年心智能力法》。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 进行评估时,应遵循该法案中的原则。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions
如果患者被评估为缺乏心智能力,应与其近亲协商符合“最大利益”的决策,同时考虑到患者自己先前所表达的偏好。[125]Office of the Public Guardian. Mental Capacity Act: making decisions. Jun 2023 [internet publication]https://www.gov.uk/government/collections/mental-capacity-act-making-decisions 根据英格兰和威尔士的《2005 年心智能力法》,如果患者“无亲无故”(即无人代表其最大利益,无人照顾赡养)而决策并非时间紧迫,则应寻找独立的有心智能力的权益维护人(independent mental capacity advocate, IMCA)来执行该任务。[126]Social Care Institute for Excellence. Independent mental capacity advocate (IMCA). January 2010 [internet publication]https://www.scie.org.uk/mca/imca/do
针对特定患者群中所有患者的治疗建议
在患者入院时检查其血糖水平和 HbA1c。
排除低血糖、糖尿病酮症酸中毒(diabetic ketoacidosis, DKA),以及高渗性高血糖状态,这些均为医学急症。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[84]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
入院 HbA1c 可能会提示您患者既往糖尿病控制情况,并可能影响出院时的治疗(基于专家意见)。
对于患急性疾病或发生损伤的 1 型糖尿病患者,切勿停止使用基础胰岛素(长效/背景胰岛素 [例如,地特胰岛素、甘精胰岛素或德谷胰岛素])。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
胰岛素缺乏(例如由于用药延迟或漏用)会迅速引起酮症酸中毒。[85]Chowdhury TA, Cheston H, Claydon A. Managing adults with diabetes in hospital during an acute illness. BMJ. 2017 Jun 22;357:j2551http://www.ncbi.nlm.nih.gov/pubmed/28642274?tool=bestpractice.com
将任何使用胰岛素泵入院的糖尿病患者转诊至糖尿病专家团队。[86]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
一般情况下,所有接受基础胰岛素治疗的 2 型糖尿病患者均应继续接受治疗,但情况可能并非总是如此,因此应咨询您上级医生和/或糖尿病专科医生团队意见(基于专家意见)。
在患者入院时,考虑是否需要调整其胰岛素剂量。
如果 1 型或 2 型糖尿病患者正在使用胰岛素,血糖控制良好,入院时未出现严重的高血糖,则可能适当将基础胰岛素剂量减少 20%,尤其是当他们的进食量不及平时在家中时。需要考虑到的另一个因素是医院的膳食通常比患者在家的膳食含有更少的碳水化合物。
相反,危重症感染患者有时需要更高剂量的胰岛素。
定期监测血糖(每日至少 4 次)有助于指导合理调整胰岛素剂量。如有疑问,应寻求专家意见。
应尽早向糖尿病住院团队寻求专家建议,尤其是当诊疗较为复杂(例如,存在代谢紊乱、复发性或重度低血糖、持续高血糖),或者患者需要接受一段时间的肠内喂饲时。[87]Joint British Diabetes Societies for Inpatient Care. Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes. Nov 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 糖尿病团队还将能够就住院期间最合适的胰岛素方案和给药提出建议。
可变速率静脉胰岛素输注(VRIII)指征包括:[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[89]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
罹患糖尿病或医院相关性高血糖,且其无法进食或饮水,并无法调整胰岛素治疗方案的患者。例如,当:
呕吐
禁食禁饮,患者多餐不进
存在严重疾病,需要实现良好的血糖控制(例如脓毒症)。
需进行急诊手术的糖尿病患者可能需要给予 VRIII。遵循当地常规或英国围手术期诊疗中心建议。[90]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
在这些情况下,请从糖尿病团队获取专科医生建议。
若起始 VRIII:
始终持续给予基础胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果 VRIII 意外中断(例如由于导管移位或阻塞)或关闭(例如在转移病房期间),这会降低发生酮症的风险。
采用 VRIII 时让患者停用常规速效和混合胰岛素。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
尽可能缩短使用 VRIII 的时间。[88]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
遵循医院常规,执行包括停药在内的正确处理。
对于因 急性病症 入院的糖尿病患者,考虑停止或调整口服降糖药 。
以下所有患者应停用二甲双胍:[91]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
存在禁忌证,例如严重的肾脏损伤(eGRF <30 mL/[min·1.73m]),无论是慢性还是继发于急症。
伴代谢性酸中毒(包括乳酸酸中毒和糖尿病酮症酸中毒)
服用二甲双胍可能存在引发乳酸酸中毒风险。这包括与急性肾损伤、组织缺氧(包括急性心力衰竭或呼吸衰竭)有关的疾病,脱水,或已经/准长时间禁食或将要注射不透射线造影剂进行影像学检查的患者存在肾脏损伤(基于专家意见)。遵循当地常规,了解提示肾脏损伤的具体 eGFR 水平,以指导用药。
请注意,停用二甲双胍可导致高血糖。
如果您的患者正在服用其他降糖药物,这些药物可能需要增加剂量;如果没有,可能需要开处另一种降糖药(基于专家意见)。
一些患者可能需要胰岛素作为临时措施,但请寻求糖尿病住院专科医生团队的建议。
如果患者新近出现肾功能受损或恶化,或进食量比平时少,则应减少格列齐特剂量或停服一次药物,以免出现夜间低血糖。
对于所有危重症患者(包括进行大手术的患者),尤其是脱水或感染的情况下,应停用钠-葡萄糖协同转运蛋白-2(sodium-glucose cotransporter-2, SGLT-2)抑制剂并监测血酮,从而降低血糖正常的酮症酸中毒风险。[92]Medicines and Healthcare products Regulatory Agency. SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness. March 2020 [internet publication]https://www.gov.uk/drug-safety-update/sglt2-inhibitors-monitor-ketones-in-blood-during-treatment-interruption-for-surgical-procedures-or-acute-serious-medical-illness
SGLT-2 抑制剂(例如,达格列净、卡格列净、恩格列净)可减少肾脏中的血糖重吸收(与葡萄糖的胰岛素代谢无关)。[93]Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: a potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015 Jun 15;38(9):1687-93http://www.ncbi.nlm.nih.gov/pubmed/26078479?tool=bestpractice.com
它们可以掩盖潜在的酮症酸中毒,因为患者的血糖水平可能正常或接近正常(血糖正常的酮症酸中毒)。
检测血酮,因为尿酮体检测可能并不可靠。
如果毛细血管或血液中的酮体浓度为 >3 mmol/L ,或有 明显的酮尿(标准尿液试纸检测显示 2+ 或更多),且静脉 pH 值为 <7.3 和/或碳酸氢根浓度 <15 mmol/L ,则应治疗糖尿病酮症酸中毒 。[83]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
针对特定患者群中所有患者的治疗建议
对于任何突发不适的糖尿病患者,每天至少监测血糖水平四次(餐前以及睡前)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
当糖尿病患者被紧急收治入院时,其发生低血糖和高血糖风险增加(基于专家意见)。
在高血糖或低血糖发作后,以及更换降糖药物后,甚至需要更频繁的监测(基于专家意见)。
如果您的患者接受了手术,请遵循您当地的方案或指南制定组织的建议,例如英国围术期护理中心的血糖管理和血糖监测频率相关建议。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
所有采取可变速率静脉胰岛素输注(variable rate intravenous insulin infusion, VRIII)的患者,起初均应每小时检测毛细血管血糖(capillary blood glucose, CBG)。[129]Joint British Diabetes Societies for Inpatient Care. The use of variable rate intravenous insulin infusion (VRIII) in medical inpatients. Oct 2014 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 根据医院 VRIII 常规进行调整。
在住院期间,支持您的患者自我管理糖尿病(包括监测血糖,在接受胰岛素治疗的患者中调整胰岛素剂量和给药),如果符合以下情况:[131]Joint British Diabetes Societies for Inpatient Care. Self-management of diabetes in hospital. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
较为安全
患者愿意,且
其符合当地常规。
根据血糖水平进行决策,并对其加以监测。
指南制定组织尚未对住院糖尿病患者的目标血糖水平达成共识。
英国糖尿病联合会住院患者诊疗组建议糖尿病内科住院患者:
理想的范围是 6-10 mmol/L(108-180 mg/dL)。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
在一些情况下,4-12 mmol/L(72-216 mg/dL)是可接受的范围。[130]Joint British Diabetes Societies for Inpatient Care. A good inpatient diabetes service. Jul 2019 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 4 mmol/L(72 mg/dL)的下限对于糖尿病控制极好且在自我管理的住院患者可能是可接受的水平(基于专家意见)
轻度衰弱的糖尿病住院患者的目标范围为 7.5-10 mmol/L(135-180 mg/dL),中度或重度衰弱患者的目标范围为不超过 12 mmol/L(216 mg/dL)。[133]Joint British Diabetes Societies for Inpatient Care. Inpatient care of the frail older adult with diabetes. Feb 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 12 mmol/L 的上限也可能适用于任何有跌倒高风险或痴呆的患者(基于专家意见)。
围手术期诊疗中心(Centre for Perioperative Care)建议围手术期患者维持于 6 至 10 mmol/L(108-180 mg/dL)范围内,可接受上限为 12 mmol/L(216 mg/dL)。[128]Centre for Perioperative Care. Guideline for perioperative care for people with diabetes mellitus undergoing elective and emergency surgery. Dec 2022 [internet publication].https://cpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
英国国家卫生与临床优化研究所建议急症或接受手术的住院 1 型糖尿病成人目标血糖水平位于 5 至 8 mmol/L(90-144 mg/dL),但这一目标低于其他指南建议。[132]National Institute for Health and Care Excellence. Type 1 diabetes in adults: diagnosis and management. Aug 2022 [internet publication].https://www.nice.org.uk/guidance/ng17
美国糖尿病学会建议,对于大多数危重患者和非危重患者,目标范围为 7.8 至 10 mmol/L(140-180 mg/dL)(一旦因持续性高血糖而起始胰岛素治疗)。[127]ElSayed NA, Aleppo G, Aroda VR, et al, on behalf of the American Diabetes Association. 16. Diabetes care in the hospital: standards of care in diabetes - 2023. Diabetes Care. 2023 Jan 1;46(suppl 1):S267-78.https://diabetesjournals.org/care/article/46/Supplement_1/S267/148051/16-Diabetes-Care-in-the-Hospital-Standards-of-Carehttp://www.ncbi.nlm.nih.gov/pubmed/36507644?tool=bestpractice.com
存在冲突的证据导致危重患者(有或无糖尿病史的混合人群)血糖控制严格程度建议具有差异。请遵循当地规程。
重症诊疗环境:
一项针对主要外科重症监护环境中的危重患者随机对照试验(randomised controlled trial, RCT)发现,严格控制血糖(4.4-6.1 mmol/L,即 80-110 mg/dL)的患者比“传统”宽松控制血糖的患者死亡率更低。[134]van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001 Nov 8;345(19):1359-67https://www.doi.org/10.1056/NEJMoa011300http://www.ncbi.nlm.nih.gov/pubmed/11794168?tool=bestpractice.com
然而,随后在其他重症诊疗机构对危重内外科患者进行的一项多中心 RCT 研究发现,更严格的血糖控制却伴发了更高的死亡率,其原因可能在于低血糖发作更为频繁。[135]NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009 Mar 26;360(13):1283-97.https://www.doi.org/10.1056/NEJMoa0810625http://www.ncbi.nlm.nih.gov/pubmed/19318384?tool=bestpractice.com
一项 2010 年对 6 项 RCT 研究进行的系统评价和荟萃分析,对危重患者在重症诊疗机构进行严格控制血糖(4.4-6.1 mmol/L [80-110 mg/dL])与不甚严格的血糖控制进行比较,发现严格血糖控制并未显著改善死亡率,但与不甚严格的血糖控制相比,低血糖发作显著增多。[136]Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010 Mar;137(3):544-51https://www.doi.org/10.1378/chest.09-1737http://www.ncbi.nlm.nih.gov/pubmed/20018803?tool=bestpractice.com
无论是否已确诊糖尿病,住院患者的高血糖与不良患者结局有关,包括死亡率升高。[137]Pasquel FJ, Lansang MC, Dhatariya K, et al. Management of diabetes and hyperglycaemia in the hospital. Lancet Diabetes Endocrinol. 2021 Mar;9(3):174-88https://www.doi.org/10.1016/S2213-8587(20)30381-8http://www.ncbi.nlm.nih.gov/pubmed/33515493?tool=bestpractice.com
迅速采取行动治疗高血糖以避免糖尿病酮症酸中毒(diabetic ketoacidosis, DKA)和高渗性高血糖状态(hyperosmolar hyperglycaemic state, HHS),这两者均为医学急症。
如果患者的 CBG ≥15 mmol/L (≥270 mg/dL),请遵循当地医院的方案。
通常在达到该 CBG 水平时需要采取措施,但不同的当地规程可能会有稍不同的临界水平,并且可能会基于患者患 1 型还是 2 型糖尿病而有所不同。
排除 DKA或HHS,两者均需给予特定紧急处理。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
通常使用钠-葡萄糖协同转运蛋白 2(sodium-glucose co-transporter-2, SGLT2)抑制剂治疗的患者应进行血酮检测以排除血糖正常的酮症酸中毒(血糖浓度正常时的酮症酸中毒),即使已停止使用 SGLT2 抑制剂(基于专家意见)。
如果患者存在 DKA 或 HHS,向糖尿病住院患者专科医生团队寻求建议,并遵循当地医院指南,或遵循英国糖尿病住院患者联合治疗协会(British Diabetes Society for Inpatient Care, JBDS-IP)指南。[138]Joint British Diabetes Societies for Inpatient Care. The management of diabetic ketoacidosis in adults. Mar 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
务必尽早由熟悉 HHS 管理的临床医生对 HHS 患者进行高级检查。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 对伴其他合并症的患者,可能需要收住高依赖病房(high-dependency unit)。[139]Joint British Diabetes Societies for Inpatient Care. The management of the hyperosmolar hyperglycaemic state (HHS) in adults. Feb 2022 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
请参阅“糖尿病酮症酸中毒” 或“高渗性高血糖状态” 。
需注意,以下药物可能与高血糖具有相关性,因此需进行评估:[140]Rehman A, Setter SM, Vue MH. Drug-induced glucose alterations part 2: drug-Induced hyperglycemia. Diabetes Spect. 2011 Nov;24(4):234-8http://spectrum.diabetesjournals.org/content/24/4/234
皮质类固醇
部分 β 受体阻滞剂(如普萘洛尔、阿替洛尔)
噻嗪类利尿剂(例如氢氯噻嗪)
部分第二代抗精神病药物(如奥氮平、氯氮平)
某些氟喹诺酮类抗生素(如环丙沙星)
钙调磷酸酶抑制剂(如环孢素、他克莫司)
蛋白酶抑制剂(例如,作为抗逆转录病毒治疗的成分,如利托那韦)。
对于复杂型患者或高血糖难以控制的患者,可向糖尿病团队寻求专家建议。
监测血糖并根据病情和住院就餐时间调整用药,从而降低低血糖发作风险。
大约 1/5 英格兰和威尔士糖尿病住院患者被发现曾在住院期间发生过低血糖。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
病因包括:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
急性疾病痊愈
胰岛素或口服降糖药用药错误
就餐相关胰岛素治疗的给药时间错误
患者进食少,但服用相同量的糖尿病药物
睡前不食用零食
食欲减退或呕吐
若在应用胰岛素或磺脲类药物情况下,血糖降至 6 mmol/L 以下(108 mg/dL)(濒临低血糖),应考虑进行干预。
此类患者进展为低血糖的风险较高。
按照低血糖指南建议,并遵循当地规程,给予碳水化合物(参阅下文)。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
如果血糖低于 4 mmol/L(72 mg/dL),则应积极治疗低血糖。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group 请遵循医院规程或 JBDS-IP 的低血糖管理流程。[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group JBDS-IP 指南也推荐:[142]Joint British Diabetes Societies for Inpatient Care. The hospital management of hypoglycaemia in adults with diabetes mellitus. Jan 2023 [internet publication].https://abcd.care/joint-british-diabetes-societies-jbds-inpatient-care-group
10-15 分钟后重新检测血糖,以确定治疗疗效
如果已经纠正低血糖,切勿停止下一次计划的胰岛素给药。否则会导致 1 型糖尿病患者出现反弹性高血糖和 DKA。
就是否需要对患者的胰岛素治疗方案进行审查,寻求糖尿病住院专家团队的建议。
采取措施降低夜间低血糖风险。假设患者可以吞咽,他们在医院所进晚餐可能比在家进食更少。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
在没有明显高血糖的情况下,考虑入院时将晚间基础胰岛素降低 20%(基于专家意见)。
请注意,如果患者错过进餐或用药剂量过大,则低血糖更可能是磺脲类药物治疗的不良反应(例如格列本脲、格列齐特、格列美脲、格列吡嗪)。
在急症医院环境中,餐时有可能被打乱,或无法每天同一时间进餐。
应在进食前或进食时给予磺脲类药物。查看当地药物处方集获取更为具体的指导信息,了解特定磺脲类药物给药时间与进食时间的关系。
切勿在睡前服用磺脲类药物,如果患者要在晚餐时服用一次,应考虑减少晚间剂量,以降低夜间低血糖发生风险(基于专家意见)。
睡前加餐可以降低清晨低血糖的风险。[141]NHS Digital. National Diabetes Inpatient Audit (NaDIA) - 2019. Nov 2020 [internet publication]https://digital.nhs.uk/data-and-information/publications/statistical/national-diabetes-inpatient-audit/2019#summary
若糖尿病患者正在接受临终关怀:
将可致低血糖药物用量减至最少,但使患者不出现有症状高血糖,其可能导致:[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
脱水
酮症
高渗性高血糖。
1 型糖尿病患者切勿停用基础胰岛素
请参阅当地常规或来自英国 TREND Diabetes 等糖尿病组织的指南。[143]TREND Diabetes. End of life guidance for diabetes care. November 2021 [internet publication]https://diabetes-resources-production.s3.eu-west-1.amazonaws.com/resources-s3/public/2021-11/EoL_TREND_FINAL2_0.pdf
针对特定患者群中所有患者的治疗建议
患者可能会忘记告诉您他们常用的吸入器。记得检查并酌情开处吸入器。
哮喘患者应继续其惯常的吸入皮质类固醇药物治疗。没有明确的医学原因,不得停止治疗。
许多吸入器含有多种药物,因此请确保不要重复开药。
对于有急性肾损伤的 COPD 或哮喘患者,如果估算 GFR <50 mL/(min·1.73 mm),可能需要暂时停用其常用的吸入性长效毒蕈碱受体拮抗剂,具体取决于其使用的特定药物。
查阅当地处方集或寻求药师建议。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能提示合并哮喘的患者发生哮喘急性发作。
根据指南建议评估严重程度和管理成人哮喘的急性加重。[144]British Thoracic Society; Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma: a national clinical guideline. July 2019 [internet publication].https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/[145]Global Initiative for Asthma. Global strategy for asthma management and prevention. 2023 [internet publication]https://ginasthma.org/2023-gina-main-report/
请参阅“成人哮喘急性发作” 专题。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理哮喘可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com
尽管有这方面的证据,但如果合并有哮喘的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
针对特定患者群中所有患者的治疗建议
呼吸道症状的急性恶化可能表明合并 COPD 的患者出现急性加重。[148]Global Initiative for Chronic Obstructive Lung Disease. Global strategy for the diagnosis, management and prevention of chronic obstructive pulmonary disease. 2023 [internet publication]https://goldcopd.org/2023-gold-report-2/
与其他疾患进行鉴别,如急性冠脉综合征、急性心力衰竭和肺炎。
请遵循指南建议。请参阅 “COPD 急性加重” 专题。
支气管舒张剂雾化吸入疗法应仅持续 24 至 48 小时,然后患者应换回他们常用的吸入剂(基于专家意见)。
如果给予患者雾化吸入短效毒蕈碱受体拮抗剂(例如异丙托溴铵),则应暂时停用患者可能正在使用的任何用于维持治疗的长效毒蕈碱受体拮抗剂(long-acting muscarinic receptor antagonist, LAMA),例如噻托溴铵、aclidinium、格隆溴铵、乌美溴铵(基于专家意见)。
因为担心可能会出现抗胆碱能成瘾的不良反应。
一旦停止雾化剂治疗,请确保重新给予 LAMA。
请注意,长期使用 β-2 受体激动剂管理 COPD 可增加心血管事件的风险。
β-2 受体激动剂可增加心肌梗死和其他不良心血管事件的风险。
β-2 受体激动剂可提高心率并降低钾水平。[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com 此类药物经吸收进入体循环,有证据表明,长期规律使用与心肌梗死、不稳定型心绞痛、充血性心力衰竭和心律失常的风险增加有关。[147]Au DH, Curtis JR, Every NR, et al. Association between inhaled beta-agonists and the risk of unstable angina and myocardial infarction. Chest. 2002 Mar;121(3):846-51https://www.doi.org/10.1378/chest.121.3.846http://www.ncbi.nlm.nih.gov/pubmed/11888971?tool=bestpractice.com[146]Salpeter SR, Ormiston TM, Salpeter EE. Cardiovascular effects of beta-agonists in patients with asthma and COPD: a meta-analysis. Chest. 2004 Jun;125(6):2309-21https://www.doi.org/10.1378/chest.125.6.2309http://www.ncbi.nlm.nih.gov/pubmed/15189956?tool=bestpractice.com
尽管有这方面的证据,但如果合并有 COPD 的患者需要使用 β-2 受体激动剂,一般不会停用该药物。
一项系统评价发现,对于 COPD 急性加重的患者,皮质类固醇的短期疗程(7 天或更短)与更长时间的传统疗程(长于 7 天)之间的结局(治疗失败、至下一次加重时间、住院时间、肺功能、不良反应、死亡率)没有差异。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
此 Cochrane 评价中包括的随机对照试验均在医院环境内进行,且仅涉及重度至极重度 COPD 患者。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
该评价的作者得出结论,由于增加了一项新的试验,他们更加确信大约 5 天的皮质类固醇疗程可能足以治疗 COPD 急性加重。[149]Walters JA, Tan DJ, White CJ, et al. Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2018 Mar 19;3:CD006897https://www.doi.org/10.1002/14651858.CD006897.pub4http://www.ncbi.nlm.nih.gov/pubmed/29553157?tool=bestpractice.com
同样,在 2019 年对证据进行了一次评价后,英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)建议在 COPD 加重期间提供泼尼松龙治疗 5 天。[150]National Institute for Health and Care Excellence. Chronic obstructive pulmonary disease in over 16s: diagnosis and management. July 2019 [internet publication]https://www.nice.org.uk/guidance/ng115
针对特定患者群中所有患者的治疗建议
在临床情况允许以及患者有反应的情况下进行精神状态检查(基于专家意见)。
精神状态检查是精神病学临床实践中常规使用的主要临床工具之一,有助于诊断并指导进一步的管理。情绪是其中一项评估内容。
考虑使用 PHQ-9 问卷评估抑郁。[151]Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep;16(9):606-13http://www.ncbi.nlm.nih.gov/pubmed/11556941?tool=bestpractice.com
这是一份自测问卷,仅需不到 3 分钟即可完成。
结果可提示抑郁症状的严重程度。
应将得分为 5 分或以上的患者转诊至接受联络精神病学服务(基于专家意见)。
考虑可能影响患者精神状态的其他因素(例如,非法成瘾物质或酒精的作用)。[152]Boden JM, Fergusson DM. Alcohol and depression. Addiction. 2011 May;106(5):906-14.http://www.ncbi.nlm.nih.gov/pubmed/21382111?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
如果紧急临床情况允许,询问患者正在服用哪些药物治疗抑郁。或查看其初级卫生保健记录,获取相关信息(若可获取)。
为患者开具其常用的抗抑郁药,除非有充分的理由不得这样做(基于专家意见)。
如果突然停用抗抑郁药,患者可能会出现停药症状。[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
停药症状的严重程度可能不一,但可能令人不快,并使急性疾病的管理复杂化。[154]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91
审评当前药物时,需注意以下情况:
当前和既往不良反应
近期用药剂量改变
最近换了一种不同类别的药物
特定抑郁症亚型的药物细微差别(例如,精神病性抑郁症患者很可能会同时服用抗精神病处方药)
治疗难治性抑郁症时可能使用的增强策略(如锂剂或喹硫平加选择性 5-羟色胺再摄取抑制剂 [selective serotonin-reuptake inhibitor, SSRI])。
考虑药物相互作用。
抗抑郁药可能会与用于其他疾病的药物发生药代动力学(通过抑制 CYP450 通路)和药效动力学相互作用。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021[153]Cleare A, Pariante CM, Young AH, et al. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2008 British Association for Psychopharmacology guidelines. J Psychopharmacol. 2015 May 12;29(5):459-525https://www.bap.org.uk/pdfs/BAP_Guidelines-Antidepressants.pdfhttp://www.ncbi.nlm.nih.gov/pubmed/25969470?tool=bestpractice.com
开具非精神类药物时,应考虑精神并发症。
开具抗惊厥药物、抗帕金森病药物和皮质类固醇时,应格外小心。
考虑不良反应,具体可能包括以下不良反应。[155]Taylor DM, Barnes TRE, Young AH. The Maudsley prescribing guidelines in psychiatry. 14th edition. Chichester: Wiley-Blackwell; 2021
低钠血症,由抗抑郁药(尤其是 SSRI)引起,会因使用同时开具的其他药物(例如利尿药)而加重。请检查患者的血清电解质。
5-羟色胺综合征(精神状态改变、激越、震颤、反射亢进、阵挛、肌强直、大量出汗、心动过速、肠鸣音增加、体温 >38℃),尤其是在多重用药和/或 5-羟色胺能药物过量时。[156]Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005 Mar 17;352(11):1112-20http://www.ncbi.nlm.nih.gov/pubmed/15784664?tool=bestpractice.com[157]Buckley NA, Dawson AH, Isbister GK. Serotonin syndrome. BMJ. 2014 Feb 19;348:g1626http://www.ncbi.nlm.nih.gov/pubmed/24554467?tool=bestpractice.com
特别要注意的是,服用 SSRI 的终末期肾病患者 5-羟色胺综合征的风险增加。治疗肾脏损伤患者的抑郁需要采取多学科方法,并需要格外谨慎。
肝毒性。必要时调整肝功能受损患者的抗抑郁药物剂量,避免使用已知具有肝毒性的药物。
与三环类抗抑郁药相关的 QTc 延长、心律失常、心率加快、体位性低血压。查看 ECG,特别是有心律失常风险的人群。
消化道出血。SSRI 与消化道出血风险增加相关。[158]Dalton SO, Sørensen HT, Johansen C. SSRIs and upper gastrointestinal bleeding: what is known and how should it influence prescribing? CNS Drugs. 2006;20(2):143-51http://www.ncbi.nlm.nih.gov/pubmed/16478289?tool=bestpractice.com[159]Dalton SO, Johansen C, Mellemkjaer L, et al. Use of selective serotonin reuptake inhibitors and risk of upper gastrointestinal tract bleeding: a population-based cohort study. Arch Intern Med. 2003 Jan 13;163(1):59-64https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/214901http://www.ncbi.nlm.nih.gov/pubmed/12523917?tool=bestpractice.com[160]Cheng YL, Hu HY, Lin XH, et al. Use of SSRI, but not SNRI, increased upper and lower gastrointestinal bleeding: a nationwide population-based cohort study in Taiwan. Medicine (Baltimore). 2015 Nov;94(46):e2022https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4652818/http://www.ncbi.nlm.nih.gov/pubmed/26579809?tool=bestpractice.com与阿司匹林、非甾体抗炎药(non-steroidal anti-inflammatory drugs, NSAID)或口服抗凝剂联用时,风险尤其增加。[161]Loke YK, Trivedi AN, Singh S. Meta-analysis: gastrointestinal bleeding due to interaction between selective serotonin uptake inhibitors and non-steroidal anti-inflammatory drugs. Aliment Pharmacol Ther. 2008 Jan 1;27(1):31-40https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2036.2007.03541.xhttp://www.ncbi.nlm.nih.gov/pubmed/17919277?tool=bestpractice.com
此清单并未详尽列出全部不良反应——请参阅当地处方集以获取更多信息。请咨询您联络的精神病学同事和/或药剂师以获取建议。
请询问患者通过哪些非药物治疗方法管理抑郁,并核实其目前在社区获得的支持情况。
这可能包括参与其护理的其他医疗卫生专业人士、慈善机构、家庭和社会网络以及心理治疗。
请注意,戒烟或从吸烟转为其他替代方案(包括尼古丁替代疗法)可能导致患者服用的精神类药物(例如,治疗抑郁的药物)血浆浓度发生变化。这是因为尼古丁替代治疗并不会像吸烟那样影响肝酶活性。[162]Flowers L. Nicotine replacement therapy. Am J Psychiatry Resid. 2016 Jun;11(6)4-7https://psychiatryonline.org/doi/10.1176/appi.ajp-rj.2016.110602[163]Desai HD, Seabolt J, Jann MW. Smoking in patients receiving psychotropic medications: a pharmacokinetic perspective. CNS Drugs. 2001;15(6):469-94http://www.ncbi.nlm.nih.gov/pubmed/11524025?tool=bestpractice.com[164]Oliveira P, Ribeiro J, Donato H, Madeira N. Smoking and antidepressants pharmacokinetics: a systematic review. Ann Gen Psychiatry. 2017;16:17https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5340025/http://www.ncbi.nlm.nih.gov/pubmed/28286537?tool=bestpractice.com[165]National Centre for Smoking Cessation and Training. Smoking cessation and mental health. 2014 [internet publication]https://www.ncsct.co.uk/usr/pub/mental%20health%20briefing%20A4.pdf寻求相关建议,确认精神类药物剂量调整是否适当。
针对特定患者群中所有患者的治疗建议
考虑将任何因急性疾病入院且伴有抑郁的患者转诊至联络精神病学团队/服务机构。[166]National Institute for Health and Care Excellence. Liaison psychiatry. In: Emergency acute medical care in over 16s: service delivery and organisation. March 2018 [internet publication]https://www.nice.org.uk/guidance/ng94[167]National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Treat as one. Bridging the gap between mental and physical healthcare in general hospitals. 2017 [internet publication]https://www.ncepod.org.uk/2017report1/downloads/TreatAsOne_Summary.pdf
如果不存在抑郁和/或其管理可能影响急性病情的顾虑,则可能不需要转诊(基于专家意见)。
对于情况不明的事故、自伤行为和/或自杀企图,都应临床怀疑共病精神障碍(基于专家意见)。
合并抑郁症与对推荐的躯体健康治疗(从药物治疗到康复治疗)的依从性差有关。[168]DiMatteo MR, Lepper HS, Croghan TW. Depression is a risk factor for noncompliance with medical treatment: meta-analysis of the effects of anxiety and depression on patient adherence. Arch Intern Med. 2000 Jul 24;160(14):2101-7http://www.ncbi.nlm.nih.gov/pubmed/10904452?tool=bestpractice.com
这可能导致更差的临床结局,包括更高的再入院风险。[169]Clarke DM, Currie KC. Depression, anxiety and their relationship with chronic diseases: a review of the epidemiology, risk and treatment evidence. Med J Aust. 2009 Apr 6;190(S7):S54-60http://www.ncbi.nlm.nih.gov/pubmed/19351294?tool=bestpractice.com[170]National Institute for Health and Care Excellence. Depression in adults with a chronic physical health problem: recognition and management. October 2009 [internet publication]https://www.nice.org.uk/guidance/cg91[171]Prina AM, Cosco TD, Dening T, et al. The association between depressive symptoms in the community, non-psychiatric hospital admission and hospital outcomes: a systematic review. J Psychosom Res. 2015 Jan;78(1):25-33https://www.sciencedirect.com/science/article/pii/S0022399914003821http://www.ncbi.nlm.nih.gov/pubmed/25466985?tool=bestpractice.com
最为重要的是,包括抑郁在内的情感症状与高死亡率有关,但其因果关系仍有待证实。[172]Archer G, Kuh D, Hotopf M, et al. Association between lifetime affective symptoms and premature mortality. JAMA Psychiatry. 2020 Aug 1;77(8):806-13https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2763796http://www.ncbi.nlm.nih.gov/pubmed/32267482?tool=bestpractice.com[173]Machado MO, Veronese N, Sanches M, et al. The association of depression and all-cause and cause-specific mortality: an umbrella review of systematic reviews and meta-analyses. BMC Med. 2018 Jul 20;16(1):112https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-018-1101-zhttp://www.ncbi.nlm.nih.gov/pubmed/30025524?tool=bestpractice.com
针对特定患者群中所有患者的治疗建议
对所有糖尿病患者在入院时和不适加重时进行足部检查。[174]National Institute for Health and Care Excellence. Diabetic foot problems: prevention and management. October 2019 [internet publication]https://www.nice.org.uk/guidance/ng19
这是为了发现新的溃疡或感染,这些溃疡或感染可能被患者忽视,甚至可能是引发其急性病的原因(例如,出现脓毒症或心内膜炎的患者,其感染的原发灶是足部病变)。
检查足部有无病损,并检查保护性感觉是否丧失。
遵循当地指南,但有一个快速简单的试验:Ipswich Touch Test©(伊普斯威奇触摸试验),即将食指指尖轻轻触摸/放置在第一、第三和第五个足趾趾尖上 1 到 2 秒。[175]Rayman G, Vas PR, Baker N, et al. The Ipswich Touch Test: a simple and novel method to identify inpatients with diabetes at risk of foot ulceration. Diabetes Care. 2011 May 18;34(7):1517-8https://www.doi.org/10.2337/dc11-0156http://www.ncbi.nlm.nih.gov/pubmed/21593300?tool=bestpractice.com
如果患者在这六个部位中的两个或以上没有感觉,则代表其保护性感觉减退。
如果患者有感觉减退,则其有较高的压疮风险。告知其护理人员并提供减压装置。
护理人员或医疗人员应每日进行踝部检查,注意压力性创伤征象。
对于糖尿病患者是否应该使用弹力袜存在争议——如果有血管疾病,请勿使用。
针对特定患者群中所有患者的治疗建议
如果患者为当前吸烟者,请提供戒烟支持途径。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209 恰当的时机取决于具体的临床情况。一般情况下,英国国家卫生与临床优化研究所建议应立刻或在 24 小时内提供戒烟途径。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
对于所有吸烟的住院患者,如果没有禁忌证,应提供尼古丁替代疗法(nicotine replacement therapy, NRT)和其他戒烟药物疗法。[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
建议:[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209
尼古丁很容易使人成瘾,但这不是吸烟相关危害的原因。
NRT 可防止入院期间快速戒断,快速戒断可能会导致痛苦和不适。
当与专科支持相结合时,有数种高效的治疗选择能提供最大的戒烟可能性。
由于联合 NRT 比单一 NRT 有效,应将长效制剂 NRT(例如,透皮贴剂)与短效制剂 NRT(例如,咀嚼胶、锭剂、舌下片剂、吸入剂、口腔黏膜或鼻喷雾剂)联用来实施 NRT。 [177]Theodoulou A, Chepkin SC, Ye W, et al. Different doses, durations and modes of delivery of nicotine replacement therapy for smoking cessation. Cochrane Database Syst Rev. 2023 Jun 19;6(6):CD013308https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD013308.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/37335995?tool=bestpractice.com[176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
询问醒后至吸第一根烟的时间。短于 30 分钟的答案可提示这些患者可能有更多的尼古丁依赖问题,从而能指导选择尼古丁透皮贴剂的剂量。
查阅当地的处方集,以了解各种注意事项,尤其当患者有一种或多种合并症和/或血流动力学不稳定时。
对于任何有意戒烟的患者,可考虑 联合使用伐尼克兰和 NRT ,因为这是一种对成人戒烟非常有效的组合。 [179]Thomas KH, Dalili MN, López-López JA, et al. Comparative clinical effectiveness and safety of tobacco cessation pharmacotherapies and electronic cigarettes: a systematic review and network meta-analysis of randomized controlled trials. Addiction. 2022 Apr;117(4):861-76.https://onlinelibrary.wiley.com/doi/10.1111/add.15675http://www.ncbi.nlm.nih.gov/pubmed/34636108?tool=bestpractice.com 对于烟草依赖,联合治疗比使用单一药物更有效。[178]Rigotti NA, Kruse GR, Livingstone-Banks J, et al. Treatment of tobacco smoking: a review. JAMA. 2022 Feb 8;327(6):566-77.https://jamanetwork.com/journals/jama/fullarticle/2788777http://www.ncbi.nlm.nih.gov/pubmed/35133411?tool=bestpractice.com
一项 Cochrane 评价发现,有高确定性证据表明伐尼克兰是烟草依赖的有效治疗方法。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 该评价还发现,伐尼克兰使用者出现导致住院的严重不良反应(例如心脏问题)几率可能会增加;但这种情况仍属罕见(伐尼克兰使用者中有 2.7%-4.0% 出现这种情况,而未使用伐尼克兰者中仅 2.7% 出现这种情况),并且其中可能包括与伐尼克兰无关的不良反应。[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 查阅当地处方集,以获取关于禁忌证/注意事项的完整清单,或者寻求药师建议。
心理卫生疾病不是开具伐尼克兰的禁忌证。然而,对于已患精神疾病的患者,应谨慎使用伐尼克兰,因为该药可能加重症状。
对于戒烟,安非他酮是另一种选择,但是取得成功的可能性更低。 [176]National Institute for Health and Care Excellence. Tobacco: preventing uptake, promoting quitting and treating dependence. Jan 2023 [internet publication].https://www.nice.org.uk/guidance/ng209[180]Livingstone-Banks J, Fanshawe TR, Thomas KH, et al. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2023 June 28;6(6):CD006103https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006103.pub9/full 应考虑药物相互作用的可能性。
完成到烟草依赖执业医师/服务机构的转诊。
每 200 至 1500 例妊娠中可出现 1 例症状性肾结石,其中有 80%-90% 发生于妊娠中后期。[71]Semins MJ, Matlaga BR. Kidney stones during pregnancy. Nat Rev Urol. 2014 Mar;11(3):163-8.http://www.ncbi.nlm.nih.gov/pubmed/24515090?tool=bestpractice.com 有报道显示,妊娠期间,有 48% 至 80% 的结石可自行排出。[33]Fulgham PF, Assimos DG, Pearle MS, et al. Clinical effectiveness protocols for imaging in the management of ureteral calculous disease: AUA Technology Assessment. J Urol. 2013 Apr;189(4):1203-13.http://www.jurology.com/article/S0022-5347%2812%2905259-7/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/23085059?tool=bestpractice.com[72]Burgess KL, Gettman MT, Rangel LJ, et al. Diagnosis of urolithiasis and rate of spontaneous passage during pregnancy. J Urol. 2011 Dec;186(6):2280-4.http://www.ncbi.nlm.nih.gov/pubmed/22014825?tool=bestpractice.com
将妊娠患者转诊至专科医生(例如,产科医生和/或泌尿科医生)。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/ 如果患者怀孕并存在以下情况,专科医生将考虑使用输尿管支架或经皮肾造瘘管:
口服镇痛药无法控制肾绞痛或
有梗阻性结石和感染征象(发热或尿液分析/尿液培养显示尿液可能存在感染)。
妊娠期代谢变化可能导致管内迅速结垢,因此应每 6-8 周换管一次。
如果患者无感染证据,专科医生将安排输尿管镜治疗。现已证实输尿管镜治疗可安全用于妊娠患者。[73]Semins MJ, Trock BJ, Matlaga BR. The safety of ureteroscopy during pregnancy: a systematic review and meta-analysis. J Urol. 2009 Jan;181(1):139-43.http://www.ncbi.nlm.nih.gov/pubmed/19012926?tool=bestpractice.com
冲击波碎石术和经皮肾镜取石术禁用于孕妇。
针对所有此类患者,改善饮食习惯和充分补液是长期治疗的重要方面。
建议患者(及其家人或照护者,视情况而定)采取以下措施:
成人每天饮水 2.5-3 升,儿童每天饮水 1-2 升[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
患者应尽量保持每日尿量超过 2 升。[74]Bao Y, Tu X, Wei Q. Water for preventing urinary stones. Cochrane Database Syst Rev. 2020 Feb 11;2:CD004292.https://www.doi.org/10.1002/14651858.CD004292.pub4http://www.ncbi.nlm.nih.gov/pubmed/32045491?tool=bestpractice.com
在饮用水中添加新鲜柠檬汁[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
柠檬汁中的枸橼酸盐含量高,可升高尿液枸橼酸盐水平,从而可能阻止钙与其他结石成分结合,因此可预防结石形成和复发。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
不限制钙的摄入量,并保持成人每天 700-1200 mg、儿童和青少年每天 350-1000 mg(视年龄而定)的正常钙摄入量[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
仅在限钙理由非常充分时才限制患者的钙摄入量。
这样有助于预防结石复发。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118 限制饮食来源的钙会减少钙与草酸盐在消化道内的结合,促发高草酸尿症并可能增加结石形成风险;而且可能会损害骨骼健康。
成人每日摄盐量不得超过 6 g,儿童和青少年每日摄盐量为 2-6 g(具体视年龄而定)[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
摄入大量的钠后,近端肾小管对钙的重吸收会下降,导致高钙尿症。而尿枸橼酸盐水平下降。因此形成尿酸钠晶体的风险增高,高钠摄入会抵消噻嗪类药物降低尿钙的作用。
多吃水果、蔬菜和纤维。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
水果和蔬菜含有对人体有益的膳食纤维,应鼓励患者多摄入。
素食中的碱性物质也会带来有益的尿 pH 值增加。
通常会嘱咐肾结石患者避免高蛋白饮食。欧洲泌尿科协会(European Association of Urology)建议动物蛋白摄入量应限定为每日 0.8-1 g/kg。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/ 但是,英国国家卫生与临床优化研究所(National Institute for Health and Care Excellence, NICE)并未就蛋白摄入量提出建议,因为 NICE 的评估显示,低蛋白摄入量对减少结石复发的有效性证据不明确。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
鼓励患者践行健康生活方式(包括坚持体力活动),达到并保持健康体重。[48]National Institute for Health and Care Excellence. Preventing excess weight gain. March 2015 [internet publication].https://www.nice.org.uk/guidance/ng7
在代谢专科诊所,可针对特定患者人群(根据所形成结石的类型)提出额外饮食建议。
针对特定患者群中部分患者治疗的附加建议
给予诸如枸缘酸钾和碳酸氢钠等药物的口服碱化治疗可能有助于尿酸结石的溶解,并预防尿酸超饱和。因此可用于治疗无需急诊手术处理和无症状的尿酸结石。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/ 对于大多数尿酸结石,碱化治疗的理想目标是将尿 pH 值保持在 7.0 至 7.2。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/ 一线治疗药物是枸缘酸钾。对充血性心力衰竭或肾衰竭患者采用碱化治疗时应格外谨慎。碱化治疗也在预防钙结石和胱氨酸结石方面发挥重要作用。
针对特定患者群中部分患者治疗的附加建议
如果患者存在特定代谢异常,除了饮食调整之外,可能还需予以个性化预防治疗。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/[75]Pearle MS, Goldfarb DS, Assimos DG, et al.; American Urological Association. Medical management of kidney stones: AUA guideline. J Urol. 2014 Aug;192(2):316-24.http://www.jurology.com/article/S0022-5347(14)03532-0/fulltexthttp://www.ncbi.nlm.nih.gov/pubmed/24857648?tool=bestpractice.com[76]Gambaro G, Croppi E, Coe F, et al; Consensus Conference Group. Metabolic diagnosis and medical prevention of calcium nephrolithiasis and its systemic manifestations: a consensus statement. J Nephrol. 2016 Dec;29(6):715-34.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5080344/http://www.ncbi.nlm.nih.gov/pubmed/27456839?tool=bestpractice.com 这些患者需在代谢专科诊所接受管理,专科医生会为他们提供个体化的治疗建议和干预措施。此类异常及建议干预措施包括:
尿酸结石:采用枸缘酸钾或碳酸氢钠进行尿液碱化。[31]Türk C, Neisius A, Petrik A, et al. European Association of Urology. Urolithiasis. 2020 [internet publication].https://uroweb.org/guideline/urolithiasis/
高钙尿症和草酸钙含量超过 50% 的复发性结石:噻嗪类利尿剂联用或不联用枸橼酸钾(先让患者将每日钠摄入量限制在 6 g 以内)[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118
低枸橼酸尿症和草酸钙含量超过 50% 的复发性结石:尿液碱化(例如枸缘酸钾);如果患者存在高钾血症风险,可考虑使用碳酸氢钠或枸橼酸钠。[15]National Institute for Health and Care Excellence. Renal and ureteric stones: assessment and management. January 2019 [internet publication].https://www.nice.org.uk/guidance/ng118[76]Gambaro G, Croppi E, Coe F, et al; Consensus Conference Group. Metabolic diagnosis and medical prevention of calcium nephrolithiasis and its systemic manifestations: a consensus statement. J Nephrol. 2016 Dec;29(6):715-34.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5080344/http://www.ncbi.nlm.nih.gov/pubmed/27456839?tool=bestpractice.com
高草酸尿症:草酸盐螯合剂(例如钙、镁或 colestyramine)、枸缘酸钾、吡哆醇;一种罕见疾病
胱氨酸尿:大量摄入液体并用枸缘酸钾碱化尿液,或使用硫醇结合剂(例如硫普罗宁,其耐受性优于 D-青霉胺);一种需要终生治疗的遗传异常。
以上大多数措施可以用于肾结石患儿中,但针对这一年龄组设计良好的临床试验数量有限。[77]Kern A, Grimsby G, Mayo H, et al. Medical and dietary interventions for preventing recurrent urinary stones in children. Cochrane Database Syst Rev. 2017;(11):CD011252.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011252.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/29117629?tool=bestpractice.com[78]Barreto L, Jung JH, Abdelrahim A, et al. Medical and surgical interventions for the treatment of urinary stones in children. Cochrane Database Syst Rev. 2018;(6):CD010784.https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD010784.pub2/fullhttp://www.ncbi.nlm.nih.gov/pubmed/29859007?tool=bestpractice.com
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