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CK注：新冠病毒所致的症状为心、肾、糖尿病等慢病的管理带来不良影响，很多内分泌专科医生已经可以看到超出以往任何时期的大量高血糖危象和电解质危象的住院患者。如何避免？对于COVID-19期间糖尿病的慢病管理的顾虑主要涉及糖尿病-低血糖风险管理、糖尿病-容量风险管理、CKD-AKI风险管理、糖尿病-高糖危象风险管理等。 什么叫“病期管理（Sick day management）”；举一个例子就明白了；比如，肾上腺功能减退患者的管理中，有关于应激情况下激素调整的内容，这种重大应激的管理就是“病期管理”。而如肾上腺功能减退患者的病期管理是有规则的，称为“病期管理规则”，可以大大减少肾上腺危象的风险（链接：疾病导论系列 l 2021肾上腺功能减退（全文.M）**）。国内缺乏各种慢病的病期患者指导共识；但疫情当下，这可能是迫切需要系统整理和宣传的；本公众号持续更新此类可借鉴内容。糖皮质激素应激给药的病期规则病期规则1（Rule No.1）：居家治疗发热疾病应包括将口服氢化可的松替代剂量增加一倍(如果发热> 38°C)或三倍(如果发热>39°C)，直至痊愈(通常在2-3天后)。病期规则2（Rule No.2）：如果患者因呕吐和/或腹泻、创伤、高热和临床情况恶化而无法耐受口服药物治疗，则应联系卫生专业人员或急诊就诊，给予100 mg胃肠外氢化可的松(静脉、肌内或皮下)(国内没有肌肉和皮下制剂，因此无法完成自主注射) CK医学有关COVID-19疫情期间的相关临床内容可持续关注：此次编译ISPAD在2022年发布的“儿童和青少年糖尿病患者病期管理”的内容；ISPAD对2018年指南进行了系统更新，已编译的内容可见：
指南共识 l 2022 l ISPAD/国际儿童和青少年糖尿病学会编译：陈康
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WHAT IS NEW OR DIFFERENT This
new version of the sick day guidelines gives a greater emphasis on 如何管理糖尿病以预防酮症 how to manage diabetes for prevention of
ketosis并采用新技术进行管理 management
with new technologies
相关更新包括： 随着更新的CGM技术变得越来越准确，特别是用于日常调整，糖尿病患者正在常规使用连续血糖监测(CGM)。 Continuous
glucose monitoring (CGM) is being routinely used by persons with diabetes with
the newer CGM technology becoming increasingly more accurate, especially for
day-to-day adjustments.在本文中，“葡萄糖值”除非特别定义，否则均指指血或CGM值。如果需要，可能需要将CGM值与指血值进行交叉检查。 In
this article, “glucose values” unless specifically defined, mean either
fingerstick or CGM values. CGM values may need to be cross-checked with
fingerstick values if required.COVID-19等传染病，甚至COVID-19疫苗接种，都可能导致胰岛素需求持续增加数天或数周。 Infections
such as COVID-19, and even vaccinations for COVID-19, can precipitate
persistent increases in insulin requirements for days or weeks.
针对胰岛素需求增加的可预测模式(如需要类固醇治疗的慢性疾病或与月经期相关的高血糖)进行前瞻性指导，将减少焦虑和不必要的并发症发生。 Anticipatory
guidance to deal with predictable patterns of increased insulin requirements
such as chronic conditions requiring steroid therapy or hyperglycemia
associated with menstrual periods, will reduce anxiety and unnecessary
morbidity.使用电子数据共享平台将有助于家庭和医疗保健团队协助进行病期管理。 Use
of electronic data sharing platforms will help families and health care teams
assist with sick day management.结合泵和传感器的闭环技术，以及人工智能系统(混合闭环系统、自动胰岛素输送或AID)对其进行的交互式调节，可能有助于在病期将葡萄糖水平保持在目标范围内；特别是那些结合了可个体化葡萄糖目标和用户启动模式以在特殊情况下减少或加强胰岛素输送的系统。 Closed
loop technologies, combining both pumps and sensors, and their interactive
regulation by artificial intelligence systems (hybrid closed loop systems,
automated insulin delivery, or AID), may be helpful to keep the glucose levels
in the target range during sick days; particularly those systems that
incorporate personalizable glucose targets and user-initiated modes to reduce
or intensify insulin delivery in special situations.
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EXECUTIVE SUMMARY AND RECOMMENDATIONS Sick
day preparation People
with diabetes, their families and/or caregivers 酮症预防管理 切勿完全停用胰岛素！更换胰岛素笔芯和针头，或泵芯、管路和导管，以确保胰岛素输送充足。B Never
completely stop insulin! Replace insulin pen cartridge and needle, or pump cartridge,
line, and catheter to ensure adequate insulin delivery. B病期务必监测血糖(定义为血液或间质葡萄糖) ，以及酮体水平 ，至少每1-2h监测。E Always
monitor glucose, defined as either blood or interstitial glucose, and ketone
levels at least every 1–2h.E监测血酮优于尿酮。疾病期间的血酮监测可减少急诊就诊和住院次数。B Monitoring
blood ketones is preferred over urine ketones. Blood ketone monitoring during
illness can reduce emergency room visits and hospitalizations. B目标通常是血糖水平在3.9-10 mmoL/L(70-180mg/dl)之间，血酮低于0.6 mmoL/L。E Aim
for glucose levels between 3.9 and 10 mmol/L (70–180 mg/dl) and blood ketones below 0.6 mmoL/L. E根据血液或间质葡萄糖和血酮水平调整胰岛素剂量。E Adjust
the insulin dose in response to blood or interstitial glucose and blood ketone
levels. E当剂量相对较低时，处于部分缓解或“蜜月”期的儿童在患病期间可能需要大幅增加胰岛素剂量。E Insulin
doses may need to be increased considerably during illness in children who are
in the partial remission or “honeymoon” phase when doses are relatively low. E保持水化，如果儿童不能饮水，则寻求紧急医疗建议 Maintain
hydration and seek urgent medical advice if the child is unable to drink如果葡萄糖水平低于14 mmol/L
(250 mg/dl)，应饮用含碳水化合物的口服液；当葡萄糖高于14 mmol/L (250 mg/dl)时，应给予不含碳水化合物的液体。 Oral fluids containing carbohydrate should be
consumed if the glucose level is below 14 mmol/L (250 mg/dl); carbohydrate-free
fluids should be given when glucose is above 14 mmol/L (250 mg/dl).如果儿童不能饮水，考虑及时开始静脉输液。E Consider
timely initiation of intravenous fluids if the child is unable to drink. E在家中有效管理的较轻症疾病将减少对医疗服务和家庭的影响和成本。E Minor
illnesses managed effectively at home will reduce the impact and costs on
health services and the family. E如果出现以下情况，必须鼓励看护人寻求医疗帮助和治疗(E，适用于以下所有情况): Caregivers
must be encouraged to seek medical review and treatment if (E for all below):the
child's condition deterioratesthe underlying condition is unclearcaregiver
understanding/language problems make it difficult to communicate with the
familythe
family does not have the resources to manage the illness at home存在共病病症(例如，唐氏综合征、饮食行为紊乱、精神疾病、癫痫、炎性肠病、疟疾、寄生虫感染等。)there
are comorbid conditions (e.g., Down syndrome, disordered eating behaviors,
mental illness, epilepsy, inflammatory bowel disease, malaria, parasitic
infections, etc.)the
child is very young (less than 5 years old)父母无法保持葡萄糖水平高于3.9mmol/L parents
are unable to keep glucose level above 3.9 mmol/L
Management
when vomiting and/or gastrointestinal illness is present 除非另有其他证据，否则应将恶心和/或呕吐视为胰岛素缺乏和酮症的体征。E Consider
nausea and/or vomiting as a sign of insulin deficiency and ketosis until proven
otherwise. E低血糖伴高酮血症，可能发生在胃肠道(GI)疾病或饥饿的情况下，需要在摄入碳水化合物的同时给予胰岛素。E Hypoglycemia
with hyperketonemia, which may occur in the setting of gastrointestinal (GI)
illness or starvation, requires administration of insulin along with
carbohydrate intake. E胃肠疾病，尤其是病毒性胃肠炎，是病期低血糖的最常见原因，可能需要减少胰岛素剂量。E GI
illnesses, especially viral gastroenteritis, are the most frequent cause of
hypoglycemia during sick days and may require decreasing insulin doses. E如果出现以下情况，则在紧急情况下寻求紧急专家医疗帮助/审查(E，适用于以下所有情况): Seek
URGENT specialist medical review in an emergency setting if (E for all below):weight
loss suggesting worsening dehydration continues and potential circulatory
compromisevomiting
persists beyond 2 h (particularly in young children)不能保持葡萄糖水平> 3.9mmol/mol (70毫克/分升)unable
to keep glucose level >3.9 mmol/mol (70 mg/dl)如果低血糖无法纠正，请就诊静脉输液+葡萄糖继续监测。 if
hypoglycemia cannot be corrected, refer for intravenous fluids with dextrose
along with continued monitoring.
Management
where ketosis is suspected or confirmed 每5-10分钟给予少量含水和电解质的液体，如果葡萄糖水平低于14 mmol/L (250 mg/dl)，则可给药含碳水化合物的液体。目标为4-6ml/kg/小时。 Give
small amounts of liquids containing water and electrolytes every 5–10 min,
carbohydrate-containing liquids if glucose level is below 14 mmol/L (250
mg/dl). Aim for 4–6 ml/kg/hour- 频繁给予额外剂量的超快速、速效或短效胰岛素，以治疗酮症，防止进展为酮症酸中毒和住院。
Give
frequent additional doses of ultrarapid, rapid-acting or short-acting insulin
to treat ketosis and prevent progression to ketoacidosis and hospital
admission. 如果出现以下情况，则在紧急情况下寻求紧急专家医疗帮助/审查(E，适用于以下所有情况): Seek
URGENT specialist medical review in an emergency setting if (E for all below):glucose
level continues to rise despite extra insulin dosesfruity
breath odor (acetone) detected or worsens尽管有额外的胰岛素和水合，血液酮保持升高(> 1.5mmol/L)或尿酮保持较高blood
ketones remain elevated (>1.5 mmol/L) or urine ketones remain large despite
extra insulin and hydration儿童或青少年变得精疲力尽、精神错乱、换气过度(Kussmaul呼吸)，或有严重的腹痛the
child or adolescent is becoming exhausted, confused, hyperventilating (Kussmaul
breathing), or has severe abdominal pain存在神经状态、精神错乱、意识丧失、癫痫发作或意识错乱进展变化者，为避免脑水肿和/或脑损伤的可能性，需就诊there
is a change in neurologic status, mental confusion, loss of consciousness,
seizures, or progression of confusion to avoid the potential for cerebral edema
and/or cerebral injury 应根据当地情况尽快为运输提供便利。 Transport
should be facilitated as soon as possible according to local circumstances.糖尿病团队应联系当地医务人员，以确保在静脉输液和胰岛素给药的同时，建立初始葡萄糖和电解质监测。 The
diabetes team should contact local medical personnel to ensure systems are in
place for initial glucose and electrolyte monitoring along with administration
of intravenous fluids and insulin.
关于使用糖尿病技术(胰岛素泵、混合闭环系统、葡萄糖传感器)的病期管理的具体建议Specific
advice regarding sick day management where diabetes technology (insulin pump,
hybrid closed loop systems, glucose sensors) is used 如果可用，优选使用连续血糖监测(CGM)设备或间歇扫描血糖监测(isCGM)设备来补充血糖监测。E If
available, continuous glucose monitoring (CGM) devices or intermittently
scanned glucose monitoring (isCGM) devices can preferably be used to supplement
blood glucose monitoring. E当医疗保健团队熟悉胰岛素泵技术，可以获得足够的胰岛素泵供应，并且/或者患者和/或其护理人员可以继续安全地操作胰岛素泵时，可以在医院继续使用胰岛素泵，包括闭环和混合模式。 The
use of insulin pumps, including both closed loop and hybrid models, can be
continued in the hospital when health care teams are familiar with the
technology, there is access to adequate insulin pump supplies, and/or the
person and/or their caregiver can continue to safely operate the pump.当出现高葡萄糖水平、呕吐和/或酮血症时，应停止闭环，泵应在开环或手动模式下运行，同时遵守病期管理规则。 In
the presence of high glucose levels and vomiting and/or ketonaemia, closed loop
should be stopped and the pump should operate in open loop or manual mode while
following rules for sick day management.
内分泌代谢病疾病 @CK医学
内分泌代谢病知识架构 @CK医学 内分泌代谢病分级诊疗 @CK医学 CK注：本公众号为什么重视指南或共识的推广？ 慢性疾病和常见病会有大量的临床研究证据，临床决策应尽量利用有价值、高强度的证据。一个好的指南或者共识，会按照一定的标准汇聚证据，会有多个该领域内的专家共同讨论，这样会极大的避免个人经验中的偏见，得到相对客观的、更有利于患者的诊治方案。结合指南或共识的个人诊治经验可能更有效。对于少见病和罕见病，共识的地位更加突出。这些疾病患者在诊治时会有自发的簇集效应，尤其在目前信息传递和搜索都非常便捷的情况下更是如此。具有特定罕见病诊治经验的专家并不多，并且需要耗费巨大的经历大量搜索文献以指导诊治，因此罕见病相关共识对于临床可遇而不可求的某些场景更为弥足珍贵。何为CK医学/CK医学科普？“CK”即Chen Kang的首字母组合；两个公众号是内分泌专业公众号，是CK个人公众号，所涉及的科普也多数是专业版内容；进一步的信息，可百度搜索“Chen kang 内分泌”
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