术中持续胰岛素输注对成人非糖尿病患者瓣膜置换术围术期血糖影响的临床观察

摘要

Objective To study the clinic effects of continuous insulin infusion on non-diabetic patients during perioperative period of cardiac valve replacement .Methods Eighty non-diabetic adult patients who underwent elective cardiac valve replacement from November 2010 to November 2012 in Changzheng Hospital were chosen for the study .With the knowledge and consent of the pa-tients and following the signing of the letter of agreement and with the approval of the Ethic Committee , the patients were randomly di-vided into 2 groups, each consisting of 40 patients.The patients in the treatment group were given continuous insulin infusion .Infusion was performed through cardiopulmonary bypass (CPB) with the micro-pump, and blood glucose was maintained at 6.1-10.0 mmol/L. The patients in the control group were intermittently infused with insulin and equal amount of saline , also through CPB and with the mi-cro-pump.If the blood glucose level of patients was higher than 10.0 mmol/L, intermittent insulin infusion was administered to control the glucose level below 10.0 mmol/L.Levels of glucose and lactic acid of the patients were monitored at the following different time points:before operation , after anesthesia induction ,10 min after obstruction of aorta , 10 min after second infilling of the heart arresting fluid, 10 min after rewarming, 10 min after the opening of aorta, 10 min after termination of CPB, and after completion of surgery. Blood glucose levels of patients were monitored at the following time points: the moment after they returned to the intensive care unit (ICU), and at hours 1, 2, 4, 8, 16 and 24.Intraoperative automatic cardioversion rate , atrial fibrillation 24h after surgery, rate of hy-popotassemia 24 h after surgery , and the length of hospital stay after surgery were recorded accordingly .Results ①For patients in the treatment group, blood glucose levels during surgery were maintained at 6.1-10.0mmol/L, which were significantly lower than those of the control (P<0.05).Peak glucose level of the patients in the treatment group was lower than that of the control group patients during CPB (7.85 ±1.57) vs (10.60 ±3.09) mmol/L, with statistical significance (P<0.05).②The level of lactic acid in the patients of the treatment group was lower than that of the control group patients , with statistical significance (P<0.05).③Automatic cardiover-sion rate during surgery for the patients in the treatment group was higher than that of the control group patients (77.5%vs 52.5%), also with statistical significance (P<0.05).④Blood glucose level at hour 24 for the experiment group was lower than that of the con-trol group.Rate of hypopotassemia for the experiment group was lower than that of the control group (19.5%vs 37.5%), with statisti-cal significance (P<0.05).And the rate of postoperative atrial fibrillation in 24 h for the experiment group was lower that of the con-trol group (27.5%vs 52.5%) (P<0.05).The length of postoperative hospital stay for the patients in the treatment group was shor -ter than that of the patients of the control group (10.8 ±2.4) d vs (13.2 ±3.2)d, all with statistical significance (P<0.05). Conclusion For the non-diabetic adult patients who underwent elective cardiac valve replacement , continuous insulin infusion during surgery could maintain blood glucose and potassium level , increase the rate of automatic cardioversion , decrease the rate of postoperative atrial fibrillation in intraoperative and early postoperative periods , and shorten the length of hospital stay after surgery .It was obviously beneficial to the prognosis of patients .%目的：探讨成人非糖尿病患者心脏瓣膜置换术中胰岛素持续输注对血糖变化的影响。方法选择2010年11月至2012年11月第二军医大学附属长征医院80例成人择期行心脏瓣膜置换术的非糖尿病患者，获伦理委员会批准并由患者签署知情同意书后，采用数字表法分为实验组和对照组，每组各40例。实验组（持续胰岛素输注组），即体外循环（ cardiopul-monary bypass， CPB）开始持续微泵输注胰岛素，维持患者血糖6．1～10．0 mmol/L；对照组（间断胰岛素输注组），即CPB开始持续微泵输注等量生理盐水，若血糖高于10．0 mmol/L，间断静脉注射胰岛素，控制患者血糖＜10．0 mmol/L。记录患者术前、麻醉诱导后、主动脉阻断后10 min、二次灌注停搏液后10 min、复温后10 min、主动脉开放后10 min、停CPB后10 min、手术结束时的血糖、血乳酸值；术后返回监护室（ intensive care unit ，ICU）即刻、1、2、4、8、16、24 h的血糖；术中心脏自动复跳率、术后24 h内房颤发生率、术后24 h内低血钾发生率，术后住院时间。结果（1）实验组患者术中维持血糖水平在6．1～10．0 mmol/L，与对照组相比明显降低，实验组和对照组血糖峰值分别为（7．85±1．57）和（10．60±3．09）mmol/L，差异有统计学意义（P＜0.05）；（2）血乳酸值方面，实验组比对照组降低，实验组和对照组血乳酸峰值分别为（5．57±1．09）和（6．35±1．87） mmol/L，差异有统计学意义（P＜0．05）；（3）术中心脏自动复跳率，实验组高于对照组，实验组和对照组分别为77．5％和52．5％，差异有统计学意义（P＜0．05）；（4）实验组术后24 h血糖水平与对照组比较，实验组低血钾发生率（19．5％）较对照组（37．5％）降低，差异有统计学意义（P＜0．05）；实验组术后24 h内房颤发生率（27．5％）低于对照组（52．5％），差异有统计学意义（P＜0．05）；术后住院时间实验组（10．8±2．4）d也短于对照组（13．2±3．2）d，差异有统计学意义（P＜0．05）。结论成人非糖尿病患者瓣膜置换术中，应用胰岛素持续输注方案控制血糖，可以维持患者术中及术后早期血糖、血钾平稳，提高术中心脏自动复跳率，降低术后24 h内房颤发生率，缩短住院时间，有利于改善预后。