Furnary Anthony P, Gao Guangqiang, Grunkemeier Gary L, Wu YingXing, Zerr Kathryn J, Bookin Stephen O, Floten H Storm, Starr Albert
Department of Cardiothoracic Surgery, Providence St Vincent Medical Center, Oregon Health and Science University, Portland, OR 97225, USA.
J Thorac Cardiovasc Surg. 2003 May;125(5):1007-21. doi: 10.1067/mtc.2003.181.
Diabetes mellitus is a risk factor for death after coronary artery bypass grafting. Its relative risk may be related to the level of perioperative hyperglycemia. We hypothesized that strict glucose control with a continuous insulin infusion in the perioperative period would reduce hospital mortality.
All patients with diabetes undergoing coronary artery bypass grafting (n = 3554) were treated aggressively with either subcutaneous insulin (1987-1991) or with continuous insulin infusion (1992-2001) for hyperglycemia. Predicted and observed hospital mortalities were compared with both internal and external (Society of Thoracic Surgeons 1996) multivariable risk models.
Observed mortality with continuous insulin infusion (2.5%, n = 65/2612) was significantly lower than with subcutaneous insulin (5.3%, n = 50/942, P <.0001). Likewise, glucose control was significantly better with continuous insulin infusion (177 +/- 30 mg/dL vs 213 +/- 41 mg/dL, P <.0001). For internal comparison, multivariable analysis showed that continuous insulin infusion was independently protective against death (odds ratio 0.43, P =.001). Conversely, cardiogenic shock, renal failure, reoperation, nonelective operative status, older age, concomitant peripheral or cerebral vascular disease, decreasing ejection fraction, unstable angina, and history of atrial fibrillation increased the risk of death. For external comparison, observed mortality with continuous insulin infusion was significantly less than that predicted by the model (observed/expected ratio 0.63, P <.001). Multivariable analysis revealed that continuous insulin infusion added an independently protective effect against death (odds ratio 0.50, P =.005) to the constellation of risk factors in the Society of Thoracic Surgeons risk model.
Continuous insulin infusion eliminates the incremental increase in in-hospital mortality after coronary artery bypass grafting associated with diabetes. The protective effect of continuous insulin infusion may stem from the effective metabolic use of excess glucose to favorably alter pathways of myocardial adenosine triphosphate production. Continuous insulin infusion should become the standard of care for glycometabolic control in patients with diabetes undergoing coronary artery bypass grafting.
糖尿病是冠状动脉旁路移植术后死亡的一个危险因素。其相对风险可能与围手术期高血糖水平有关。我们假设围手术期持续胰岛素输注严格控制血糖可降低医院死亡率。
所有接受冠状动脉旁路移植术的糖尿病患者（n = 3554），对于高血糖，1987 - 1991年采用皮下胰岛素治疗，1992 - 2001年采用持续胰岛素输注进行积极治疗。将预测的和观察到的医院死亡率与内部及外部（胸外科医师协会1996年）多变量风险模型进行比较。
持续胰岛素输注组的观察死亡率（2.5%，n = 65/2612）显著低于皮下胰岛素组（5.3%，n = 50/942，P <.0001）。同样，持续胰岛素输注组的血糖控制明显更好（177±30 mg/dL对213±41 mg/dL，P <.0001）。对于内部比较，多变量分析显示持续胰岛素输注对死亡具有独立的保护作用（优势比0.43，P =.001）。相反，心源性休克、肾衰竭、再次手术、非择期手术状态、年龄较大、合并外周或脑血管疾病、射血分数降低、不稳定型心绞痛以及房颤病史增加了死亡风险。对于外部比较，持续胰岛素输注组的观察死亡率显著低于模型预测值（观察值/预期值比例0.63，P <.001）。多变量分析表明，持续胰岛素输注在胸外科医师协会风险模型的危险因素组合基础上，对死亡增加了独立的保护作用（优势比0.50，P =.005）。
持续胰岛素输注消除了与糖尿病相关的冠状动脉旁路移植术后住院死亡率的增加。持续胰岛素输注的保护作用可能源于对过量葡萄糖的有效代谢利用，从而有利地改变心肌三磷酸腺苷产生途径。持续胰岛素输注应成为接受冠状动脉旁路移植术的糖尿病患者糖代谢控制的标准治疗方法。
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