Lecomte Patrick, Foubert Luc, Nobels Frank, Coddens José, Nollet Guy, Casselman Filip, Crombrugge Paul Van, Vandenbroucke Geert, Cammu Guy
Department of Anesthesiology and Critical Care Medicine, Onze-Lieve-Vrouw Hospital, Moorselbaan 164, 9300 Aalst, Belgium.
Anesth Analg. 2008 Jul;107(1):51-8. doi: 10.1213/ane.0b013e318172c557.
Tight blood glucose control reduces mortality and morbidity in critically ill patients, but intraoperative glucose control during cardiac surgery is often difficult, and risks hypoglycemia. In this study, we evaluated the safety and efficacy of a nurse-driven insulin protocol (the Aalst Glycemia Insulin Protocol) for achieving a target glucose level of 80-110 mg/dL during cardiac surgery and in the intensive care unit (ICU).
We included 483 nondiabetics and 168 diabetics scheduled for cardiac surgery with cardiopulmonary bypass. To anticipate rapid perioperative changes in insulin requirement and/or sensitivity during surgery, we developed a dynamic algorithm presented in tabular form, with rows representing blood glucose ranges and columns representing insulin dosages based on the patients' insulin sensitivity. The algorithm adjusts insulin dosage based on blood glucose level and the projected insulin sensitivity (e.g., reduced sensitivity during cardiopulmonary bypass and normalizing sensitivity after surgery).
A total of 18,893 blood glucose measurements were made during and after surgery. During surgery, the mean glucose level in nondiabetic patients was within targeted levels except during (112 +/- 17 mg/dL) and after rewarming (113 +/- 19 mg/dL) on cardiopulmonary bypass. In diabetics, blood glucose was decreased from 121 +/- 40 mg/dL at anesthesia induction to 112 +/- 26 mg/dL at the end of surgery (P < 0.05), with 52.9% of patients achieving the target. In the ICU, the mean glucose level was within targeted range at all time points, except for diabetics upon ICU arrival (113 +/- 24 mg/dL). Of all blood glucose measurements (operating room and ICU), 68.0% were within the target, with 0.12% of measurements in nondiabetics and 0.18% in diabetics below 60 mg/dL. Hypoglycemia < 50 mg/dL was avoided in all but four (0.6%) patients (40 mg/dL was the lowest observed value).
The Aalst Glycemia Insulin Protocol is effective for maintaining tight perioperative blood glucose control during cardiac surgery with minimal risk of hypoglycemia.
严格控制血糖可降低重症患者的死亡率和发病率，但心脏手术期间的术中血糖控制往往很困难，且有低血糖风险。在本研究中，我们评估了一种由护士主导的胰岛素方案（阿尔斯特血糖胰岛素方案）在心脏手术期间及重症监护病房（ICU）将血糖水平控制在80 - 110 mg/dL目标范围内的安全性和有效性。
我们纳入了483例非糖尿病患者和168例计划进行体外循环心脏手术的糖尿病患者。为预测手术期间胰岛素需求和/或敏感性的快速围手术期变化，我们开发了一种以表格形式呈现的动态算法，行代表血糖范围，列代表基于患者胰岛素敏感性的胰岛素剂量。该算法根据血糖水平和预计的胰岛素敏感性调整胰岛素剂量（例如，体外循环期间敏感性降低，术后敏感性恢复正常）。
手术期间及术后共进行了18,893次血糖测量。手术期间，非糖尿病患者的平均血糖水平除在体外循环期间复温时（112±17 mg/dL）和复温后（113±19 mg/dL）外均在目标范围内。在糖尿病患者中，血糖从麻醉诱导时的121±40 mg/dL降至手术结束时的112±26 mg/dL（P < 0.05），52.9%的患者达到目标。在ICU，除糖尿病患者入院时（113±24 mg/dL）外，所有时间点的平均血糖水平均在目标范围内。在所有血糖测量值（手术室和ICU）中，68.0%在目标范围内，非糖尿病患者测量值中有0.12%、糖尿病患者中有0.18%低于60 mg/dL。除4例（0.6%）患者外（观察到的最低值为40 mg/dL），所有患者均避免了血糖<50 mg/dL的低血糖情况。
阿尔斯特血糖胰岛素方案在心脏手术期间有效维持严格的围手术期血糖控制，且低血糖风险最小。
