Department of Anaesthesia, Royal Victoria Hospital, 687 Pine Ave. West, Rm. C5.20, Montreal, QC, Canada H3A 1A1.
Anesth Analg. 2010 Jun 1;110(6):1711-8. doi: 10.1213/ANE.0b013e3181d90087. Epub 2010 Apr 7.
Although hyperglycemia is a well-recognized risk factor in the context of cardiac surgery, the relevance of perioperative glycemic control for patients undergoing major noncardiac operations has received little attention. We designed this study to assess the hyperglycemic response to liver resection, and to test the hypothesis that perioperative glucose and insulin administration while maintaining normoglycemia (GIN therapy) provides glycemic control superior to that achieved by the conventional use of insulin.
Patients were randomly assigned to GIN therapy or standard therapy (control group). In the GIN therapy group, insulin was administered at 2 mU . kg(-1) . min(-1) during surgery. At the end of surgery, the insulin infusion was decreased to 1 mU . kg(-1) . min(-1) and continued for 24 hours. Dextrose 20% was infused at a rate adjusted to maintain blood glucose within the target range of 3.5 to 6.1 mmol . L(-1) (63-110 mg . dL(-1)). Patients in the standard therapy group received a conventional insulin sliding scale during and after surgery. The mean and SD of blood glucose as well as the percentage of blood glucose values within the target range were calculated. To evaluate intrasubject variability, the coefficient of variability (CV) of blood glucose was calculated for each patient. Episodes of severe hypoglycemia, i.e., blood glucose <2.2 mmol . L(-1) (40 mg . dL(-1)), were recorded. The primary outcome was the proportion of normoglycemic measurements.
We studied 52 patients. The mean blood glucose value in patients receiving GIN therapy always remained within the target range. The blood glucose levels were lower in the GIN therapy group than in the standard therapy group (during surgery, P < 0.01; after surgery, P < 0.001). In nondiabetic patients receiving GIN therapy (n = 19), target glycemia was achieved in 90.1% of the blood glucose measurements during surgery and in 77.8% of the measurements after surgery. In diabetic patients receiving GIN therapy (n = 7), target glycemia was achieved in 81.2% of the blood glucose measurements during surgery and in 70.5% of the measurements after surgery. In nondiabetic patients receiving standard therapy (n = 19), target glycemia was achieved in 37.4% of the blood glucose measurements during surgery and in 18.3% of the measurements after surgery. In diabetic patients receiving standard therapy (n = 7), target glycemia was achieved in 4.3% of the blood glucose measurements during surgery and in 2.9% of the measurements after surgery. The SD and CV of blood glucose were smaller in the GIN therapy group than in the standard therapy group, especially in nondiabetic patients after surgery (SD, P < 0.001; CV, P = 0.027). No patients receiving GIN therapy experienced severe hypoglycemia during surgery. One patient receiving GIN therapy experienced hypoglycemia in the intensive care unit after surgery without neurological sequelae.
GIN therapy effectively provides normoglycemia in patients undergoing liver resection (clinicaltrials.gov, NCT00774098).
尽管高血糖是心脏手术背景下公认的危险因素，但围手术期血糖控制对接受重大非心脏手术患者的相关性却很少受到关注。我们设计本研究旨在评估肝切除术的高血糖反应，并检验这样一个假说，即在维持正常血糖的情况下进行葡萄糖和胰岛素输注（GIN 治疗）可提供优于常规使用胰岛素的血糖控制。
患者被随机分配到 GIN 治疗组或标准治疗组（对照组）。在 GIN 治疗组中，手术期间以 2 mU. kg(-1). min(-1) 的速度输注胰岛素。手术结束时，将胰岛素输注速度降低至 1 mU. kg(-1). min(-1)，并持续 24 小时。20%的右旋糖输注速度调整以维持血糖目标范围 3.5 至 6.1 mmol. L(-1)（63-110 mg. dL(-1)）。对照组患者在手术期间和术后接受常规胰岛素滴注。计算血糖的平均值和标准差以及血糖值在目标范围内的百分比。为了评估个体内变异性，为每位患者计算血糖的变异系数（CV）。记录严重低血糖发作，即血糖 <2.2 mmol. L(-1)（40 mg. dL(-1)）。主要结局是血糖正常的测量比例。
我们研究了 52 例患者。接受 GIN 治疗的患者的平均血糖值始终保持在目标范围内。与标准治疗组相比，GIN 治疗组的血糖水平较低（手术期间，P < 0.01；术后，P < 0.001）。在接受 GIN 治疗的非糖尿病患者（n = 19）中，手术期间 90.1%的血糖测量值和术后 77.8%的血糖测量值达到了目标血糖。在接受 GIN 治疗的糖尿病患者（n = 7）中，手术期间 81.2%的血糖测量值和术后 70.5%的血糖测量值达到了目标血糖。在接受标准治疗的非糖尿病患者（n = 19）中，手术期间 37.4%的血糖测量值和术后 18.3%的血糖测量值达到了目标血糖。在接受标准治疗的糖尿病患者（n = 7）中，手术期间只有 4.3%的血糖测量值和术后 2.9%的血糖测量值达到了目标血糖。GIN 治疗组的血糖标准差和 CV 均小于标准治疗组，尤其是术后非糖尿病患者（标准差，P < 0.001；CV，P = 0.027）。接受 GIN 治疗的患者在手术期间均未发生严重低血糖。1 例接受 GIN 治疗的患者在术后重症监护病房发生低血糖，但无神经后遗症。
GIN 治疗可有效为接受肝切除术的患者提供正常血糖（clinicaltrials.gov，NCT00774098）。
