Department of Nutritional Sciences, University of Toronto, Toronto, Ontario, Canada.
Anesth Analg. 2013 Aug;117(2):305-13. doi: 10.1213/ANE.0b013e318295e8d1. Epub 2013 Jun 11.
Surgical stress creates a state of insulin resistance which may contribute to the development of hyperglycemia and, subsequently, postoperative complications. Consumption of an oral carbohydrate supplement before surgery may improve insulin sensitivity and reduce hyperglycemia. In this trial, we investigated the effects of carbohydrate supplementation on insulin resistance in coronary artery bypass graft and spinal decompression and fusion surgical patients.
Twenty-six patients undergoing coronary artery bypass graft and 12 undergoing spine surgery were randomized to receive 800 mL of an oral carbohydrate supplement the evening before and 400 mL 2 hours before surgery (CHO) or to fasting per standard hospital protocol (FAST). Baseline and postoperative measurements of insulin sensitivity were assessed using the short insulin tolerance test and homeostasis model assessment (HOMA). Interleukin-6, C-reactive protein, and free fatty acid levels were determined at baseline, postoperatively, and 24, 48, and 72 hours after surgery. Adiponectin was measured at baseline. Subjective feelings of well-being were measured immediately before surgery, and intra- and postoperative outcomes were documented.
Postoperative insulin sensitivity did not differ significantly between the FAST and CHO groups whether measured by the short insulin tolerance test (rate of disappearance of blood glucose: 0.29%/min vs 0.38%/min; 99% confidence interval [CI] for difference, -0.17 to 0.32, P = 0.41) or HOMA (insulin resistance at values >1: 2.3 vs 3.3; 99% CI for difference, -0.8 to 2.8, P = 0.14). Circulating blood glucose levels after surgery in the CHO group, 6.2 mmol/L, tended to be lower than the FAST group, 6.9 mmol/L (99% CI for difference, -1.7 to 0.25, P = 0.05) and postoperative β-cell function, measured by HOMA-β (impaired β-cell function at values <100%), tended to be higher in the CHO group, 87%, vs 47.5% in the FAST group (99% CI for difference, -9.4 to 88.4), but these differences were not significant. Adiponectin levels were not different between groups at baseline, and levels of free fatty acid, interleukin-6 and C-reactive protein were not affected by treatment.
Preoperative carbohydrate loading did not improve postoperative insulin sensitivity. However, the observed postoperative blood glucose levels and β-cell function as well as secondary outcomes warrant further study to reevaluate traditional fasting practices in surgical patients.
手术应激会导致胰岛素抵抗，这可能导致高血糖的发生，并进而导致术后并发症。术前口服碳水化合物补充剂可能会提高胰岛素敏感性并降低高血糖。在这项试验中，我们研究了碳水化合物补充对冠状动脉旁路移植术和脊柱减压融合术患者胰岛素抵抗的影响。
26 例接受冠状动脉旁路移植术的患者和 12 例接受脊柱手术的患者被随机分为两组，分别在术前一晚和术前 2 小时接受 800 毫升口服碳水化合物补充剂（CHO）或按照标准医院方案禁食（FAST）。使用短期胰岛素耐量试验和稳态模型评估（HOMA）评估胰岛素敏感性的基线和术后测量值。在基线、术后以及术后 24、48 和 72 小时测定白细胞介素-6、C 反应蛋白和游离脂肪酸水平。在基线时测定脂联素。在手术前立即测量患者的整体舒适度，并记录术中及术后结果。
无论通过短期胰岛素耐量试验（血糖清除率：0.29%/min 比 0.38%/min；差值的 99%置信区间，-0.17 至 0.32，P = 0.41）还是 HOMA（胰岛素抵抗值>1：2.3 比 3.3；差值的 99%置信区间，-0.8 至 2.8，P = 0.14）测量，术后胰岛素敏感性在 FAST 组和 CHO 组之间无显著差异。CHO 组术后血糖水平为 6.2mmol/L，较 FAST 组的 6.9mmol/L（差值的 99%置信区间，-1.7 至 0.25，P = 0.05）偏低，而术后胰岛β细胞功能（HOMA-β，<100%为胰岛β细胞功能受损）在 CHO 组为 87%，高于 FAST 组的 47.5%（差值的 99%置信区间，-9.4 至 88.4），但无统计学意义。两组患者基线时脂联素水平无差异，游离脂肪酸、白细胞介素-6 和 C 反应蛋白水平不受治疗影响。
术前碳水化合物负荷并未改善术后胰岛素敏感性。然而，观察到的术后血糖水平和胰岛β细胞功能以及其他次要结果需要进一步研究，以重新评估手术患者的传统禁食实践。
