Saager Leif, Duncan Andra E, Yared Jean-Pierre, Hesler Brian D, You Jing, Deogaonkar Anupa, Sessler Daniel I, Kurz Andrea
From the Departments of Outcomes Research (L.S., A.E.D., J.-P.Y., B.D.H., J.Y., D.I.S., A.K.), Cardiothoracic Anesthesia (A.E.D., J.-P.Y.), Quantitative Health Sciences (J.Y.), Regional Practice Anesthesiology (A.D.), and General Anesthesiology (A.K.), Cleveland Clinic, Cleveland, Ohio.
Anesthesiology. 2015 Jun;122(6):1214-23. doi: 10.1097/ALN.0000000000000669.
Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery.
The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness).
Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy.
Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.
术后谵妄在心脏手术康复患者中很常见。严格的血糖控制已被证明可降低死亡率和发病率。因此，作者试图确定采用高胰岛素-正常血糖钳夹法进行术中严格血糖控制对心脏手术患者术后谵妄的影响。
在这项随机、双盲、单中心试验中，作者纳入了198例接受心脏手术的成年患者。患者被随机分配至术中采用高胰岛素-正常血糖钳夹进行严格血糖控制组（目标血糖，80至110mg/dl）或标准治疗组（常规胰岛素给药，血糖目标<150mg/dl）。使用综合谵妄评估工具评估谵妄。当在任何评估中混乱评估方法测试呈阳性时，作者认为患者经历了术后谵妄。混乱评估方法阳性的定义为存在特征1（急性起病和波动病程）和2（注意力不集中）以及3（思维紊乱）或4（意识改变）中的一项。
在调整术前钙通道阻滞剂使用情况和美国麻醉医师协会身体状况后，随机分配至严格血糖控制组的患者比分配至常规血糖控制组的患者更有可能被诊断为谵妄（93例中的26例 vs. 105例中的15例；相对风险，1.89；95%CI，1.06至3.37；P = 0.03）。在谵妄患者中，谵妄严重程度在每种血糖管理策略之间具有可比性。
术中高胰岛素-正常血糖血症会增加心脏手术后谵妄的风险，但不会增加其严重程度。
