一所学术医疗中心的术中血糖管理决策实践与模式

Decisional practices and patterns of intraoperative glucose management in an academic medical center.

作者信息

Grunzweig Katherine, Nair Bala G, Peterson Gene N, Horibe Mayumi, Neradilek Moni B, Newman Shu-Fang, Van Norman Gail, Schwid Howard A, Hao Wei, Dellinger E Patchen, Hirsch Irl B

机构信息

School of Medicine, University of Washington, Seattle, WA.

Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.

出版信息

J Clin Anesth. 2016 Aug;32:214-23. doi: 10.1016/j.jclinane.2016.02.027. Epub 2016 Apr 22.

DOI:10.1016/j.jclinane.2016.02.027

PMID:27290979

Abstract

OBJECTIVE

To understand the decisional practices of anesthesia providers in managing intraoperative glucose levels.

DESIGN

This is a retrospective cohort study.

SETTING

Operating rooms in an academic medical center.

PATIENTS

Adult patients undergoing surgery.

INTERVENTION

Intraoperative blood glucose management based on an institutional protocol.

MEASUREMENTS

Glucose management data was extracted from electronic medical records to determine compliance to institutional glucose management protocol that prescribes hourly glucose measurements and insulin doses to maintain glucose levels between 100 to 140mg/dL. Effect of patient and surgery specific factors on compliance to glucose management protocol was explored.

MAIN RESULTS

In 1903 adult patients compliances to hourly glucose measurements was 72.5% and correct insulin adjustments was 12.4%. Insulin was under-dosed compared to the prescribed value by a mean of 0.85U/h (95% CI 0.76-0.95). Multivariate analysis showed that compliance to hourly glucose measurements decreased with increasing length of the procedure (OR=0.92 per hour, 95% CI 0.89-0.95) but increased with ASA status codes (OR=1.25 per ASA unit, 95% CI=1.06-1.49). Greater compliance to correct insulin adjustment was found in diabetic patients compared with non-diabetic patients (OR=1.31, 95% CI 1.09-1.55). On average, providers administered progressively more insulin with an additional 0.11U/h (95% CI=0.00-0.21] for every additional 10kg/m(2) of BMI and 0.20U/h (95% CI=0.01-0.39) less in diabetic patients than in non-diabetic patients. With the above practice pattern, the mean±SD of glucose level was 158±36mg/dL. Hypoglycemic (<60mg/dL) incident rate was 0.1% (9/8301 measurements) while hyperglycemic (>180mg/dL) incident rate was 28%. Glucose levels were within the target range (100-140mg/dL) only 28% of the time.

CONCLUSIONS

Low compliance and considerable variability in initiating and following institutional glucose management protocol were observed.

摘要

目的

了解麻醉医护人员管理术中血糖水平的决策实践。

设计

这是一项回顾性队列研究。

地点

一所学术医疗中心的手术室。

患者

接受手术的成年患者。

干预措施

根据机构规程进行术中血糖管理。

测量指标

从电子病历中提取血糖管理数据，以确定对机构血糖管理规程的依从性，该规程规定每小时测量血糖并确定胰岛素剂量，以将血糖水平维持在100至140mg/dL之间。探讨了患者和手术特定因素对血糖管理规程依从性的影响。

主要结果

在1903例成年患者中，每小时血糖测量的依从率为72.5%，胰岛素调整正确的比例为12.4%。与规定值相比，胰岛素剂量平均少0.85U/h（95%CI 0.76-0.95）。多因素分析显示，随着手术时间延长，每小时血糖测量的依从性降低（OR=0.92/小时，95%CI 0.89-0.95），但随着美国麻醉医师协会（ASA）分级增加而升高（OR=1.25/ASA分级单位，95%CI=1.06-1.49）。与非糖尿病患者相比，糖尿病患者胰岛素调整正确的依从性更高（OR=1.31，95%CI 1.09-1.55）。平均而言，医护人员每增加10kg/m(2)体重指数（BMI），胰岛素用量增加0.11U/h（95%CI=0.00-0.21），糖尿病患者比非糖尿病患者每小时少用0.20U/h（95%CI=0.01-0.39）。按照上述实践模式，血糖水平的均值±标准差为158±36mg/dL。低血糖（<60mg/dL）发生率为0.1%（8301次测量中有9次），而高血糖（>180mg/dL）发生率为28%。血糖水平仅在28%的时间内处于目标范围（100-140mg/dL）。