在择期体外循环心脏手术的中高危患者中，葡萄糖-胰岛素-钾的心肌保护作用：一项随机对照试验。
Myocardial Protection by Glucose-Insulin-Potassium in Moderate- to High-Risk Patients Undergoing Elective On-Pump Cardiac Surgery: A Randomized Controlled Trial.
机构信息
From the Department of Anesthesiology, Pharmacology and Intensive Care.
Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland.
出版信息
Anesth Analg. 2018 Apr;126(4):1133-1141. doi: 10.1213/ANE.0000000000002777.
BACKGROUND
Low cardiac output syndrome is a main cause of death after cardiac surgery. We sought to assess the impact of glucose-insulin-potassium (GIK) to enhance myocardial protection in moderate- to high-risk patients undergoing on-pump heart surgery.
METHODS
A randomized controlled trial was performed in adult patients (Bernstein-Parsonnet score >7) scheduled for elective aortic valve replacement and/or coronary artery bypass surgery. Patients were randomized to GIK (20 IU of insulin, 10 mEq of potassium chloride in 50 mL of glucose 40%) or saline infusion given over 60 minutes on anesthetic induction. The primary end point was postcardiotomy ventricular dysfunction (PCVD), defined as new/worsening left ventricular dysfunction requiring inotropic support (≥120 minutes). Secondary end points were the intraoperative changes in left ventricular function as assessed by transoesophageal echocardiography, postoperative troponin levels, cardiovascular and respiratory complications, and intensive care unit and hospital length of stay.
RESULTS
From 224 randomized patients, 222 were analyzed (112 and 110 in the placebo and GIK groups, respectively). GIK pretreatment was associated with a reduced occurrence of PCVD (risk ratio [RR], 0.41; 95% confidence interval [CI], 0.25-0.66). In GIK-treated patients, the left systolic ventricular function was better preserved after weaning from bypass, plasma troponin levels were lower on the first postoperative day (2.9 ng·mL(-) [interquartile range {IQR}, 1.5-6.6] vs 4.3 ng·mL(-) [IQR, 2.4-8.2]), and cardiovascular (RR, 0.69; 95% CI, 0.50-0.89) and respiratory complications (RR, 0.5; 95% CI, 0.38-0.74) were reduced, along with a shorter length of stay in intensive care unit (3 days [IQR, 2-4] vs 3.5 days [IQR, 2-7]) and in hospital (14 days [IQR, 11-18.5] vs 16 days [IQR, 12.5-23.5]), compared with placebo-treated patients.
CONCLUSIONS
GIK pretreatment was shown to attenuate PCVD and to improve clinical outcome in moderate- to high-risk patients undergoing on-pump cardiac surgery.
背景
低心排血量综合征是心脏手术后死亡的主要原因。我们旨在评估葡萄糖-胰岛素-钾（GIK）在体外循环心脏手术的中高危患者中增强心肌保护的作用。
方法
在择期主动脉瓣置换术和/或冠状动脉旁路移植术的成年患者（Bernstein-Parsonnet 评分>7）中进行了一项随机对照试验。患者在麻醉诱导时接受 GIK（20 IU 胰岛素、10 mEq 氯化钾和 50 mL 40%葡萄糖）或生理盐水输注 60 分钟。主要终点是心脏手术后心室功能障碍（PCVD），定义为需要正性肌力支持（≥120 分钟）的新/恶化左心室功能障碍。次要终点是经食管超声心动图评估的术中左心室功能变化、术后肌钙蛋白水平、心血管和呼吸系统并发症以及重症监护病房和住院时间。
结果
在 224 名随机患者中，222 名患者被分析（安慰剂组和 GIK 组各 112 名和 110 名）。GIK 预处理与 PCVD 的发生减少相关（风险比 [RR]，0.41；95%置信区间 [CI]，0.25-0.66）。在 GIK 治疗的患者中，体外循环脱机后左心室收缩功能更好地保留，术后第一天的血浆肌钙蛋白水平较低（2.9 ng·mL(-) [四分位距 {IQR}，1.5-6.6] vs 4.3 ng·mL(-) [IQR，2.4-8.2]），心血管（RR，0.69；95% CI，0.50-0.89）和呼吸系统并发症（RR，0.5；95% CI，0.38-0.74）减少，重症监护病房（3 天 [IQR，2-4] 与 3.5 天 [IQR，2-7]）和住院（14 天 [IQR，11-18.5] 与 16 天 [IQR，12.5-23.5]）时间缩短，与安慰剂治疗的患者相比。
结论
GIK 预处理可减轻中高危体外循环心脏手术患者的 PCVD，并改善临床结局。
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