Ljungqvist O, Thorell A, Gutniak M, Häggmark T, Efendic S
Department of Surgery, Karolinska Hospital and Institute, Stockholm, Sweden.
J Am Coll Surg. 1994 Apr;178(4):329-36.
In severe catabolic states, such as burn injury, sepsis and accidental injury, a state of marked insulin resistance is encountered. Insulin resistance is also present after elective surgical treatment, more pronounced with increasingly greater magnitude of operation performed. Results of recent animal experiments have shown that even short periods of food deprivation, reducing carbohydrate reserves, alter responses to stress. This notion resulted in our questioning the rationale of carbohydrate depletion associated with overnight preoperative fasting. Twelve patients undergoing elective open cholecystectomy were randomly given no infusion (control group) or 5 milligrams per kilogram per minute of glucose infusion (glucose group) during preoperative overnight fasting. Insulin sensitivity (M value, milligram per kilogram per minute) was determined using the hyperinsulinemic normoglycemic clamp (plasma insulin level, 65 microunits per milliliter and blood glucose level, 4.5 millimoles per liter) before and the first postoperative day. Preoperative insulin sensitivity was similar in the two groups. Postoperatively, M values decreased by 55 +/- 3 percent (control group) and by 32 +/- 4 percent (glucose group) (p < 0.01). Plasma levels of insulin, c-peptide, glucagon, growth hormone, catecholamines and cortisol in connection with clamps were similar in both groups preoperatively and postoperatively. The present results indicate that active preoperative carbohydrate preservation may improve postoperative metabolism because postoperative occurrence of insulin resistance was reduced with preoperative glucose infusion.
在严重的分解代谢状态下，如烧伤、脓毒症和意外伤害，会出现明显的胰岛素抵抗状态。在择期手术治疗后也存在胰岛素抵抗，且随着手术规模的增大而更加明显。最近的动物实验结果表明，即使短期禁食，减少碳水化合物储备，也会改变对应激的反应。这一观点促使我们质疑术前禁食一夜导致碳水化合物消耗的合理性。12例行择期开腹胆囊切除术的患者在术前禁食一夜期间被随机分为不输液组（对照组）或按每分钟每千克体重5毫克葡萄糖输液组（葡萄糖组）。在术前及术后第一天，采用高胰岛素正常血糖钳夹技术（血浆胰岛素水平为65微单位/毫升，血糖水平为4.5毫摩尔/升）测定胰岛素敏感性（M值，毫克/千克/分钟）。两组术前胰岛素敏感性相似。术后，对照组M值下降55±3%，葡萄糖组下降32±4%（P<0.01）。两组术前和术后与钳夹相关的胰岛素、C肽、胰高血糖素、生长激素、儿茶酚胺和皮质醇的血浆水平相似。目前的结果表明，术前积极保存碳水化合物可能改善术后代谢，因为术前输注葡萄糖可降低术后胰岛素抵抗的发生率。
