CAJ | 학술논문

目的：探讨成人非糖尿病患者心脏瓣膜置换术中胰岛素持续输注对血糖变化的影响。方法选择2010年11月至2012年11月第二军医大学附属长征医院80例成人择期行心脏瓣膜置换术的非糖尿病患者，获伦理委员会批准并由患者签署知情同意书后，采用数字表法分为实验组和对照组，每组各40例。实验组（持续胰岛素输注组），即体外循环（ cardiopul-monary bypass， CPB）开始持续微泵输注胰岛素，维持患者血糖6．1～10．0 mmol/L；对照组（间断胰岛素输注组），即CPB开始持续微泵输注等量生理盐水，若血糖高于10．0 mmol/L，间断静脉注射胰岛素，控制患者血糖＜10．0 mmol/L。记录患者术前、麻醉诱导后、主动脉阻断后10 min、二次灌注停搏液后10 min、复温后10 min、主动脉开放后10 min、停CPB后10 min、手术结束时的血糖、血乳酸值；术后返回监护室（ intensive care unit ，ICU）即刻、1、2、4、8、16、24 h的血糖；术中心脏自动复跳率、术后24 h内房颤发生率、术后24 h内低血钾发生率，术后住院时间。结果（1）实验组患者术中维持血糖水平在6．1～10．0 mmol/L，与对照组相比明显降低，实验组和对照组血糖峰值分别为（7．85±1．57）和（10．60±3．09）mmol/L，差异有统计学意义（P＜0.05）；（2）血乳酸值方面，实验组比对照组降低，实验组和对照组血乳酸峰值分别为（5．57±1．09）和（6．35±1．87） mmol/L，差异有统计学意义（P＜0．05）；（3）术中心脏自动复跳率，实验组高于对照组，实验组和对照组分别为77．5％和52．5％，差异有统计学意义（P＜0．05）；（4）实验组术后24 h血糖水平与对照组比较，实验组低血钾发生率（19．5％）较对照组（37．5％）降低，差异有统计学意义（P＜0．05）；实验组术后24 h内房颤发生率（27．5％）低于对照组（52．5％），差异有统计学意义（P＜0．05）；术后住院时间实验组（10．8±2．4）d也短于对照组（13．2±3．2）d，差异有统计学意义（P＜0．05）。结论成人非糖尿病患者瓣膜置换术中，应用胰岛素持续输注方案控制血糖，可以维持患者术中及术后早期血糖、血钾平稳，提高术中心脏自动复跳率，降低术后24 h内房颤发生率，缩短住院时间，有利于改善预后。目的：探討成人非糖尿病患者心髒瓣膜置換術中胰島素持續輸註對血糖變化的影響。方法選擇2010年11月至2012年11月第二軍醫大學附屬長徵醫院80例成人擇期行心髒瓣膜置換術的非糖尿病患者，穫倫理委員會批準併由患者籤署知情同意書後，採用數字錶法分為實驗組和對照組，每組各40例。實驗組（持續胰島素輸註組），即體外循環（ cardiopul-monary bypass， CPB）開始持續微泵輸註胰島素，維持患者血糖6．1～10．0 mmol/L；對照組（間斷胰島素輸註組），即CPB開始持續微泵輸註等量生理鹽水，若血糖高于10．0 mmol/L，間斷靜脈註射胰島素，控製患者血糖＜10．0 mmol/L。記錄患者術前、痳醉誘導後、主動脈阻斷後10 min、二次灌註停搏液後10 min、複溫後10 min、主動脈開放後10 min、停CPB後10 min、手術結束時的血糖、血乳痠值；術後返迴鑑護室（ intensive care unit ，ICU）即刻、1、2、4、8、16、24 h的血糖；術中心髒自動複跳率、術後24 h內房顫髮生率、術後24 h內低血鉀髮生率，術後住院時間。結果（1）實驗組患者術中維持血糖水平在6．1～10．0 mmol/L，與對照組相比明顯降低，實驗組和對照組血糖峰值分彆為（7．85±1．57）和（10．60±3．09）mmol/L，差異有統計學意義（P＜0.05）；（2）血乳痠值方麵，實驗組比對照組降低，實驗組和對照組血乳痠峰值分彆為（5．57±1．09）和（6．35±1．87） mmol/L，差異有統計學意義（P＜0．05）；（3）術中心髒自動複跳率，實驗組高于對照組，實驗組和對照組分彆為77．5％和52．5％，差異有統計學意義（P＜0．05）；（4）實驗組術後24 h血糖水平與對照組比較，實驗組低血鉀髮生率（19．5％）較對照組（37．5％）降低，差異有統計學意義（P＜0．05）；實驗組術後24 h內房顫髮生率（27．5％）低于對照組（52．5％），差異有統計學意義（P＜0．05）；術後住院時間實驗組（10．8±2．4）d也短于對照組（13．2±3．2）d，差異有統計學意義（P＜0．05）。結論成人非糖尿病患者瓣膜置換術中，應用胰島素持續輸註方案控製血糖，可以維持患者術中及術後早期血糖、血鉀平穩，提高術中心髒自動複跳率，降低術後24 h內房顫髮生率，縮短住院時間，有利于改善預後。
목적：탐토성인비당뇨병환자심장판막치환술중이도소지속수주대혈당변화적영향。방법선택2010년11월지2012년11월제이군의대학부속장정의원80례성인택기행심장판막치환술적비당뇨병환자，획윤리위원회비준병유환자첨서지정동의서후，채용수자표법분위실험조화대조조，매조각40례。실험조（지속이도소수주조），즉체외순배（ cardiopul-monary bypass， CPB）개시지속미빙수주이도소，유지환자혈당6．1～10．0 mmol/L；대조조（간단이도소수주조），즉CPB개시지속미빙수주등량생리염수，약혈당고우10．0 mmol/L，간단정맥주사이도소，공제환자혈당＜10．0 mmol/L。기록환자술전、마취유도후、주동맥조단후10 min、이차관주정박액후10 min、복온후10 min、주동맥개방후10 min、정CPB후10 min、수술결속시적혈당、혈유산치；술후반회감호실（ intensive care unit ，ICU）즉각、1、2、4、8、16、24 h적혈당；술중심장자동복도솔、술후24 h내방전발생솔、술후24 h내저혈갑발생솔，술후주원시간。결과（1）실험조환자술중유지혈당수평재6．1～10．0 mmol/L，여대조조상비명현강저，실험조화대조조혈당봉치분별위（7．85±1．57）화（10．60±3．09）mmol/L，차이유통계학의의（P＜0.05）；（2）혈유산치방면，실험조비대조조강저，실험조화대조조혈유산봉치분별위（5．57±1．09）화（6．35±1．87） mmol/L，차이유통계학의의（P＜0．05）；（3）술중심장자동복도솔，실험조고우대조조，실험조화대조조분별위77．5％화52．5％，차이유통계학의의（P＜0．05）；（4）실험조술후24 h혈당수평여대조조비교，실험조저혈갑발생솔（19．5％）교대조조（37．5％）강저，차이유통계학의의（P＜0．05）；실험조술후24 h내방전발생솔（27．5％）저우대조조（52．5％），차이유통계학의의（P＜0．05）；술후주원시간실험조（10．8±2．4）d야단우대조조（13．2±3．2）d，차이유통계학의의（P＜0．05）。결론성인비당뇨병환자판막치환술중，응용이도소지속수주방안공제혈당，가이유지환자술중급술후조기혈당、혈갑평은，제고술중심장자동복도솔，강저술후24 h내방전발생솔，축단주원시간，유리우개선예후。
Objective To study the clinic effects of continuous insulin infusion on non-diabetic patients during perioperative period of cardiac valve replacement .Methods Eighty non-diabetic adult patients who underwent elective cardiac valve replacement from November 2010 to November 2012 in Changzheng Hospital were chosen for the study .With the knowledge and consent of the pa-tients and following the signing of the letter of agreement and with the approval of the Ethic Committee , the patients were randomly di-vided into 2 groups, each consisting of 40 patients.The patients in the treatment group were given continuous insulin infusion .Infusion was performed through cardiopulmonary bypass (CPB) with the micro-pump, and blood glucose was maintained at 6.1-10.0 mmol/L. The patients in the control group were intermittently infused with insulin and equal amount of saline , also through CPB and with the mi-cro-pump.If the blood glucose level of patients was higher than 10.0 mmol/L, intermittent insulin infusion was administered to control the glucose level below 10.0 mmol/L.Levels of glucose and lactic acid of the patients were monitored at the following different time points:before operation , after anesthesia induction ,10 min after obstruction of aorta , 10 min after second infilling of the heart arresting fluid, 10 min after rewarming, 10 min after the opening of aorta, 10 min after termination of CPB, and after completion of surgery. Blood glucose levels of patients were monitored at the following time points: the moment after they returned to the intensive care unit (ICU), and at hours 1, 2, 4, 8, 16 and 24.Intraoperative automatic cardioversion rate , atrial fibrillation 24h after surgery, rate of hy-popotassemia 24 h after surgery , and the length of hospital stay after surgery were recorded accordingly .Results ①For patients in the treatment group, blood glucose levels during surgery were maintained at 6.1-10.0mmol/L, which were significantly lower than those of the control (P<0.05).Peak glucose level of the patients in the treatment group was lower than that of the control group patients during CPB (7.85 ±1.57) vs (10.60 ±3.09) mmol/L, with statistical significance (P<0.05).②The level of lactic acid in the patients of the treatment group was lower than that of the control group patients , with statistical significance (P<0.05).③Automatic cardiover-sion rate during surgery for the patients in the treatment group was higher than that of the control group patients (77.5%vs 52.5%), also with statistical significance (P<0.05).④Blood glucose level at hour 24 for the experiment group was lower than that of the con-trol group.Rate of hypopotassemia for the experiment group was lower than that of the control group (19.5%vs 37.5%), with statisti-cal significance (P<0.05).And the rate of postoperative atrial fibrillation in 24 h for the experiment group was lower that of the con-trol group (27.5%vs 52.5%) (P<0.05).The length of postoperative hospital stay for the patients in the treatment group was shor -ter than that of the patients of the control group (10.8 ±2.4) d vs (13.2 ±3.2)d, all with statistical significance (P<0.05). Conclusion For the non-diabetic adult patients who underwent elective cardiac valve replacement , continuous insulin infusion during surgery could maintain blood glucose and potassium level , increase the rate of automatic cardioversion , decrease the rate of postoperative atrial fibrillation in intraoperative and early postoperative periods , and shorten the length of hospital stay after surgery .It was obviously beneficial to the prognosis of patients .