60岁以上糖尿病患者的冠状动脉旁路移植术围术期处理

Perioperative management of coronary artery bypass grafting in diabetic patients over 60

目的回顾性分析60岁以上老年糖尿病患者行冠状动脉旁路移植术(coronary artery bypass grafting,CABG)的围术期治疗效果和经验。方法对671例60岁以上接受CABG患者的情况进行回顾性分析,其中糖尿病组158例,非糖尿病组513例。按常规方法行非体外循环和体外循环下搭桥术,搭桥材料常规使用左侧乳内动脉(IMA)和大隐静脉(SV)。术前术后严密监测血糖,采用以口服降糖药或皮下注射胰岛素为主的血糖调控策略,将血糖控制在术前6 mmol/L、术后8 mmol/L左右。术中使用即时超声血流仪(TTFM)测量移植血管血流,保证吻合口通畅。术后加强物理治疗和营养支持。结果围术期总死亡率1.0%,糖尿病组病死率(1.9%)显著高于非糖尿病组(0.77%),(P<0.05)。总并发症发生率2.53%,糖尿病组并发症率(3.8%)显著高于非糖尿病组(2.1%)(P<0.05)。术后脑梗死发生率糖尿病组(1.2%)也显著高于非糖尿病组(0.7%),(P<0.05)。结论糖尿病是老年患者CABG围术期死亡和脑卒中等并发症的危险因素。围术期应采用精细的血糖监测和调控及综合治疗措施控制手术死亡率和并发症率,使老年糖尿病患者取得很好的手术效果。

grafting （CABG） for aged patients over 60 with diabetes mellitus. Methods A total of 671 patients over 60 years old underwent CABG （ either off-pump CABG or conventional coronary bypass grafting）, 158 diabetic patients and 513 free from diabetes. Left internal mammary artery （LIMA） and saphenous vein were harvested and utilized. Blood sugar level was strictly controlled at 6 mmol/L before operation and 8 mmol/L after operation by oral drugs or subcutaneous insulin. Transit time flowmeter （TTFM） was utilized to insure patent grafts with enough blood flow. Adequate nutrition and gradually increased physical activity were encouraged for ＂fast-track＂ protocol. Results The overall perioperative mortality was 1.0%, 1.9% in diabetic patients and 0.77% in non-diabetes patients （ P 〈 0. 05）. The total occurrence rate of postoperative complications was 2.53%, 3.8% in diabetic patients and 2. 1% in non-diabetes patients （ P 〈 0. 05 ）. Cerebral infarction occurred in 1.2% of diabetic patients and 0. 7% in non-diabetes patients （ P 〈 0. 05 ）. Conclusion Diabetes was a risk factor of mortality and cerebral complications after CABG in aged patients. Precisely perioperative monitor and control of blood sugar, and comprehensive management are necessary to short-term results of low mortality and less complications in aged diabetic patients undergoing CABG.