深低温停循环围手术期的高血糖监测及控制

Perioperative monitoring and control of hyperglycemia during deep hypothermic circulatory arrest

目的观察深低温停循环（DHCA）围手术期患者血糖的变化趋势，评价血糖升高的各种影响因素以及应用胰岛素控制高血糖的临床效果。方法选择2000年1月至2010年1月长海医院胸心外科176例应用DHCA技术实施主动脉手术患者。在体外循环（CPB）前、DHCA前、DHCA后、术后进入重症监护病房（ICU）后检测血糖、动脉血气和乳酸。采用间断皮下注射或持续静脉微泵注射胰岛素的方式控制术后血糖在6～8mmol／L，同时统计术后24h内的胰岛素累积用量。结果DHCA前血糖（mmol／L）较CPB前明显升高（9．62土1．79比5．04±1．40，P〈0．05），DHCA后血糖（14．91±2．36）进一步升高（P〈0．01），进入ICU后血糖（15．32±2．47）仍持续升高（P〈0．01），且血糖升高水平与血乳酸升高水平呈明显正相关；134例患者（占76．1％）术后因间断皮下注射胰岛素控制血糖效果不佳而改用持续静脉微泵注射胰岛素，其中30例患者（占17．O％）有明显的胰岛素抵抗现象；高龄（≥50岁），合并原发性高血压、主动脉瓣中-重度病变、糖尿病或严重冠心病病史，急诊手术，CPB时间≥3h及DHCA时间≥45min等影响因素会明显加重DHCA围手术期高血糖，且术后24h内胰岛素累积用量明显增加。入ICU后血糖（mmol／L）在年龄≥50岁和〈50岁（18．66±2．52比12．90±2．27）、有无原发性高血压（18．98±2．55比12．31±2．34）、有无主动脉瓣中一重度病变（19．59±2．95比12．13±2．23）、有无糖尿病（20．62±1．76比11．75±1．11）、有无冠心病（19．77±2．98比12．01±2．02）、有无急诊手术（19．78±1．97比12．23±1．38）、CPB时间≥3h和〈3h（19．86±1．89比11．70±1．15）、DHCA时间≥45min和〈45min（19．92±1．88比11．64±1．12）等因素间差异均有统计学意义（均P〈0．05）；术后24h内胰岛素累积用量（U）在年龄≥50岁和〈50岁（169．5±56．6比110．2±38．5）、有无原发性高血压（171．6±64．0比104．8±34．3）、有无主动脉瓣中-重度病变（171．4±36．8比109．4±27．6）、有无糖尿病（202．5±46．7比100．4±31．5）、有无冠心病（178．5±38．6比104．6±26．4）、有无急诊手术（178．3±35．7比102．7±26．8）、CPB时间≥3h和〈3h（168．6±37．2比107．3±27．5）、DHCA时间≥45min和〈45min（172．5±36．1比105．4±28．7）等因素间差异均有统计学意义（均P〈0．05）。结论DHCA可引起围手术期明显的血糖和乳酸升高，甚至导致胰岛素抵抗，术后常需持续静脉应用大剂量胰岛素；DHCA围手术期高血糖与诸多影响因素有关，在临床控制血糖的过程中应综合考虑。

Objective To observe the trend of change in perioperative blood glucose level in patients undergoing deep hypothermic circulatory arrest （DHCA）, in order to evaluate the influencing factors of inciting hyperglycemia and the clinical effects of insulin control. Methods In the Department of Cardiothoracic Surgery of Changhai Hospital, 176 patients underwent aortic operation under DHCA from January 2000 to January 2010. Blood glucose, arterial blood gas and lactate levels were determined at four time points, including pre-cardiopulmonary bypass （CPB）, pre-DHCA, post-DHCA, and at admission to intensive care unit （ICU）. Hyperglycemia after surgery was controlled at the level of 6 - 8 mmol/L by intermittent subcutaneous injection or intravenous micropump injection of insulin. At the same time, the cumulative amount of insulin within 24 hours after surgery was recorded. Results The blood glucose （mmol/L） level at pre-DHCA time point was significantly higher than that of pre-CPB （9.62 ±1.79 vs. 5. 04±1. 401, P〈0. 05）, and the blood glucose level was further elevated at the time point of post-DHCA （14.91±2.36, P〈0. 01） and in-ICU （15. 32±2.47） compared with that of pre-CPB （P〈0.01）. The level of blood glucose elevation was positively correlated with blood lactate level. One hundred and thirty-four patients （76.1%） insulin was given with intravenous micropump due to poor effect of intermittent subcutaneous injection of insulin in controlling blood glucose. Among whom 30 patients （17.0%） developed the phenomenon of insulin resistance. Perioperative hyperglycemia during DHCA was associated with old age （≥50 years old）, primary hypertension, serious aortic valve disease, diabetes or coronary heart disease, emergency operation, CPB time≥3 hours and DHCA time≥45 minutes. The cumulative amount of insulin within 24 hours after surgery was increased significantly. The results of blood glucose （mmol/L） in-ICU were as follows： age≥50 years old or 〈 50 years old （18.66±2.52 vs. 12.90±2.27）; hypertension with and without （18.98 ± 2.55 vs. 12.31± 2.34） ; serious aortic valve disease with and without （19.59 ± 2.95 vs. 12.13±2.23）; diabetes with and without （20.62±1.76 vs. 11.75±1.11）; coronary heart disease with and without （19.77 ± 2.98 vs. 12.01± 2.02） ; emergency operation with and without （19.78 ±1.97 vs. 12.23±1.38） ; CPB time≥3 hours or 〈 3 hours （19.86±1.89 vs. 11.70±1.15） ; DHCA time≥45 minutes or 〈 45 minutes （19.92 ±1.88 vs. 11.64 ± 1.12）, and all of them should statistical difference （all P 〈 0.05）. The cumulative amount of insulin （U） within 24 hours after surgery was as follows： age≥50 years old or 〈 50 years old （169.5±56.6 vs. 110. 2±38.5）; hypertension with and without （171.6±64.0 vs. 104.8±34.3）; aortic valve disease with and without （171.4± 36.8 vs. 109.4± 27.6）; diabetes with and without （202.5 ±46.7 vs. 100.4 ±31.5） ; coronary heart disease with and without （178.5 ±38.6 vs. 104.6±26.4）; emergency operation with and without （178.3±35.7 vs. 102.7±26.8）; CPB time≥3 hours or 〈 3 hours （168. 6±37.2 vs. 107.3±27.5）; DHCA time≥45 minutes or 〈 45 minutes （172.5±36.1 vs. 105.4±28.7）, and all of them showed significant statistical difference （all P〈0.05）. and all of them showed significant statistical difference （all P〈0. 05）. Conclusion DHCA may cause significant increase in perioperative blood glucose and lactate, and even may lead to insulin resistance. Patients often require continuous intravenous administration of large doses of insulin. Perioperative hyperglycemia during DHCA is related to many factors, which should be considered in control of blood glucose.