两种不同麻醉和镇痛方法对糖耐量减低的老年高血压患者全膝置换术后糖代谢的影响

Effect of two different anesthesia and analgesia methods on glycometabolism in elderly hypertensive patients with impaired glucose tolerance following total knee arthroplasty

目的两种不同麻醉和镇痛方法对糖耐量减低的老年患者全膝置换术后糖代谢的影响。方法60例择期行全膝置换术的糖耐量减低患者随机分成腰硬联合麻醉联合术后硬膜外镇痛组(腰硬组)和全身麻醉联合术后静脉镇痛组(全麻组)各30例,分别测定入手术室后,术后30min、1、3、7d的空腹血糖和胰岛素浓度;术后10d空腹和口服糖耐量试验(OGTT)2h的血糖和胰岛素浓度,并计算相应胰岛素抵抗指数,以视觉模糊疼痛评分(VAS)评估术后1h、1、3、7d的疼痛评分,并记录围手术期相关不良事件发生率。结果腰硬组术后30min、1、3d的空腹血糖相比全麻组明显较低(均P<0.05);腰硬组在术后30min、1、3、7d的胰岛素浓度和胰岛素抵抗指数相比全麻组明显较低(均P<0.05)。腰硬组在术后1d和3d的中餐后2h血糖浓度相比全麻组明显较低(均P<0.05)。全麻组术后10d空腹、OGTT 2h的胰岛素浓度和胰岛素抵抗指数相比术前均明显升高(均P<0.05),且相比腰硬组明显更高(均P<0.05)。术后1h和术后1d腰硬组VAS评分明显小于全麻组(均P<0.05)。结论腰硬联合麻醉和硬膜外镇痛能减轻糖耐量减低的老年高血压患者的全膝置换术后糖代谢紊乱。

Objective To evaluate the effect of two different anesthesia and analgesia methods on glycometabolism in elderly hypertensive patients with impaired glucose tolerance after total knee arthroplasty. Methods Sixty elderly hypertensive patients with impaired glucose tolerance undergoing elective total knee arthroplasty were randomized into two groups： 30 patients received combined spinal-epidural anesthesia （CSEA） followed by postoperative patient-controlled epidural analgesia （CSEA group） and another 30 patients received general anesthesia （GA） followed by postoperative patient-controlled intravenous analgesia group （GA group）, respectively. Fasting plasma glucose and insulin concentrations were measured before anesthesia, 30min, 1d, 3d and 7d after operation. Fasting and oral glucose tolerance test （OGTT） 2h plasma glucose and insulin concentrations at d10 after operation were measured and insulin resistance index was calculated. The pain scores at postoperative 1h, d1, d3 and d7 were evaluated by Visual Analog Scale （VAS） and the incidence of perioperative adverse events were recorded. Results Postoperative fasting glucose levels in CSEA group were significantly lower at 30min, dl and d3 after surgery than those in GA group （P〈0.05）. The insulin concentration and insulin resistance index of CSEA group were significantly lower than those of GA group at 30min, d1, d3 and d7 after surgery（P〈0.05）. The plasma glucose levels of CSEA group in 2h after lunch were significantly lower those of GA group at the same time in dl and d3 after surgery （P〈0.05）. However, the fasting and OGTT 2h insulin concentrations and insulin resistance index at d10 after operation were significantly elevated compared with those before operation in both groups （P〈0.05）. VAS score of CSEA group was significantly lower than GA group at lh and ld after operation. Conclusion Compared to general anesthesia followed by postoperative patient-controlled intravenous analgesia, the combined spinal-epidural anesthesia followed by postoperative pat glycometabolic disorders in elderly hypertensive patients with ent-controlled epidural analgesia can more effectively improve impaired glucose tolerance after elective total knee arthroplasty.