择期全身麻醉手术禁食2型糖尿病患者围术期血糖管理分析与评价

Analysis and Evaluation of Perioperative Blood Glucose Management of Patients with Type 2 Diabetes Mellitus Underwent Fasting for Elective Surgery with General Anesthesia

目的优化2型糖尿病患者围术期的血糖管理。方法依据2016年版《围术期血糖管理专家共识》,选取2018年9月至2019年2月入住首都医科大学宣武医院普外科、泌尿外科、骨科、妇科择期行全身麻醉手术禁食的2型糖尿病患者,统计并评价其围术期降血糖治疗及血糖监测情况。结果入组患者222例。术前使用降血糖药物并于术前1 d开始禁食的160例患者中,98.12%(157/160)手术当日停用口服降血糖药物。术前服用磺脲类或格列奈类药物且术前停用时间>24 h的患者占5.00%(2/40),术前服用二甲双胍且肾功能不全的患者无1例术前停用时间>24 h。术后恢复服用二甲双胍的患者中,17.31%(9/52)恢复使用时间迟于术后48 h。禁食期间,81.08%(180/222)的患者使用添加胰岛素的含葡萄糖注射液,49.55%(110/222)的患者进行过血糖监测,其中22.73%(25/110)平均监测间隔时间≤6 h;长时间大手术,术后禁食,血糖监测结果>10 mmol/L的患者中,仅9.09%(1/11)使用静脉胰岛素泵。术中,57.75%(41/71)手术时间>2 h的患者通过动脉血气分析监测血糖,23.73%(14/59)的患者术中血糖高于10 mmol/L,均未接受降血糖治疗。未发现术后感染与禁食期间血糖达标率有显著相关性,而术后住院时间与禁食期间血糖达标率有显著相关性[B=-1.716,95%CI(-3.353,-0.079),P=0.043]。结论目前临床2型糖尿病患者围术期的血糖管理未完全达到前述共识要求,国内外指南存在一定差异,建议临床进一步加强围术期血糖精细化管理,且由一个多学科团队来共同负责,临床药师或可成为其中一员。

Objective To optimize perioperative blood glucose management in patients with type 2 diabetes mellitus(T2DM).Methods According to the Expert Consensus Statement on Perioperative Blood Glucose Management(2016 Edition),patients with T2DM underwent fasting for elective surgery with general anesthesia in the Department of General Surgery,Department of Urology,Department of Gynecology and Department of Gynecology in the Xuanwu Hospital of Capital Medical University were selected from September 2018 to February 2019,and their perioperative hypoglycemic therapy and blood glucose monitoring were evaluated.Results A total of 222 patients were enrolled in the research.Precisely 5.0%(2/40)of the patients took sulfonylureas or glinides before surgery and their preoperative withdrawal time was longer than 24 h.No patients with renal insufficiency discontinued metformin for 24 h before surgery.Among the patients who resumed taking metformin after surgery,17.31%(9/52)of patients resumed taking metformin later than 48 h after surgery.During fasting,81.08%(180/222)of patients took glucose injection with insulin,and 49.55%(110/222)of patients had blood glucose monitoring,of which 22.73%(25/110)of patients had an average monitoring interval of no longer than 6 h.Only 9.09%(1/11)of patients with long-term major surgery,postoperative fasting and blood glucose more than 10 mmol/L used intravenous insulin pump.During the surgery,57.75%(41/71)of patients with surgery time longer than 2 h were monitored by arterial blood gas,and 23.73%(14/59)of patients with intraoperative blood glucose higher than 10 mmol/L did not receive hypoglycemic treatment.There was no significant correlation between the postoperative infection and blood glucose compliance rate during fasting,but there was a significant correlation between postoperative hospital stay and blood glucose compliance rate during fasting[B=-1.716,95%CI(-3.353,-0.079),P=0.043].Conclusion At present,perioperative blood glucose management in patients with T2DM does not fully meet the requirements of consensus.There are some differences between domestic and international guidelines.It is suggested that further refined management should be strengthened and be jointly responsible by a multi-disciplinary team,and the clinical pharmacist may become a member of this team.