- 期刊
手術麻醉期間的血糖控制
Perioperative and Perianesthesia Glycemic Control
摘要
手術麻醉期間的病患，不論是否有糖尿病病史，常患有高血糖，而這種情況並不只是單純反應病患在面臨壓力下的臨床表現，也會造成病患產生不良的預後，因此，血糖控制有其必要性。而實施IIT(intensive insulin therapy)，將血糖嚴格控制在80-110mg/dl，2001年由Van den Berghe等人對外科重症病人的研究顯示，可顯著的改善預後。但IIT在手術麻醉期間的實施，其研究對象多數是接受心臟手術的病人，然而在2007年，Gunjan等人的一篇前瞻性、隨機、雙盲的研究顯示，IIT應用在這群病人並無益處，反而產生一些併發症。另外，2009年NICE-SUGAR這個前瞻性、隨機、雙盲及跨國性、共收集6,104個重症病人的研究顯示，重症病人血糖值控制在140-180mg/dl，比IIT能降低死亡率及減少嚴重低血糖（血糖＜40mg/dl）的發生率。而且IIT應用在手術麻醉期間，若造成低血糖更難以被監測。因此，手術麻醉期間的血糖控制，目前並不建議實施IIT。 然而，目前關於手術麻醉期間的血糖控制，理想的目標值仍無共識。未來，必須依照不同時期（術前、術中或術後），不同病人族群（如有無糖尿病史）及不同手術方式及風險，作進一步的研究，但2009年NICE-SUGAR的研究結論，值得參考。另外，爲避免低血糖的發生，在執行控制血糖的流程時，須密集監測血糖，並且注意使用血糖機測血糖的不準確性。
並列摘要
Perioperative and perianesthesia patients often have hyperglycemia, whether or not they have history of diabetes mellitus. This kind of hyperglycemia is considered not only to be part of the physiological responses to critical illness or anesthesia but to adverse patient's outcome. In the past, most of the anesthesiologists and intensivists did not pay much attention to this phenomenon. Until 2001, doctor Van den Berghe and her colleagues studied intensive insulin therapy (IIT) to surgical critical ill patients to keep blood sugar between 80-110 mg/dL. The results showed that IIT had less mortality and morbidity. However, most studies involved in perioperative IIT focused on the cardiac surgery population. In 2007, a RCT of patients undergoing on-pump CABG applied intraoperative IIT and showed not only no reduction in perioperative morbidity and mortality but increased in the incidence of stroke and a trend toward increased mortality. In 2009, the results of NICE-SUGAR study showed that IIT increased mortality and the incidence of severe hypoglycemia among critical adult patients. Based on these clinical evidences, IIT is not recommended for perioperative and perianesthesia glycemic control at present. Currently, the ideal target for glycemic control is not known. In the future, we need more investigations focused on different periods of operation, different patient populations and different surgical risks for glycemic control. Until these investigations will been published, the results of NICE-SUGAR study could be used as reference. Besides, blood sugar should be monitored aggressively to avoid the complication of hypoglycemia.