【作者】 窦昊颖；

【导师】 刘纯艳； 张鹏；

【作者基本信息】 天津医科大学 ， 护理学， 2003， 硕士

【摘要】 手术应激使患者体内肾上腺素、胰高血糖素和生长激素等应激激素分泌增加，从而导致胰岛素的靶细胞对胰岛素的敏感性(Insulin Sensibility，IS)下降，即产生术后胰岛素抵抗(Insulin Resistance，IR)。因此，非糖尿病患者在择期手术中会出现高血糖和高胰岛素血症，其反应类似Ⅱ型糖尿病。另外，传统的术前禁食水(Nothing Per-os，NPO)不仅会引起患者饥饿和口渴等诸多不适，还可加重患者的应激反应，从而促使患者术后IS降低。然而，临床工作者大多未认识到NPO对患者心理及IS的影响，对如何预防术后IR的研究更是少有报导，这正是本文要探讨的问题。 目的 1)验证视觉模拟量表(Visual Analog Scales，VAS)是否可用于评估NPO引起的不适。2)NPO和冠状动脉搭桥术(Coronary Artery Bypass Grafting，CABG)对患者心理及IS的影响。3)术前口服碳水化合物对CABG患者心理及术后IS的影响，从而为建立新的NPO制度提供实验依据。 方法 首先将拟进行手术的33名心胸外科患者分别用状态焦虑问卷(State Anxiety Inventory，SAI)和VAS进行调查，用SAI对VAS进行信度及效度检验。然后将30例拟行CABG的患者随机分为两组。实验组患者术前晚6点进流质，术前晚7～8点间饮用16.7％葡萄糖水溶液(100克葡萄糖)600ml，术日晨零时起禁水，但手术前3小时再饮用300ml葡萄糖水溶液(50克葡萄糖)。对照组患者术前晚6点进流质后禁食，术日晨零时起禁水。用VAS评估NPO和饮用碳水化合物对患者术日晨的心理影响。同时，用放免法和氧化法测定患者入院、术前、术中及术后各时段的血胰岛素(Blood Insulin，BI)和血糖(Blood Glucose，BG)浓度。 结果VAS重测相关系数厂=0.98且p<0.01。VAS与SAI的相关系数二=0.87，且p<0.01。用VAS判定SAI效率为76%。 患者术晨SAI评分，实验组为36.13士3.04，对照组为39.53士5.45护<0.05)。患者术晨VAS评分，实验组为6.63士3.99，对照组为n.33士4.52(尸<0.05)。实验组患者较对照组相比，饥饿感和口渴感减轻，但恶心感增加(P<0.05)。 对照组麻醉诱导时BG为4.13士0. 51 Inlnol.L一，，从肝素化时BG开始升高，于术后24小时达到高峰(8 .45士0.46 mlnol一‘)，至术后第7天降至5.46士0.36 min01.L一，。而实验组麻醉诱导时BG为5.10士0.56 001一，;关胸时BG才开始升高，术后24小时BG达到高峰(9 .16士2.23 Inmol一‘)，术后第7天降至5.51士0.46 nunol·L一，。 对照组术晨BI为8.93士4.12 mU.L一‘，麻醉诱导时BI为8.26士4.01mU.L一，，术后24小时达到高峰(36.05士20.44 mU一‘)，术后第7天降至11.30士3.83 mU·L一，。而实验组在术晨Bl为12.71士4.49 mU·L一，，麻醉诱导时为11.39士3.72mU·L一‘，术后24小时升至44.18士14.48 mU·L一‘，术后第7天降至14.59士2.32 mu·L一，。 实验组术后1小时Is较入院时降低了20.91%，对照组则降低了47.01%。术后24小时两组IS均下降了约81%。术后第7天时两组均恢复正常。 结论VAS不仅精度高，而且稳定可靠。另外，VAS有与SAI相似的平行效度。所以，VAS可以用于评估术前不适。 术前饮用碳水化合物，不仅可减轻患者术晨焦虑和紧张，而且还能缓解NPO引起的口渴和饥饿感。同时，术前饮用碳水化合物也未引起患者吸入性肺炎，所以术前3小时饮用16.7%的葡萄糖水溶液300ml是有效而安全的。 NPO使以BG患者血糖和血胰岛素浓度降低，术前饮入碳水化合物可以使以BG患者术日晨及麻醉诱导时血糖和血胰岛素浓度维持正常。 禁食的CABG患者术中即出现血糖升高，至术后24小时达到高峰，术后第7天仍未恢复正常。而血胰岛素术后1小时开始升高，术后24小时达到高峰，术后第7天恢复正常。 术前饮入碳水化合物可延迟CABG患者血糖和血胰岛素浓度升高，但不能减轻术后24小时血糖和血胰岛素升高的幅度，以及缩短术后高血糖和高血胰岛素维持的时间。 禁食的CABG患者术后1小时IS开始降低，术后24降至低谷，术后第7天时恢复至入院时水平。术前饮入碳水化合物可减缓CABG患者术后1小时的工S降低，但不能减轻手术后24小时IS降低，也不能缩短术后IS降低持续的时间。更多还原

【Abstract】 Surgical stress induces the release of stress hormones, such as catecholamines, glucagon and growth hormone, and is the development of insulin resistance (IR) after operation. It usually results in a reduction of the insulin sensitivity (IS) and a compensatory increase of insulin release. Therefore, symptoms of elevated levels of blood glucose and insulin, just like a state of metabolism similar to non-insulin-dependent diabetes mellitus, can appear for patients who do not suffer from diabetes mellitus during elective surgery. In addition, the overnight preoperative fasting (Nothing per-os, NPO) has not only impaired to attenuate the preoperative discomfort, for instance, hunger, thirst and anxiety, but added to the serious reduction of IS as well. However, most of the clinical colleagues fail to realize the effect of NPO on the psychology and IS of the patients, and there was rarely administration of preoperative oral liquid in order to prevent IR after surgery in China. The objective of this study is to investigate the effect of preoperative oral carbohydrate treatment on psychology and insulin sensitivity of patients undergoing coronary artery bypass grafting surgery (CABG).Objective 1) To evaluate the validity and utility of the visual analog scales (VAS) to measure preoperative discomfort, compared with the standard State Anxiety Inventory (SAI). 2) To investigatethe effect of NPO and elective CABG on the patients’ psychology and IS. 3) To evaluate the effect of treating patients with carbohydrate drink at some time before surgery on the psychology and IS in comparison with NPO.Methods A total of 33 consecutive adult patients scheduled for elective cardiothoracic surgery were firstly included in the study. They were scored with VAS and SAI respectively, and SAI was employed to examine the validity and utility of VAS.Then, thirty else patients who were about to undergo elective CABG surgery were randomly assigned two preoperative treating groups with equal size: one preparing with oral glucose (G), and another fasting from midnight till surgery (F). In both two groups, there was food restriction after the last meal at six o’clock the night before the operation. However, during the evening before surgery, each patient in the G group was allowed to consume extra 600 ml of a glucose-rich drink (16.7% glucose). Besides, the same drink of 300 ml was respectively taken drink at least 3 hours (h) before surgery in the patients of G group. All patients of the two groups were scored their subjective sense of anxiety and discomfort with SAI and VAS on the following different occasions: 1) the day after hospitalization, 2) the day before surgery, 3) 2 h before surgery.Venous blood samples were drawn from each group on different points during the operation. The times of sampling were: 1) the day after hospitalization, 2) the day before surgery, 3) the morning of surgery, 4) induction of anesthesia, 5) giving heparin, 6) closure of thorax cavity, 7) 1 and 24 h after surgery, 8) 2, 3 and 7 days (d) after surgery. At each sampling time, approximately 3 ml of blood was collected for subsequently analysis of blood glucose and insulin.Blood glucose was immediately measured with glucose oxidase method. Then, all samples were rapidly centrifuged for 10 minutes at 3000g. The supernatants were stored at -70 癈 before batch analysis of insulin. Serum insulin was determined using radioimmunoassay method with an antibody.Results In this study, a high test-retest reliability assessed by the correlation was found (r = 0.98, P <0.01). There was also a significant correlation between SAI and VAS (r = 0.87, P < 0.01). Cmpared with SAI, a high level of face validity in VAS of 76% was accepted.The mean SAI score was significantly lower in G group than in F group (36.13 + 3.04 versus 39.53 + 5.45, t = 2.11, P = 0.04) . This was also observed on the mean VAS score (6.63+4.52 versus 11.33 + 3.99, t - 3.02, P = 0.01). In contrast to the fasted patients, the drink-treating group showed greatly decreasing trends for更多还原