术前碳水化合物对瘢痕切除术后胰岛素抵抗的影响
作者 蒲小兰 孙充洲 李丽 曾鑫 王卫华。
［摘 要］ 目的 观察术前口服碳水化合物及静脉输注葡萄糖对术后胰岛素抵抗程度的影响。 方法 择期瘢痕切除术病人60例，随机分为对照组、口服组和静注组，每组20例。术前对照组常规禁食禁饮;口服组口服12.5%碳水化合物的饮料（CHO）;静注组持续静脉输注10%葡萄糖液。分别于口服或静注前、术后6h采血，测定血糖、血清胰岛素以及红细胞胰岛素受体。 结果 处理前各组血糖、血清胰岛素、胰岛素敏感指数及红细胞胰岛素高亲和力受体、低亲和力受体无明显差异;术后6h口服组、静注组的血糖明显低于对照组，与处理前无显著差别;术后6h各组血清胰岛素无显著差别，均显著高于处理前;胰岛素敏感指数、红细胞低亲和力受体三组均较处理前显著降低，但口服组、静注组明显高于对照组;术后6h口服组、静注组红细胞高亲和力受体无明显降低;口服组与静注组间的血糖、胰岛素、胰岛素敏感指数及红细胞胰岛素受体无明显差别。 结论 术前静脉输注葡萄糖可缓解术后胰岛素抵抗的程度，术前饮用碳水化合物具有同样的效果，是一种简单有效的治疗方法。
Abstract:Objective To evaluate effect of preoperative oral carbohydrate and infusion of glucose on insulin resistance in patients after scar ec—tomy.Methods A total of60cases of elective scar ectomy were divided randomly into three groups:control group，with overnight fasting;oral group，receiving preparation with12.5%carbohydrate drink（CHO）before operation;and infusion group，continuously infused with10%glucose fluid before operation.The concentration of blood glucose and plasma insulin and insulin receptor in erythrocytes were detected before preoperative carbohydrate supplementation and at6h after operation.Results Among three groups，the concentration of blood glucose and plasma insulin，the level of insulin sensitivity index and the number of insulin receptor in erythrocytes were of no difference.Blood glucose in oral group and infusion group at6h after operation was obviously lower than that of control group，but showed no significant difference with that before preoperative carbo—hydrate supplementation.The concentration of plasma insulin at6h after operation among three groups were of no significant difference，but markedly higher than that before preoperative carbohydrate supplementation.After scar ectomy，the level of insulin sensitivity index and the number of low af—finity of erythrocyte insulin receptor in oral group and infusion group were markedly elevated as compared with control group although theywere all re—duced.And in oral group and infusion group，the number of high affinity of erthrocyte insulin receptor was of no difference with that before preopera—tive carbohydrate supplementation.The concentration of blood glucose and plasma insulin，the level of insulin sensitivity index and the number of in—sulin receptor in erythrocytes were no significant difference between oral group and infusion group.Conclusion Preoperative glucose infusion could relieve postoperative insulin resistance.Preoperative oral carbohydrate is simple and helpful to reduce postoperative insulin resistance.
Keywords:insulin resistance;carbohydrate;scar ectomy。
手术创伤后早期引起明显的胰岛素抵抗（insulin resistance，IR） ，严重IR带来的干扰已成为临床急待解决的问题，研究如何预防术后IR对于病人的术后护理和康复具有重要的意义。本研究比较了瘢痕切除术病人术前口服碳水化合物与静脉输注葡萄糖对术后胰岛素及其敏感指数（insulin sensitivity index，ISI）和红细胞胰岛素受体的影响，为寻找降低术后胰岛素抵抗的合理方法提供依据。 1 资料与方法。
1.1 一般资料。
择期瘢痕切除术病人60例，年龄6～15岁，体重18～37kg，四肢瘢痕约占1%体表面积，术前检查排除内分泌疾患，近期未用影响糖代谢和胰岛素分泌的药物，空腹血糖正常。随机分为口服组、静注组和对照组，每组20例。各组病人一般情况无明显差异。
1.2 麻醉与手术方式。
所有患者术前30min肌注阿托品0.03mg.kg、苯巴比妥钠2mg.kg。麻醉采用安定—氯胺酮诱导，术中丙泊酚4～8mg・kg —1 ・h —1 、氯胺酮2～3mg・kg—1 ・h—1 微泵输注维持麻醉深度，鼻饲持续吸氧2L.min维持SpO。
2 为99%～100%。手术采用单纯瘢痕切除缝合、瘢痕切除加腹部全厚皮片植皮、瘢痕切除加腹部皮瓣转移三种方式，手术时间70～135min，各组手术方式与时间无显著差别。
1.3 方法。
1.3.1 术前处理及标本采集。
对照组术前常规禁食禁饮;口服组在术前2h口服富含12.5%碳水化合物的饮料（CHO）10ml.kg;静注组在术前4h静脉输注10%葡萄糖液，5mg・kg—1 ・min—1 持续均匀滴入2h。分别于处理前、术后6h采血，测定血糖、血清胰岛素以及红细胞胰岛素受体。
1.3.2 血糖、血清胰岛素测定 血糖采用酶法，血清胰岛素采用放免法，按试剂盒操作说明进行测定。
1.3.3 ISI值计算。
1.3.4 红细胞胰岛素受体测定 采用放射配体结合法测定。取血5ml，使用Ficoll—Hypeque白细胞分离液分离红细胞。4℃放置30min，16000×g低温离心30min，制备红细胞膜悬液。取红细胞膜100μl分别加入不同浓度（0～100mg.L）未标记的胰岛素50μl、A14 —125 I—胰岛素50μl，加缓冲液至反应总体积300μl。4℃孵育24h，离心，弃上清后用放免测量仪测定样品放射性。通过Scatchard曲线拟合计算两种不同亲和力受体结合的胰岛素量，代表与胰岛素结合的受体数目。
1.4 统计分析。
资料用均数±标准差（ˉx±s）表示，用SPSS10.0统计软件分析，组间比较先进行方差齐性检验（按双侧α=0.05为水准），方差齐时采用单因素方差分析，方差不齐时采用F′检验，P0.05表示差异具有统计学意义。