糖尿病患者全麻手术围手术期血糖控制

Sabiston textbook of surgery 21th edition

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In general, long-acting insulin (glargine or detemir) should be administered as scheduled during the perioperative period. Intermediate-acting insulin (NPH, zinc insulin, extended zinc insulin) should be administered at one half dose on the morning of surgery and resumed at normal dose once a normal diet has been resumed. Short-acting insulins (regular, lispro, glulisine, aspart, and proportional combinations of intermediatewith short-acting insulins such as 70/30 or 50/50) are generally held and not administered during the morning of surgery. Insulin pumps should be set to the basal infusion rate and reprogrammed to regular settings once a normal diet has been established. Inpatient endocrinology consultation is frequently helpful in the management of patients with complex insulin regimens or poor glycemic control.

Perioperative management of oral hypoglycemics also has evolved. In general, sulfonylureas (e.g., glyburide, glipizide, glimepiride, and other single-agent or combination sulfonylureas) are withheld the day of surgery. DPP-4 inhibitors (gliptins) typically are administered the morning of surgery. Administration of metformin the morning of surgery is controversial. Historical data suggested an increased risk of lactic acidosis among patients on metformin; thus, liberal withholding parameters were used. More recent data, including a Cochrane systematic review, do not corroborate this increased risk; instead, they note a number of potential benefits of continuing metformin the day of surgery including improved perioperative glucose control.

口腔外科小手术操作指南， 2nd edition

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• 手术当天停用所有口服降糖药物。术前停用口服降糖药，而停用时间取决于药物的类别：第一代磺脲类长效口服降糖药（妥拉磺脲、氯磺丙脲等）应在术前3d左右停用；第二代磺脲类药物（格列本脲、格列吡嗪，格列美脲）可在手术当天停药。但因噻唑烷二酮及二甲双胍可能会诱发乳酸中毒，所以应在术前48h停药。
• 使用胰岛素治疗的患者：手术应安排在上午；如果只采用基础胰岛素量（全天胰岛素治疗量的50%)治疗的患者，其围术期胰岛素使用剂量不变；对血糖控制较好的使用全天胰岛素治疗的患者，应将手术当天上午使用的胰岛素剂量减少一半；对于血糖控制较差的患者，术中应严密监测血糖浓度变化，并采用静脉注射胰岛素的方式控制血糖，对这类患者采用皮下注射胰岛素通常难以达到术中控制血糖的目的。
• 静脉用药应使用生理盐水而不是葡萄糖。
• 术中患者血糖浓度每隔2-3h检测1次。
• 术中应根据患者血糖浓度变化采用皮下注射胰岛素的方法调节血糖浓度。
• 一旦术后患者恢复正常进食，糖尿病的治疗方法同术前。