术前口服碳水化合物对冠状动脉搭桥术患者心理及胰岛素敏感性影响
|
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4.01
mU.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。
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 in
vestigate 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 investigate
the 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
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4.01
mU.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。
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 in
vestigate 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 investigate
the 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
引文
1．邓尚平主编．临床糖尿病学[M]．第一版．成都：四川科学技术出版社，1999．30-31．
2．朱禧星主编．现代糖尿病学[M]．第一版．上海：上海医科大学出版社，2000，395-396．
3．朱禧星主编．现代糖尿病学[M]．第一版．上海：上海医科大学出版社，2000．174-175．
4. Ljungqvist Olle, NygrenJonas, Thorell Anders. Insulin resistance and elective surgery[J]. Surgery, 2000, 128(5): 757-760.
5. Thorell A, Nygren J, Essen P, et al. The metabolic response to cholecystectomy: insulin resistance after open compared to laparoscopic operation[J]. Eur J Surg, 1996, 162: 187-191.
6. Nygren Jonas, Thorell Anders, Suad Efendic, et al. Site of insulin resistance after surgery: the contribution of hypocaloric nutrition and bed rest[J]. Cli Sci, 1997, 93: 137-146.
7．姚尚龙，王明玲．预防误吸与麻醉前禁食新观念[J]．中华麻醉学杂志，2000，20：255-256．
8. Brandi L S, Frediani M, Oleggini M, et al. Insulin resistance after surgery: normalization by insulin treatment [J]. Cli Sci, 1990, 70: 443-450.
9. Thorell A, Efendic S, Gutniak A ThM, et al. Insulin Resistance after abdominal surgery[J]. Br J Surg, 1994, 81: 59-63.
10. Thorell A, Efendic S, Gutuiak M, et al. Development of postoperative insulin resistance is associated with the magnitude of operation[J]. Eur J Surg, 1993, 159: 593-599.
11. Kehlet H. Multimodal apporoach to control postoperative patho_(pH)ysilogy and rehabilitation[J]. Br J Anaest, 1997, 78(5):606-617.
12. Bardram L, Funch-Jeusen P, Jensen P, et al. Recovery after laparoscopic colonic surgery with epidural analgesia and early oral induction and mobilization[J]. Lancet, 1995, 345: 763-764.
13. Moiniche S, Biilow S, Hesselfeldt P, et al. Convalescence and hospital stay after colonic surgery with balanced analgesia, early oral feed and enforced mobilization[J]. Eur J Surg, 1995,161: 283-288.
14. Chernow Bart, Alexander H Richard, Robert C. Smallridge. Hormonal responses to graded surgical stress[J]. Arch Intern Med, 1987, 147: 1273-1278.
15. Thorell A, Loftenius A, Andersson B and Ljungqvist O. Postoperative insulin resistance and circulating concentrations of stress hormones and cytokines[J]. Cli Nutr, 1996, 15: 75-79.
16. Nygren J, Soop M, Thorell A, Efendic S, et al. Preoperative oral carbohydrate administration reduces postoperative insulin resistance[J]. Cli Nutr, 1998, 17: 65-71.
17. Hernandez C, Simo R, Chacon P, Sabin P, et al. Influence of surgical stress and parental nutrition on serum leptin concentration[J]. Cli Nutr, 2000, 19(1): 61-64.
18. Ljungqvist O, Thorell A, Gutniak M, et al. Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance[J]. J Am Coll Surg, 1994, 178: 319-326.
19. Nygren Jonas O, Thorell Anders, Soop Mattias, et al. Preoperative insulin and glucose infusion maintains normal insulin sensitivity after surgery[J]. AJP Endocrinology Metabolism, 1998, 275(1): E140-148.
20. Nygren J, Thorell A, Lagercranser M, et al. Safety and patient well-being after preoperative oral intake carbohydrate rich beverage[J]. Clin Nutr, 1996, 16(Suppl): 28.
21. Hausel Jonatan, Nygren Jonas, Lagerkranser Michael, et al. A Carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients[J]. Anesth Analg, 2001, 93: 1334-1350.
22．安友仲，祝学光，杜如昱，等．创伤后早期神经内分泌改变与应激性高血糖[J]．北京医科大学学报，1997，29(4)：362-363．
23．黑飞龙，房秀生．围体外循环期应激激素及胰岛素抵抗的研究[J]．中华心胸血管外科杂志，1999，15(5)：301-302．
24．黑飞龙，房秀生．体外循环心内手术对胰腺细胞功能影响[J]．中华麻醉学杂志，1997，17(12)：711-712．
25．管玉龙，董培青，潘玉春，等．冠状动脉搭桥围手术期糖代谢的变化研究[J]．中华外科杂志，1999，37(11)：703．
26．李秀钧主编．胰岛素抵抗综合征[M]．第一版．北京：人民卫生出版社，2001．84-85．
27．李秀钧主编．胰岛素抵抗综合征[M]．第一版．北京：人民卫生出版社，2001．58-80．
28．钱荣立，杨泽，佟之复主编．21世纪的糖尿病防治[M]．第一版．郑州：河南医科大学出版社，2000．68-69．
29．景华主编．实用外科重症监护与治疗[M]。第一版．上海：第二军医大学出版社，1999．452-453．
30．贾恩志，陈士伟，戚光跃等．胰岛素抵抗与心血管危险因素聚集的流行病学研究[J]．中华医学杂志，2002，82(17)：1183-1186．
31．田声放，李常贵，康维强等．冠心病患者冠状动脉与糖耐量变化的关系[J]．中华内分泌代谢杂志，2002，18(4)：289-292．
32．汪向东，王希林，马弘主编．心理卫生评定量表手册[M]．增订版．北京：中国心理卫生杂志社，1999．238-241．
33. Christo_(pH) H Kkindler, Christo_(pH) Harms, Felix Amsler, et al. The Visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns[J]. Anesth Analg, 2000,90:700-712.
34. Zeev N. Kain, Linda C. Mayes, Domenic V, Cicchetti, et al. The YALE preoperative anxiety scale: how does it compare with a "gold standard"?[J]. Anesth Analg, 1997,85: 783-788.
35．孙振球，徐勇勇主编．医学统计学[M]．第一版．北京：人民卫生出版社，2002．485-495．
36．张海兰，催永武，刘苏．手术前禁食新观念[J]．中华护理杂志，2002，37(2)：159-160．
37. Fasting S, Soreide E, Raeder J C. Changing preoperative fasting policies, impact of a national consensus[J]. Acta Anaesthesiol Scand, 1998, 42: 1188-1191.
38. L.I. Eriksson, R. Sandin. Fasting Guidelines in different countries[J]. Acta Anaesthesiol Scand, 1996,40: 971-974.
39. Ljungqvist O, Nygren J, Thorell A, et al. Preoperative nutrition-elective surgery in the fed or the overnight fasted state[J]. Cli Nutr 2001, 20(supplement 1): 167-171.
40. Molly Mcmahon, Harold Marsh and Robert Rizza. Comparison of pattern of postprandial carbohydrate metabolism after ingestion of a glucose drink or mixed meal[J]. J Clin Endocrinol Metab, 1989, 68: 647-653.
41. Nygren Jonas, Thorell Anders, Jacobsson Hans, et al. Preoperative gastric emptying effect of anxiety and oral carbohydrate administration[J]. Annals Surgery, 1995, 222: 728-734.
42. Gutniak M, Grill V, Efendic S. Effect of composition of mixed meal low versus high-carbohydrate content-on insulin, glucagon and somatostatin release in healthy humans and patients with NIDDM[J]. Diabetes Care, 1986, 9: 224-249.
43．孙振球，徐勇勇主编．医学统计学[M]．第一版．北京：人民卫生出版社，2002．200-210．
44．刘润幸主编．SPSS 10.0医学统计方法与应用[M]，下册．高级统计[M]．第一版．广州：广东人民出版社，2001．1-13．
45．黑飞龙，龙村，房秀生．葡萄糖-胰岛素-氯化钾对体外循环内分泌、代谢及胰岛素抵抗的防治作用[J]．中华实验外科杂志，2000，17(6)：499-500．
46. Luigi S Brandi, Donatella Santoro, Andrea Natali, et al. Insulin resistance of stress: sites and mechanisms[J]. Cli Sci, 1993,85: 525-535.
47． Mark A Chaney, Mihail P Nikolov, Bradford P Blakeman, et al. Attempting to maintain normoglycemia during cardiopulmonary bypass with insulin may initiate postoperative hypoglycemia [J]. Anaesth Analg, 1999, 89: 1091-1095．
48． Crow P, Dennision A and Royle G. The effect of preoperative glucose loading on postoperative nitrogen metabolism [J]. Br J Surg, 1984, 71: 635-637．
49． Nygren Jonas, Thorell Anders and Ljunqvist Olle. Preoperative oral carbohydrate nutrition: an update [J]. Curr Opin Nutr Meta Care, 2001, 4: 255-259．
50． Hausel J, Nygren J, Almstrom C, et al. Preoperative oral carbohydrates improve well being after elective colorecctal surgery [J]. Clin Nutr, 1999, 18(Suppl): 80．
51． Nygren J, Soop M, Thorell A, Efendic S, et al. Preoperative oral carbohydrate administration reduces postoperative insulin resistance [J]. Cli Nutr, 1999, 17: 65-71．
52． Soop Mattias, Nygren Jonas, Myrenfors Perter. et al. preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance [J]. Am J PHysiol Endocrinol Metab, 2001, 280: E576-583．
53． Henriksen M, Hansen H, Dela F, et al. Preoperative feeding might improve postoperative voluntary muscle function [J]. Clin Nutr, 1999, 18(Suppl): 82．
54． Nygren J, Soop M, Thorell A, et al. Preoperative oral carbohydrates and postoperative insulin resistance [J]. Clin Nutr, 1999, 18(2) : 117-120．
55． 朱禧星主编．现代糖尿病学[M]．第一版．上海：上海医科大学出版社， 2000． 160-161．
56． Bang Peter, Nygren Jonas, Carlsson-Skwirut Christine, et al. Post-operative induction of insulin-like growth factor binding protein-3 proteolytiv activity: relation to insulin and insulin sensitivity [J]. J Clin Endocrion Metab, 1998, 83: 2509-2515．
57． Thorell A, Nygren J, Hirshman M F. Surgery induced insulin resistance in human patients: relation to glucose transport and utilization [J]. AJP Endorinology and metabolism, 1999, 276(4) : E754-761．
58． Nygren J, Sammann M, Malm M, et al. Distributed anabolic hormonal pattens in burned patients: the relation to glucagon [J]. Clin Endocrinol (oxf), 1995, 43: 491-450．
59． Skjaerbaek C, Frystyk J, Orskov H, et al. Differential change in free and total insulin-like growth factor-1 after major, elective abdominal surgery: the possible role of insulin-like
growth factor-binding protein-3 proteolysis [J], J Clin Endovrinal Metab, 1992, 74: 177-183．
60． Timmins A C, Cotterill A M, Hughes S C. Critical illness is associated with low circulating concentration of insulin like growth factors-1 and 2, alterations insulin like growth factor binding proteins, and induction of an insulin like growth factor binding protein-3 protease [J]. Crit Care Med, 1996, 24: 1406-1466．
61． Nygren J, Carlsson-skwirut C, Brismar K, et al. Insulin infusion increases levels of free IGF-1 and IGFBP-3 proteolytic activity in patients after surgery [J]. Am J PHysiol Endocrinol Metab, 2001, 281: E736-741．
2．朱禧星主编．现代糖尿病学[M]．第一版．上海：上海医科大学出版社，2000，395-396．
3．朱禧星主编．现代糖尿病学[M]．第一版．上海：上海医科大学出版社，2000．174-175．
4. Ljungqvist Olle, NygrenJonas, Thorell Anders. Insulin resistance and elective surgery[J]. Surgery, 2000, 128(5): 757-760.
5. Thorell A, Nygren J, Essen P, et al. The metabolic response to cholecystectomy: insulin resistance after open compared to laparoscopic operation[J]. Eur J Surg, 1996, 162: 187-191.
6. Nygren Jonas, Thorell Anders, Suad Efendic, et al. Site of insulin resistance after surgery: the contribution of hypocaloric nutrition and bed rest[J]. Cli Sci, 1997, 93: 137-146.
7．姚尚龙，王明玲．预防误吸与麻醉前禁食新观念[J]．中华麻醉学杂志，2000，20：255-256．
8. Brandi L S, Frediani M, Oleggini M, et al. Insulin resistance after surgery: normalization by insulin treatment [J]. Cli Sci, 1990, 70: 443-450.
9. Thorell A, Efendic S, Gutniak A ThM, et al. Insulin Resistance after abdominal surgery[J]. Br J Surg, 1994, 81: 59-63.
10. Thorell A, Efendic S, Gutuiak M, et al. Development of postoperative insulin resistance is associated with the magnitude of operation[J]. Eur J Surg, 1993, 159: 593-599.
11. Kehlet H. Multimodal apporoach to control postoperative patho_(pH)ysilogy and rehabilitation[J]. Br J Anaest, 1997, 78(5):606-617.
12. Bardram L, Funch-Jeusen P, Jensen P, et al. Recovery after laparoscopic colonic surgery with epidural analgesia and early oral induction and mobilization[J]. Lancet, 1995, 345: 763-764.
13. Moiniche S, Biilow S, Hesselfeldt P, et al. Convalescence and hospital stay after colonic surgery with balanced analgesia, early oral feed and enforced mobilization[J]. Eur J Surg, 1995,161: 283-288.
14. Chernow Bart, Alexander H Richard, Robert C. Smallridge. Hormonal responses to graded surgical stress[J]. Arch Intern Med, 1987, 147: 1273-1278.
15. Thorell A, Loftenius A, Andersson B and Ljungqvist O. Postoperative insulin resistance and circulating concentrations of stress hormones and cytokines[J]. Cli Nutr, 1996, 15: 75-79.
16. Nygren J, Soop M, Thorell A, Efendic S, et al. Preoperative oral carbohydrate administration reduces postoperative insulin resistance[J]. Cli Nutr, 1998, 17: 65-71.
17. Hernandez C, Simo R, Chacon P, Sabin P, et al. Influence of surgical stress and parental nutrition on serum leptin concentration[J]. Cli Nutr, 2000, 19(1): 61-64.
18. Ljungqvist O, Thorell A, Gutniak M, et al. Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance[J]. J Am Coll Surg, 1994, 178: 319-326.
19. Nygren Jonas O, Thorell Anders, Soop Mattias, et al. Preoperative insulin and glucose infusion maintains normal insulin sensitivity after surgery[J]. AJP Endocrinology Metabolism, 1998, 275(1): E140-148.
20. Nygren J, Thorell A, Lagercranser M, et al. Safety and patient well-being after preoperative oral intake carbohydrate rich beverage[J]. Clin Nutr, 1996, 16(Suppl): 28.
21. Hausel Jonatan, Nygren Jonas, Lagerkranser Michael, et al. A Carbohydrate-rich drink reduces preoperative discomfort in elective surgery patients[J]. Anesth Analg, 2001, 93: 1334-1350.
22．安友仲，祝学光，杜如昱，等．创伤后早期神经内分泌改变与应激性高血糖[J]．北京医科大学学报，1997，29(4)：362-363．
23．黑飞龙，房秀生．围体外循环期应激激素及胰岛素抵抗的研究[J]．中华心胸血管外科杂志，1999，15(5)：301-302．
24．黑飞龙，房秀生．体外循环心内手术对胰腺细胞功能影响[J]．中华麻醉学杂志，1997，17(12)：711-712．
25．管玉龙，董培青，潘玉春，等．冠状动脉搭桥围手术期糖代谢的变化研究[J]．中华外科杂志，1999，37(11)：703．
26．李秀钧主编．胰岛素抵抗综合征[M]．第一版．北京：人民卫生出版社，2001．84-85．
27．李秀钧主编．胰岛素抵抗综合征[M]．第一版．北京：人民卫生出版社，2001．58-80．
28．钱荣立，杨泽，佟之复主编．21世纪的糖尿病防治[M]．第一版．郑州：河南医科大学出版社，2000．68-69．
29．景华主编．实用外科重症监护与治疗[M]。第一版．上海：第二军医大学出版社，1999．452-453．
30．贾恩志，陈士伟，戚光跃等．胰岛素抵抗与心血管危险因素聚集的流行病学研究[J]．中华医学杂志，2002，82(17)：1183-1186．
31．田声放，李常贵，康维强等．冠心病患者冠状动脉与糖耐量变化的关系[J]．中华内分泌代谢杂志，2002，18(4)：289-292．
32．汪向东，王希林，马弘主编．心理卫生评定量表手册[M]．增订版．北京：中国心理卫生杂志社，1999．238-241．
33. Christo_(pH) H Kkindler, Christo_(pH) Harms, Felix Amsler, et al. The Visual analog scale allows effective measurement of preoperative anxiety and detection of patients' anesthetic concerns[J]. Anesth Analg, 2000,90:700-712.
34. Zeev N. Kain, Linda C. Mayes, Domenic V, Cicchetti, et al. The YALE preoperative anxiety scale: how does it compare with a "gold standard"?[J]. Anesth Analg, 1997,85: 783-788.
35．孙振球，徐勇勇主编．医学统计学[M]．第一版．北京：人民卫生出版社，2002．485-495．
36．张海兰，催永武，刘苏．手术前禁食新观念[J]．中华护理杂志，2002，37(2)：159-160．
37. Fasting S, Soreide E, Raeder J C. Changing preoperative fasting policies, impact of a national consensus[J]. Acta Anaesthesiol Scand, 1998, 42: 1188-1191.
38. L.I. Eriksson, R. Sandin. Fasting Guidelines in different countries[J]. Acta Anaesthesiol Scand, 1996,40: 971-974.
39. Ljungqvist O, Nygren J, Thorell A, et al. Preoperative nutrition-elective surgery in the fed or the overnight fasted state[J]. Cli Nutr 2001, 20(supplement 1): 167-171.
40. Molly Mcmahon, Harold Marsh and Robert Rizza. Comparison of pattern of postprandial carbohydrate metabolism after ingestion of a glucose drink or mixed meal[J]. J Clin Endocrinol Metab, 1989, 68: 647-653.
41. Nygren Jonas, Thorell Anders, Jacobsson Hans, et al. Preoperative gastric emptying effect of anxiety and oral carbohydrate administration[J]. Annals Surgery, 1995, 222: 728-734.
42. Gutniak M, Grill V, Efendic S. Effect of composition of mixed meal low versus high-carbohydrate content-on insulin, glucagon and somatostatin release in healthy humans and patients with NIDDM[J]. Diabetes Care, 1986, 9: 224-249.
43．孙振球，徐勇勇主编．医学统计学[M]．第一版．北京：人民卫生出版社，2002．200-210．
44．刘润幸主编．SPSS 10.0医学统计方法与应用[M]，下册．高级统计[M]．第一版．广州：广东人民出版社，2001．1-13．
45．黑飞龙，龙村，房秀生．葡萄糖-胰岛素-氯化钾对体外循环内分泌、代谢及胰岛素抵抗的防治作用[J]．中华实验外科杂志，2000，17(6)：499-500．
46. Luigi S Brandi, Donatella Santoro, Andrea Natali, et al. Insulin resistance of stress: sites and mechanisms[J]. Cli Sci, 1993,85: 525-535.
47． Mark A Chaney, Mihail P Nikolov, Bradford P Blakeman, et al. Attempting to maintain normoglycemia during cardiopulmonary bypass with insulin may initiate postoperative hypoglycemia [J]. Anaesth Analg, 1999, 89: 1091-1095．
48． Crow P, Dennision A and Royle G. The effect of preoperative glucose loading on postoperative nitrogen metabolism [J]. Br J Surg, 1984, 71: 635-637．
49． Nygren Jonas, Thorell Anders and Ljunqvist Olle. Preoperative oral carbohydrate nutrition: an update [J]. Curr Opin Nutr Meta Care, 2001, 4: 255-259．
50． Hausel J, Nygren J, Almstrom C, et al. Preoperative oral carbohydrates improve well being after elective colorecctal surgery [J]. Clin Nutr, 1999, 18(Suppl): 80．
51． Nygren J, Soop M, Thorell A, Efendic S, et al. Preoperative oral carbohydrate administration reduces postoperative insulin resistance [J]. Cli Nutr, 1999, 17: 65-71．
52． Soop Mattias, Nygren Jonas, Myrenfors Perter. et al. preoperative oral carbohydrate treatment attenuates immediate postoperative insulin resistance [J]. Am J PHysiol Endocrinol Metab, 2001, 280: E576-583．
53． Henriksen M, Hansen H, Dela F, et al. Preoperative feeding might improve postoperative voluntary muscle function [J]. Clin Nutr, 1999, 18(Suppl): 82．
54． Nygren J, Soop M, Thorell A, et al. Preoperative oral carbohydrates and postoperative insulin resistance [J]. Clin Nutr, 1999, 18(2) : 117-120．
55． 朱禧星主编．现代糖尿病学[M]．第一版．上海：上海医科大学出版社， 2000． 160-161．
56． Bang Peter, Nygren Jonas, Carlsson-Skwirut Christine, et al. Post-operative induction of insulin-like growth factor binding protein-3 proteolytiv activity: relation to insulin and insulin sensitivity [J]. J Clin Endocrion Metab, 1998, 83: 2509-2515．
57． Thorell A, Nygren J, Hirshman M F. Surgery induced insulin resistance in human patients: relation to glucose transport and utilization [J]. AJP Endorinology and metabolism, 1999, 276(4) : E754-761．
58． Nygren J, Sammann M, Malm M, et al. Distributed anabolic hormonal pattens in burned patients: the relation to glucagon [J]. Clin Endocrinol (oxf), 1995, 43: 491-450．
59． Skjaerbaek C, Frystyk J, Orskov H, et al. Differential change in free and total insulin-like growth factor-1 after major, elective abdominal surgery: the possible role of insulin-like
growth factor-binding protein-3 proteolysis [J], J Clin Endovrinal Metab, 1992, 74: 177-183．
60． Timmins A C, Cotterill A M, Hughes S C. Critical illness is associated with low circulating concentration of insulin like growth factors-1 and 2, alterations insulin like growth factor binding proteins, and induction of an insulin like growth factor binding protein-3 protease [J]. Crit Care Med, 1996, 24: 1406-1466．
61． Nygren J, Carlsson-skwirut C, Brismar K, et al. Insulin infusion increases levels of free IGF-1 and IGFBP-3 proteolytic activity in patients after surgery [J]. Am J PHysiol Endocrinol Metab, 2001, 281: E736-741．