尼卡地平对原发性高血压患者围术期胰岛素抵抗的影响

1、尼卡地平对原发性高血压患者围术期胰岛素抵抗的影响明豫军 徐军美湘雅二医院麻醉科 410011摘 要 目的：观察原发性高血压患者围术期胰岛素敏感性的变化规律，探讨尼卡地平对原发性高血压患者围术期胰岛素抵抗的影响。 方法：择期行肺叶切除手术肺癌患者57例，ASA级，男35例，女22例，年龄4372岁，体重4571kg。继发性高血压、糖尿病、肝和肾功能衰竭予以排除。根据患者术前是否有高血压及术中是否使用尼卡地平分为三组：A组（n=20）为高血压与尼卡地平组；B组（n=18）为高血压组；C组为非高血压（n=19）。A组麻醉诱导后持续输注尼卡地平1g·kg- 1·min-1，B和C组

2、给予等量的生理盐水持续输注，直到麻醉结束，麻醉方案两组相同。记录术中平均动脉压（MAP）、心率（HR）、芬太尼与异丙酚的使用情况、脑电双频谱指数（BIS）和术后视觉模拟疼痛评分（VAS）。分别在麻醉诱导前即刻（T0）、手术结束时(T1)、术后4小时(T2)和术后24小时(T3)经颈外静脉采血3ml, 肝素抗凝后以3000r/min离心10分钟，留取血浆标本于20冷冻保存待测。用葡萄糖氧化酶法检测空腹血糖（FPG），采用放射免疫法测定血浆胰岛素（INS）。胰岛素敏感性( ISI)计算采用李光伟等介绍的方法：血糖与胰岛素乘积的倒数，再取其自然对数，即ISI = ln 1 / ( INS ×

3、;FPG) 。统计学处理：所有数据用均数±标准差（± s）表示，应用SPSS 13. 0统计软件处理。组内比较采用采用重复测量数据的方差分析，组间比较采用单因素方差分析LSD法检验。P<0.05表示有统计学意义。 结果：三组患者年龄、身高、性别比例、体重指数(BMI)、手术和麻醉时间、芬太尼和异丙酚总用量、术中BIS值和术后VAS无显著性差异。A组在麻醉诱导后MAP有所下降，但术中MAP和HR基本保持平稳；B组MAP术中较高且波动明显（P <0.05，P <0.01），而C组术中MAP和HR平稳。与T0比较：B和C组FPG、INS在T2和T3时明显升高（P

4、 <0.05，T3时INS值P<0.01），A组FPG和INS在T3时明显升高（P <0.05），A组ISI在T3时明显降低(P <0.05)，B和C组ISI在T2和T3显著降低（P <0.05，T3时P<0.01）。与B组同时相对应值比较：A组T2时FPG, T3时INS，T2和T3时ISI的差异有显著意义（P <0.05，T3时INS P<0.01）；C组各时相FPG、INS和ISI的差异有显著意义（P <0.05，T3时INS值 P<0.01）。 结论：原发性高血压病患者术前就存在胰岛素抵抗，肺叶切除术后胰岛素抵抗更加明显。术中

5、持续输注尼卡地平1g·kg- 1·min-1可以改善原发性高血压患者围术期胰岛素抵抗。 关键词：原发性高血压，胰岛素抵抗，血糖，血浆胰岛素，胰岛素敏感指数，尼卡地平，肺叶切除术1硕士学位论文 英文摘要The Effect of Nicardipine on Perioperative Insulin Resistance in Patients with Essential HypertensionAbstract Objective:To investigate the changes of insulin sensitivity and explore the effe

6、ct of nicardipine on insulin resistance in patients with essential hypertension(EH) during peri-operation. Methods: Fifty-seven ASA I or II patients aged 43-72 yrs,weighing 45-71 kg undergoing lobectomy for lung cancer ,which had no signs of Secondary Hypertension, Diabetes Mellitus,liver function f

7、ailure and renal failure , were devidedinto three groups: group A (n=20, Essential Hypertension and Nicardipine) , group B (n=19 , Essential Hypertension), group C (n=18 , without Essential Hypertension).IN group A nicardipin 1g·kg- 1·min-1 was infused continuously after induction of anest

8、hesia while in B and C groups normal saline was infused instead of nicardipin. MAP,HR,BIS,VAS and accumulated dose of Fentanly and propofol were recored.Venous blood samples were obtained immediately before induction of anesthesia (T0,baseline) ,at the end of surgery(T1),4h(T2) and 24h(T3) after the

9、 end of operation for determination of the concentrations of fasting plasma glucose(GOD-PAP) and insulin(radio-immunoassay). The value of ISI was determined with the formula introduced by Li Guangwei which calculate the value of ISI with the follow formula:ISI = ln1/(INS×FPG).Statistics treatme

10、nt:The measurement data was expressed as “s”, and using REPEATED MEASUREMENT ANOVA program and One-Way ANOVA program of SPSS 13.0 software to analyze it.when the value of “p” is lower than 0.05,it has significance. Results: The age,body height,body weight,value of BMI,operation and anesthesia time,a

11、ccumulated dose of Fentanly and propofol ,value of BIS and VAS had no significant difference in three groups（P >0.05）. MAP decreased in group A after induction of anesthesia,but MAP and HR almost maintenancd steadily during operation; MAP in group B was higher and the change was obvious（P <0.0

12、5，P <0.05）.MAP and HR in group C was steady.The concentrations of FPG and INS at T2 and T3 increased significantly compared to baseline(T0) in groups B and C than that in group A (P<0.05,INS at T3 P < 0.01) . The concentrations of FPG and INS at T3 was significantly higher in group A than t

13、hat at baseline(T0) ( P<0.05).The value of ISI at T3 was lower in group A compared to baseline(T0)( P<0.05) and at T2 and T3 was significantly lower in groups B and C compared to baseline(T0)( P<0.05, at T3 P < 0.01). The concentrations of FPG at T2 and INS at T3 and ISI at T2 and T3 inc

14、reased significantly in group A than that in group B (P<0.05, INS at T3 P < 0.01) .The concentrations of FPG,INS and ISI at all times increased significantly in group C than that in group B (P<0.05, INS at T3 P < 0.01). Conclusion:Patients with Essential Hypertension have insulin resistance before anesthesia induction,and developed significant increasing of insulin resistance on the first pstoperative day,nicardipine can improve the insulin resistan