（翻译）2015AAGBI糖尿病患者围手术期管理

Guidelines

Peri-operative management of the surgical patient with diabetes2015 Association of Anaesthetists of Great Britain and Ireland 2015AAGBI糖尿病患者围手术期管理 英国和爱尔兰麻醉医师协会

Membership of the Working Party: P. Barker, P. E. Creasey, K. Dhatariya,1 N. Levy, A. Lipp,2 M. H. Nathanson (Chair), N. Penfold,3 B. Watson and T. Woodcock 1 Joint British Diabetes Societies Inpatient Care Group 2 British Association of Day Surgery 3 Royal College of Anaesthetists

Summary

Diabetes affects 10–15% of the surgical population and patients with diabetes undergoing surgery have greater complication rates, mortality rates and length of hospital stay. Modern management of the surgical patient with diabetes focuses on: thorough pre-operative assessment and optimisation of their diabetes (as defined by a HbA1c < 69 mmol.mol1); deciding if the patient can be managed by simple manipulation of pre-existing treatment during

a short starvation period (maximum of one missed meal) rather than use of a variable-rate intravenous insulin infusion; and safe use of the latter when it is the only option, for example in emergency patients, patients expected not to return to a normal diet immediately postoperatively, and patients with poorly controlled diabetes. In addition, it is imperative that communication amongst healthcare professionals and between them and the patient is accurate and well informed at all times. Most patients with diabetes have many years of experience of managing their own care. The purpose of this guideline is to provide detailed guidance on the peri-operative management of the surgical patient with diabetes that is specific to anaesthetists and to ensure that all current national guidance is concordant. 摘要

糖尿病影响着近10% ~ 15% 的手术患者，并且，接受外科手术的糖尿病患者的手术并发症发生率、死亡率和住院天数都相对较高。现代的针对伴有糖尿病的手术患者的管理重点是：通过术前评估和对糖尿病病情的强化管理（糖化血红蛋白 ＜ 69 mmol.mol-1）；如果患者可以简单地采用之前既有的调整方案加之一定的饮食控制就能管理好血糖水平，就不要采取 可调节的胰岛素静脉输注；当后者是唯一选择需要使用时要注意安全性，例如急诊患者、手术后预期不能马上恢复正常饮食的患者、糖尿病控制很差的患者等。另外，医疗保健专业人员之间以及和患者之间的沟通准确是当务之急，整个过程都需要沟通顺畅。大多数糖尿病患者都有多年的对自己血糖的管理经验了，本指南的目的是对糖尿病患者围手术期处理提供详细的指导，这对麻醉师很有特殊的意义，并且确保现行指南的一致性。

Introduction

The demographics describing the dramatic increase in the number of patients with diabetes are well known. Patients with diabetes require surgical procedures more frequently and have longer hospital stays than those without the condition [2]. The presence of diabetes or hyperglycaemia in surgical patients has been shown to lead to increased morbidity and mortality, with perioperative mortality rates up to 50% greater than the non-diabetic population [2]. The reasons for these adverse outcomes are multifactorial, but include: failure

to identify patients with diabetes or hyperglycaemia [3, 4]; multiple co-morbidities including microvascular and macrovascular complications [5]; complex polypharmacy and insulin prescribing errors [6]; increased peri-operative and postoperative infections [2, 7, 8]; associated hypoglycaemia and hyperglycaemia [2]; a lack of, or inadequate, institutional guidelines for management of inpatient diabetes or hyperglycaemia [2, 9]; and inadequate

knowledge of diabetes and hyperglycaemia management amongst staff delivering care [10].

Anaesthetists and other peri-operative care providers should be knowledgeable and skilled in the care of patients with diabetes. Management of diabetes is a vital element in the management of surgical patients with diabetes. It is not good enough for the diabetic care to be a secondary, or sometimes forgotten, element of the peri-operative care package.

指南简介

众所周知流行病学调查显示糖尿病患者的数量在急剧增加。糖尿病患者需要外科手术更频繁，并有更长的住院时间。相对于非糖尿患者群，患有糖尿病或高血糖的外科患者相应的发病率和死亡率会增加，比起非糖尿病患者，围手术期死亡率增加 50%。导致上述不良结果的原因是多方面的，包括：未能确定患者患有糖尿病或高血糖；包括微血管和大血管并发症的多种疾病；多重用药的复杂性和胰岛素处方错误；围手术期和术后感染的增加；伴有低血糖或高血糖；对糖尿病或高血糖住院管理制度知识的缺乏；对于糖尿病和高血糖患者管理知识匮乏尤其是在护理方面。麻醉师和围手术期护理人员对于护理糖尿病患者应该具有详尽的知识和熟练的技能。对于伴有糖尿病的外壳患者的管理中糖尿病护理是至关重要的环节，在围手术期的护理中是第一位的。

Previous guidelines

In April 2011 NHS Diabetes (now part of NHS Improving Quality) published a document: NHS Diabetes Guideline for the Peri-operative Management of the Adult Patient with Diabetes, in association with the Joint British Diabetes Societies (JBDS) [1] (an almost identical version, Management of Adults with Diabetes Undergoing Surgery and Elective Procedures: Improving Standards, is available at www.diabetologists-abcd.org.uk/JBDS/JBDS.htm).

This comprehensive guideline provided both background information and advice to clinicians caring for patients with diabetes. Some of the recommendations in that document were due for review in the light of new evidence and, in addition, it was felt that anaesthetists and other practitioners caring for patients with diabetes in the peri-operative period needed shorter, practical advice. The Association of Anaesthetists of Great Britain and Ireland (AAGBI) offered to co-author this shortened guideline, in collaboration with colleagues involved with the 2011 document. The previous 2011 NHS Diabetes guidelines will also be updated in 2015. 先前的指南

在2011年4月NHS和JBDS发表了一版成年糖尿病患者围手术期管理指南。这版详尽的指南提供了背景知识以及对于糖尿病患者护理的建议。这些建议很多出自循证医学证据，并且表明，麻醉师和临床医生对于糖尿病患者的围手术护理需要更精简贴近实际的建议。结合2011版的这版指南，AAGBI出版了这版更精简的指南。之前的2011NHS糖尿病指南在2015也会更新。

The risks of poor diabetic control

Studies have shown that high pre-operative and perioperative glucose and glycated haemoglobin (HbA1c) levels are associated with poor surgical outcomes. These findings have been seen in both

elective and emergency surgery including spinal [11], vascular [12], colorectal [13], cardiac [14, 15], trauma [16], breast[17], orthopaedic [18], neurosurgical, and hepatobiliary surgery [19, 20]. One study showed that the adverse outcomes include a greater than 50% increase in mortality, a 2.4-fold increase in the incidence of postoperative respiratory infections, a doubling of surgical site infections, a threefold increase in postoperative urinary tract infections, a doubling in the incidence of myocardial infarction, and an almost twofold increase in acute kidney injury [2]. Paradoxically, there are some data to show that the outcomes of patients with diabetes may

not be different from, or may indeed be better than, those without diabetes if the diagnosis is known before surgery [21]. The reasons for this are unknown, but may be due to increased vigilance surrounding glucose control for those with a diagnosis of diabetes.

糖尿病控制不佳的风险

研究结果表明围手术期和手术期间的高血糖、高糖化血红蛋白水平与患者术后预后不佳关系密切，这种预后不佳无论是择期手术还是急诊手术均有体现，这些手术包括脊髓、血管、结肠直肠、心脏、创伤、乳腺、整形、神外以及肝胆手术等。一项研究显示这些不良结局包括：死亡率增加50%、术后呼吸道感染增加2.4倍、手术部位感染加倍、尿道感染增加三倍、心肌梗死的发生率加倍，急性肾损伤几乎增加两倍。矛盾的是，也有一些数据表明术前诊断明确的伴有糖尿病的患者和普通患者的预后没有差别，甚至更好。但是这是什么原因还不得而知，也许是因为患者之前已明确诊断为糖尿病，对血糖的管理有更为积极的控制。

Referral from primary care and planning surgery 从初级保健到计划手术的转诊 The aim is to ensure that diabetes is as well controlled as possible before elective surgery and to avoid delays to surgery due to poor control. The Working Party supports the consensus advice published in the 2011 NHS Diabetes guideline that the HbA1c should be< 69 mmol.mol1 (8.5%) for elective cases [1], and that elective surgery should be delayed if it is≥ 69 mmol.mol1, while control is improved. Changesto diabetes management can be made concurrently with

referral to ensure the patient’s diabetes is as well controlled as possible at the time of surgery. Elective surgery in patients with diabetes should be planned with the aim of minimising disruption to their self-management.

其目的是确保糖尿病在择期手术前尽可能地控制良好，避免因为血糖控制不佳而手术延期。遵循2011 版的 NHS 糖尿病指南，择期手术情况下 HbA1c 应 ＜ 69 mmol.mol-1（8.5%），当HbA1c ≥ 69 mmol-1 时，手术应延迟到血糖控制有所改善的时候。糖尿病管理策略可以适时改变以确保手术期患者的糖尿病可以尽可能地控制到最好。伴有糖尿病的手术患者的择期手术计划应该尽可能地把对患者自我管理的破坏降到最低。

? Recommendation: Glycaemic control should bechecked at the time of referral for surgery. Information about duration, type of diabetes, current treatment and complications should be made available to the secondary care team.

建议：转诊手术时应检查血糖控制水平、病程、类型、现有治疗方案和并发症。

Surgical outpatient clinic

The adequacy of diabetes control should be assessed again at the time of listing for surgery, ideally with a recorded HbA1c < 69 mmol.mol1 in the previous three months. If it is ≥ 69

mmol.mol1, elective surgery should be delayed while control is improved. In a small number

of cases it may not be possible to improve diabetic control pre-operatively, particularly if the reason for surgery, such as chronic infection, is contributing to poor control, or if surgery is semi-urgent. In these circumstances, it may be acceptable to proceed with surgery after explanation to the patient of the increased risks. Patients should be managed as a day case if the procedure is suitable and the patient fulfils the criteria for day-case surgery management. Well-controlled diabetes should not be a contra-indication to day-case surgery. 外科门诊病人

手术期间应对患者血糖控制水平进行充分的评估，理想状态是术前三个月HbA1c控制在＜ 69 mmol.mol-1（8.5%）当HbA1c ≥ 69 mmol-1 时，手术应延迟到血糖控制有所改善的时候。有一小部分的情况患者的血糖可能在术前难以控制，特别是需要手术的病因本身就引起血糖控制不佳，如慢性感染；或者手术比较紧急。这种情况下，需要和病人沟通解释因此带来的风险，患者接受，可以进行手术。在程序适宜的情况下管理病人以满足日间手术的标准。糖尿病的良好控制不应该是日间手术的禁忌。

Patients with poorly controlled diabetes at the time of surgery will need close monitoring and may need to start a variable-rate intravenous insulin infusion (VRIII).

? Recommendation: Patients with diabetes should be identified early in the pre-operative pathway.

无法很好控制血糖的糖尿病患者在手术期间需要严密的监测及采用可调节的静脉胰岛素输注（VRIII）

提示：伴有糖尿病的患者应在手术前应进行提前鉴定

Pre-operative assessment 术前评估 Appropriate and early pre-operative assessment should be arranged. A pre-operative assessment nurse may undertake the assessment with support from either an anaesthetist or a diabetes specialist nurse. It should occur sufficiently in advance of the planned surgery to ensure optimisation of glycaemic control before the date of proposed surgery. The aim is to ensure that all relevant investigations are available and checked in advance of the planned surgery, that the patient understands how to manage his/her diabetes in the peri-operative period, and that the period of pre-operative fasting is minimised.

应安排适当的或早期的术前评估。进行术前评估护士可能需要来自麻醉师或糖尿病专科护士的支持。术前评估应在计划手术之前以确保手术日期前血糖得到控制优化。术前评估的目的是：在计划手术前确保获得所有相关检查以及进一步的检查；使患者了解在围手术期如何管理他 / 她的糖尿病；减少术前禁食时间。

? Recommendation: Tests should be ordered to assess co-morbidities in line with National Institute for Health and Care Excellence (NICE) guidance on pre-operative testing [22]. This should include urea and electrolytes and ECG for all patients with diabetes; however, a random blood glucose measurement is not indicated.

建议：检查遵循NICE指南，应该包括尿检、糖尿病患者电解质及心电图检查；然而，随机血糖测量未注明。

Planning admission (including day surgery)

The aim is to minimise the fasting period, ensure normoglycaemia (capillary blood glucose (CBG)

6–10 mmol.l1) and minimise as far as possible disruption to the patient’s usual routine. Ideally, the patient should be booked first on the operating list to minimize the period of fasting. If the fasting period is expected to be limited to one missed meal, the patient can be managed by modification of his/her usual diabetes medication (see below). Patients should be provided with written instructions from the pre-operative assessment team about management of their diabetes medication on the day of surgery, the management of hypo- or hyperglycaemia in the peri-operative period, and the likely effects of surgery on their diabetes control. Patients should be advised to carry a form of glucose that they can take in case of symptoms of hypoglycaemia that will not cause surgery to be cancelled, for example a clear, sugar-containing drink (glucose tablets may be used instead, but some anaesthetists may feel they should not be taken within 6 h of the start of anaesthesia). Patients should be warned that their blood glucose control may be erratic for a few days after the procedure.

术前管理（包括日间手术）

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其目的是尽可能地缩短周期，确保血糖正常（6-10mmol.l）尽可能少地打乱患者的日常护理。理论上，患者应列入手术队列计划以尽可能减少禁食期。如果禁食期需要限制患者一次进餐，需要相应调整他/她日常的用药。术前评估团队需要对病人的手术期间用药管理、围手术期间的高血糖或者低血糖以及手术可能对糖尿病控制带来影响的可能因素给予指导，

应该给患者列一个可摄入糖的列表，以预防万一出现的低血糖带来手术取消，举个例子详加说明，比如含糖饮料（或者糖块也可以，但是麻醉师要求麻醉前六小时不能摄入）患者应该被警告在术后可能有几天的血糖波动。

? Recommendation: When possible, admission should be planned for the day of surgery, with both the patient and the ward staff aware of the planned peri-operative diabetes care, including a plan to manage hypo- and hyperglycaemia. Surgery should be scheduled at the start of the theatre list to minimise disruption to the patient’s glycaemic control.

*建议：只有当患者和医护人员确定了糖尿病围手术期护理方案，包括低血糖高血糖管理，才能准入手术。手术应尽早确定日程以尽可能少的打乱患者控糖。

Management of existing therapy 既有治疗的管理 With appropriate guidance, patients with diabetes should be allowed to retain control and possession of, and continue to self-administer, their medication. Many patients will have several years’ experience and be expert in self-medication.

在适当的指引下，应允许糖尿病患者进行自我药物管理。许多患者会有数年的经验并已成为自我药物管理的专家。

The aim is to avoid hypo- or hyperglycaemia during the period of fasting and the time during and after the procedure, until the patient is eating and drinking normally. In people who are likely to miss one meal only, this can often be achieved by manipulating the patient’s normal medication using the guidance provided in Tables 1 and 2.

其目的是在禁食期及手术中和手术后防止高血糖或者低血糖的发生直到患者可以正常饮食为止。如果患者需要一餐的禁食，可以根据表格1和表格2对患者的用药进行调整。

Glycaemic control in patients with diabetes is a balance between their carbohydrate intake and utilization (for example, exercise). It also depends on what medication they take and how those

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