该文章选自BJA《英国麻醉杂志》2023年8月刊
翻译：凌子杰 徐医麻醉2023级硕士研究生
审校：赵林林 徐医附院麻醉科
2024年11月14日是第18个联合国糖尿病日/世界糖尿病日。今年联合国糖尿病日的主题是“糖尿病与幸福感”。旨在呼吁将糖尿病患者的整体幸福感置于治疗的核心，进一步提升糖尿病患者的生活质量。
通过联合国糖尿病日的活动，以创建一个相互支持的全球糖尿病社区，并倡导更好的治疗方法，不仅要关注糖尿病患者的身体健康，还要关注他们的精神和情感需求。
Current practice in the perioperative management of patients with diabetes mellitus: a narrative review
糖尿病患者围手术期管理的现状：叙述性综述
Summary 摘要
The prevalence of diabetes is increasing, and patients with diabetes mellitus have both an increased likelihood of requiring surgery and of developing postoperative complications when they do. We summarise available evidence underpinning current guidelines on preoperative assessment and optimisation, perioperative management of prescribed insulin and oral hypoglycaemic medication, intraoperative glycaemic control, and postoperative patient care.
糖尿病的患病率正在增加，糖尿病患者需要手术的可能性和术后并发症的可能性都在增加。我们总结了现有的证据，这些证据支持当前关于术前评估和优化、处方胰岛素和口服低血糖药物的围手术期管理的指南，术中血糖控制和术后患者护理。
Keywords: diabetes mellitus; insulin; oral hypoglycaemic agent; postoperative complications; surgery
关键词：糖尿病；胰岛素；口服降糖药；术后并发症；外科手术
Editor’s key points
编者的要点
The prevalence of diabetes mellitus is increasing, but evidence for many decisions important in optimal perioperative management is lacking.
糖尿病的患病率正在增加，但缺乏对最佳围手术期管理具有重要意义的许多决策的证据。
This narrative review summarises current evidence underpinning updated guidelines.
本叙述性综述总结了支持最新指南的当前证据。
Patients with type 2 diabetes mellitus (T2DM) undergoing elective surgery should continue their metformin, GLP-1RA analogues, and DPP-4 inhibitors including on the day of surgery, but SGLT-2 inhibitors should be stopped 3 days before.
接受择期手术的2型糖尿病（T2DM）患者应继续使用二甲双胍、GLP-1RA类似物和DPP-4抑制剂，包括在手术当天，但SGLT-2抑制剂应在3天前停止使用。
Large observational studies and trials are needed in patients with diabetes mellitus undergoing surgery to define optimal perioperative management for early and intermediate postoperative outcomes.
需要对接受手术的糖尿病患者进行大规模的观察性研究和试验，以确定术后早期和中期结果的最佳围手术期管理。
Diabetes mellitus (DM) is a chronic multisystem disease which is becoming increasingly prevalent in the general population.It is estimated that approximately 537 million people worldwide have DM. Projections are that this may increase to 700 million by 2045. In Europe, approximately 1 in 11 adults have DM -equating to roughly 61 million individuals.
糖尿病（DM）是一种慢性多系统疾病，在普通人群中越来越普遍。据估计，全世界约有5.37亿人患有糖尿病。预计到2045年，这一数字可能会增加到7亿。在欧洲，大约每11名成年人中就有1人患有糖尿病，相当于大约6100万人。
It has been shown in numerous studies that patients with DM undergo surgical procedures more often than patients without it.A study suggests that one in four patients undergoing surgery has a chronic disease -which has an associated 10-fold increase in postoperative death.
许多研究表明，糖尿病患者比没有糖尿病的患者更经常接受手术。一项研究表明，四分之一接受手术的患者患有慢性病，术后死亡人数增加了10倍。
It analysed data for more than 8 million patients and found that 8% had diabetes -making it the second most common perioperative comorbidity. A separate study suggests that patients with diabetes account for 15% of all operative procedures,placing a major burden on healthcare systems as these patients are clinically more complex.
它分析了800多万患者的数据，发现8%的患者患有糖尿病，使其成为第二常见的围手术期合并症。另一项研究表明，糖尿病患者占所有手术程序的15%，这给医疗系统带来了重大负担，因为这些患者在临床上更为复杂。
Perioperative management of the patient with diabetes is an often under-emphasised clinical challenge, even though it is a vulnerable time for this already higher-risk patient cohort.
糖尿病患者的围手术期管理是一个经常被低估的临床挑战，尽管对于这个已经很高风险的患者群体来说，这是一个脆弱的时期。
Unpredictable preoperative fasting times, potentially hazardous administration of intravenous medications including insulin, and the stress response of surgery may lead to adverse postoperative outcomes. Besides the human cost, there are also economic consequences including increased hospital length of stay.
不可预测的术前禁食时间、包括胰岛素在内的静脉注射药物的潜在危险给药以及手术的应激反应可能会导致不良的术后结果。除了人力成本外，还有经济后果，包括住院时间增加。
There are numerous guidelines available for the perioperative management of DM.These are based largely on expert opinion and consensus from best practice panels, which sometimes results in differing clinical practice between centres at a regional level and internationally.
DM的围手术期管理有许多可用的指南。这些指南主要基于最佳实践小组的专家意见和共识，这有时会导致区域和国际中心之间的临床实践不同。
Discrepancies between these different guidelines reflect both the scarcity of available evidence in perioperative management of the patient with diabetes, and the use of outdated guidelines. This narrative review aims to summarise current data on how perioperative management of patients with diabetes may influence clinical outcomes and highlight priorities for future original investigation for this important, and often neglected, clinical cohort.
这些不同的指南之间的差异既反映了糖尿病患者围手术期管理中可用证据的缺乏，也反映了使用过时的指南。这篇叙述性综述旨在总结糖尿病患者围手术期管理如何影响临床结果的当前数据，并强调未来对这一重要且经常被忽视的临床队列进行原始研究的优先事项。
Table 1 Classification of diabetes mellitus. MODY, maturityonset diabetes of the young.
表1糖尿病的分类。MODY，年轻人的成熟期糖尿病。
1.Type 1 diabetes mellitus (caused by β-cell destruction - therefore absolute insulin deficiency) (a) Autoimmune (b) Idiopathic
2.Type 2 diabetes mellitus (owing to a combination of peripheral insulin resistance and insulin deficiency)
3. Other
A. Monogenic diabetes syndromes - MODY, neonatal diabetes
B. Diseases of the exocrine pancreas - Pancreatitis, neoplasm, cystic fibrosis, pancreatectomy
C. Endocrinopathies -Cushing’s syndrome, acromegaly, phaeochromocytoma
D. Drug or chemical induced -Thiazides, glucocorticoids, nicotinic acid, β-adrenergic agonists
E. Infections - Cytomegalovirus, congenital rubella
F. Genetic syndromes associated with diabetes mellitus - Down’s syndrome, Klinefelter’s syndrome, myotonic dystrophy, Friedreich’s ataxia
4. Gestational diabetes
1.1型糖尿病（由β细胞破坏引起，因此绝对胰岛素缺乏）（a）自身免疫（b）特发性2型。
2.2型糖尿病（由于外周胰岛素抵抗和胰岛素缺乏的组合）
3。其他
A.单源性糖尿病综合征-MODY、新生儿糖尿病
B.外分泌胰腺疾病-胰腺炎、肿瘤、囊性纤维化、胰腺切除术
C.内分泌学-库欣综合征、肢端肥大症、嗜铬细胞瘤
D.药物或化学诱导的-噻嗪类、糖皮质激素、烟酸、β-肾上腺素能激动剂
B.感染-巨细胞病毒、先天性风疹
F。与糖尿病相关的遗传综合征-唐氏综合症、克氏综合症、强直性肌营养不良、弗里德里希共济失调
4。妊娠期糖尿病
Methods
方法
We searched databases including PubMed, MEDLINE, and EMBASE for all types of articles in the English language. We used several keywords and combinations of keywords including diabetes, perioperative management, perioperative care, perioperative outcomes, surgery, emergency surgery, surgical outcomes, anaesthesia, anaesthetics, and postoperative outcomes. These keywords were limited to either ‘Title’ or ‘Title/abstract’. Our Boolean search strategy is shown in Supplementary Appendix 1.
我们在PubMed、MEDLINE和EMBASE等数据库中搜索了所有类型的英语文章。我们使用了几个关键词和关键词的组合，包括糖尿病、围术期管理、围手术期护理、围手术期结果、手术、急诊手术、手术结果、麻醉、麻醉学和术后结果。这些关键字被限制为“标题”或“标题/摘要”。我们的布尔搜索策略如补充附录1所示。
Preoperative care Type of diabetes mellitus
糖尿病的术前护理
Preoperative assessment of the patient with diabetes mellitus comprises several requirements. The type of diabetes mellitus must be ascertained. Traditionally this is classified (as shown in Table 1) into type 1 diabetes mellitus (T1DM; absolute insulin deficiency, DM 1), T2DM (peripheral insulin resistance and inadequate insulin secretion, DM 2), gestational diabetes, and specific types of diabetes attributable to other causes.
糖尿病患者的术前评估包括几个要求。必须查明糖尿病的类型。传统上将其分类（如表1所示）为1型糖尿病（T1DM；绝对胰岛素缺乏，DM 1）、T2DM（外周胰岛素抵抗和胰岛素分泌不足，DM 2）、妊娠期糖尿病和可归因于其他原因的特定类型的糖尿病。
A recent scoping review found that the definition of DM is variable between different studies.Not only is DM defined in different ways, but definitions for glycaemic control are also not uniformly defined.This makes it difficult to compare evidence between different studies.
最近的一项范围界定审查发现，不同研究对糖尿病的定义各不相同。糖尿病不仅以不同的方式定义，而且对血糖控制的定义也没有统一的定义。这使得很难比较不同研究之间的证据。
Often, hospitals poorly differentiate patients with T1DM from patients with T2DM. A retrospective cross-sectional study (n¼2259) demonstrated that if similar perioperative treatment is provided to both T1DM and T2DM patients, those with T1DM will have poorer glycaemic control.
通常，医院很难区分T1DM患者和T2DM患者。一项回顾性横断面研究(n¼2259)表明，如果对T1DM和T2DM患者提供类似的围手术期治疗，T1DM患者的血糖控制会较差。
It also showed that patients with T1DM had a higher perioperative peak glucose concentration (11.0 [8.2-14.7] vs 9.4 [7.7-11.7], P<0.001) and a higher incidence of perioperative hyperglycaemia compared with T2DM patients (63% vs 43%, P<0.001), along with more frequent episodes of hypoglycaemia (7.1% vs 1.3%, P<0.001).
研究还显示，与T2DM患者相比，T1DM患者围手术期血糖峰值浓度更高(11.0 [8.2-14.7] vs 9.4 [7.7-11.7]， P<0.001)，围手术期高血糖发生率更高(63% vs 43%， P<0.001)，低血糖发作更频繁(7.1% vs 1.3%， P<0.001)。
It is clear from studies such as this that the different physiology and disease process between T1DM and T2DM is poorly appreciated at a clinical level and that more needs to be done to establish clear perioperative pathways to safely manage these patients.
从这些研究中可以清楚地看出，临床对T1DM和T2DM之间不同的生理和疾病过程知之甚少，需要做更多的工作来建立明确的围手术期途径，以安全管理这些患者。
Even though the incidence of gestational and other types of diabetes is much lower than T2DM and T1DM, it is important to recognise the actual diagnosis. For example, patients with pancreatogenic diabetes are more unstable in the perioperative period as compared with gestational or glucocorticoid induced diabetes.
尽管妊娠期和其他类型糖尿病的发病率远低于T2DM和T1DM，但认识到实际诊断是很重要的。例如，与妊娠期或糖皮质激素诱导的糖尿病相比，胰源性糖尿病患者在围手术期更不稳定。
Non-insulin medication
非胰岛素药物
The second component of preoperative assessment is patients’ current medication. These may be classified as insulin and non-insulin agents (Table 2). There are various conflicting guidelines as to whether injectable and oral glucose-lowering agents should be continued preoperatively, reflecting a lack of evidence addressing this clinical question.
术前评估的第二个组成部分是患者目前的用药情况。这些药物可分为胰岛素和非胰岛素药物(表2)。关于术前是否应继续使用注射降糖药和口服降糖药，有各种相互矛盾的指南，反映了缺乏解决这一临床问题的证据。
The well-known risks with some of these agents is that they may cause hypoglycaemia or diabetic ketoacidosis. Therefore, preoperative review of the patients’ medication by a pharmacist may be of benefit to reduce medication errors.
其中一些药物众所周知的风险是它们可能导致低血糖或糖尿病酮症酸中毒。因此，术前检查患者的药物由药剂师可能有利于减少用药错误。
A small RCT consisting of 160 ambulatory surgery patients with T2DM sought to answer whether oral hypoglycaemic drugs (OHDs) should be continued in the perioperative period.Patients were randomised to continue their OHDs or withhold them.
一项由160名门诊手术T2DM患者组成的小型随机对照试验试图回答口服降糖药(OHDs)是否应该在围手术期继续使用。患者被随机分为继续或停止OHDs。
They found that perioperative blood glucose levels were significantly lower (mean, 7.7 mmol L/L ; confidence interval [CI], 7.2-8.1 mmol L/L) in the group that continued vs the group that discontinued OHDs (mean, 8.7 mmol L/L ; CI, 8.1-9.3 mmol L/L; P<0.001),concluding that perioperative blood glucose levels were significantly better controlled in patients that continued their OHDs. However, this study was limited by its small sample size and that it evaluated only metformin and sulphonylureas (SUs).The potential side-effects of sodium-glucose co-transporter-2 (SGLT-2) inhibitors were not addressed.
他们发现围手术期血糖水平显著降低(平均7.7 mmol L/L；置信区间[CI]， 7.2-8.1 mmol L/L)，继续服用OHDs的组与停止服用OHDs的组(平均值，8.7 mmol L/L;CI为8.1-9.3 mmol L/L;P<0.001)，得出结论围手术期血糖水平明显更好地发生在继续他们的OHDs的患者。然而，这项研究的局限性在于样本量小，而且它只评估了二甲双胍和磺脲类药物(SUs)。钠-葡萄糖共转运蛋白-2 (SGLT-2)抑制剂的潜在副作用尚未解决。
A single-blind multicentre RCT examined the effects of continuing or withholding metformin from T2DM patients undergoing noncardiac surgery (n¼70). The primary outcome measures were the differences in perioperative blood glucose and lactate between the groups.
一项单盲多中心随机对照试验研究了继续或停止二甲双胍对接受非心脏手术的T2DM患者的影响。主要观察指标是两组患者围手术期血糖和乳酸水平的差异。
They found that postoperative blood glucose was similar (8.2 [1.8] in the metformin group vs 8.3 [2.3] mmol L1 in the withheld group; P¼0.95). Furthermore, they found that although preoperative lactate levels were marginally higher in the metformin group (1.5 vs 1.2 mmol L1 ; P¼0.02), postoperative lactate levels were not significantly different (1.2 vs 1.0 mmol L1 ; P¼0.18).
他们发现术后血糖相似(二甲双胍组8.2 [1.8]vs扣留组8.3 [2.3]mmol L1;P¼0.95)。此外，他们发现，尽管术前二甲双胍组乳酸水平略高(1.5 vs 1.2 mmol L1;P¼0.02)，术后乳酸水平无显著差异(1.2 vs 1.0 mmol L1;P¼0.18)。
The authors concluded that the continuation of metformin in this patient cohort does not cause hypoglycaemia, nor does it significantly raise lactate levels. Therefore, metformin should be continued perioperatively, even in the fasting patient.
作者得出结论，在该患者队列中继续使用二甲双胍不会导致低血糖，也不会显著提高乳酸水平。因此，即使在禁食患者中，也应在围手术期继续使用二甲双胍。
Table 2 A comparison of guidelines from professional societies of key interventions in perioperative management of patients with diabetes mellitus. ADA, American Diabetes Association; BD, twice daily; BGL, blood glucose level; CPOC, Centre for Perioperative Care; CSII, continuous subcutaneous insulin infusion; DPP-4, dipeptidyl peptidase-4; DrEaMing, drinking, eating, and mobilising; ERAS, enhanced recovery after surgery; GKI, glucoseepotassiumeinsulin; GLP-1RA, glucagon-like peptide 1 receptor agonist; HbA1c, glycated haemoglobin; OD, once daily; SGLT-2, sodium-glucose cotransporter 2; TDS, three times daily; VRIII, variable rate intravenous insulin infusion.
表2糖尿病患者围手术期管理关键干预措施专业协会指南的比较。ADA，美国糖尿病协会；BD，每天两次；BGL，血糖水平；CPOC，围手术期护理中心；CSII，持续皮下胰岛素输注；DPP-4、二肽基肽酶-4；做梦，喝酒、吃饭和动员；ERAS，增强术后恢复；GKI；胰高血糖素样肽1受体激动剂GLP-1RA；糖化血红蛋白；OD，每日一次；SGLT-2、钠-葡萄糖协同转运蛋白2；TDS，每天三次；VRIII，可变速率静脉注射胰岛素。
Sulphonylureas are insulin secretagogues that have been in use since the 1950s. They function by stimulating insulin release from beta cells in the pancreas by binding to sulphonylurea receptors, thereby causing hypoglycaemia in the fasted patient by increasing insulin secretion.
磺酰脲类药物是自20世纪50年代以来一直在使用的胰岛素促分泌剂。它们的作用是通过与磺酰脲受体结合刺激胰腺β细胞释放胰岛素，从而通过增加胰岛素分泌导致禁食患者低血糖。
Therefore, it is widely accepted that this class of medication is withheld on the day of surgery to avoid the risk of hypoglycaemia. We found little recent evidence regarding the perioperative management of sulphonylureas.
因此，人们普遍认为，这类药物在手术当天不服用，以避免低血糖的风险。我们发现关于磺脲类药物围手术期管理的最新证据很少。
A current focus of research into diabetes pertains to perioperative management of patients with T2DM using medications other than insulin. One small RCT (n¼90) demonstrated that the glucagon-like peptide-1 receptor agonist (GLP-1RA) liraglutide is superior to insulin in the perioperative management of patients with T2DM undergoing elective surgery within Enhanced Recovery After Surgery (ERAS) protocols.
目前糖尿病研究的重点是使用胰岛素以外的药物对T2DM患者进行围手术期管理。一项小型随机对照试验（n¼90）表明，胰高血糖素样肽-1受体激动剂（GLP-1RA）利拉鲁肽在T2DM患者的围手术期管理中优于胰岛素，这些患者在术后增强恢复（ERAS）方案下经历择期手术。
This study showed that the patient cohort receiving liraglutide demonstrated more stable glycaemic levels, required less additional insulin and lower insulin doses on the day of surgery, and less additional insulin volume throughout the perioperative period.
这项研究表明，接受利拉鲁肽治疗的患者队列表现出更稳定的血糖水平，在手术当天需要更少的额外胰岛素和更低的胰岛素剂量，并且在整个围手术期需要更少的附加胰岛素量。
Another small RCT (n¼70) recruited patients with T2DM undergoing elective cardiac surgery. Patients were randomised to receive either insulin alone or insulin and liraglutide (0.6 mg day1 ). The primary endpoint was the average M value (a derived parameter indicating the proximity of measured blood glucose to the target level) from Day 1 to Day 10 postoperatively.
另一项小型随机对照试验（n¼70）招募了接受择期心脏手术的T2DM患者。患者被随机分配接受单独的胰岛素或胰岛素和利拉鲁肽（0.6 mg，第1天）。主要终点是术后第1天至第10天的平均值（一个指示测量血糖接近目标水平的衍生参数）。
The M value in the liraglutide plus insulin group was significantly lower than in the insulin-alone group (liraglutide plus insulin 5.8 [inter-quartile range, IQR¼4.4-7.8] vs insulin-alone 12.3 [IQR, 9.4-16.0]; P<0.001). They concluded that the addition of low dose liraglutide may achieve better glycaemic control in the perioperative period than insulin alone.
利拉鲁肽加胰岛素组的平均值显著低于单用胰岛素组（利拉鲁肽加胰岛素5.8[四分位间距，IQR¼4.4-7.8]vs单用胰岛素12.3[IQR，9.4-16.0]；P<0.001）。他们得出结论额外的低剂量利拉鲁肽可能在围手术期比单独使用胰岛素能获得更好的血糖控制。
A multi-centre open-label RCT (n¼150) studied the effects of subcutaneous liraglutide in patients with T2DM undergoing noncardiac inpatient surgery. The authors compared three treatment strategies to lower glucose and reduce the need for rescue insulin. One cohort received premedication with liraglutide the night before surgery and the morning of surgery.
一项多中心开放标签随机对照试验（n¼150）研究了皮下利拉鲁肽对接受非心脏住院手术的T2DM患者的影响。作者比较了三种降低血糖和减少对胰岛素需求的治疗策略。一组患者在手术前一晚和手术当天上午接受了利拉鲁肽的药物治疗。
The other two groups consisted of a glucoseeinsulinepotassium infusion cohort and an insulinebolus cohort. The primary outcome was the difference in median glucose levels 1 h after surgery. They found that the median (IQR [range]) plasma glucose at 1 h postoperatively was lower in the liraglutide group (6.6 [5.6-7.7] mmol L1 ) compared with the insulin infusion group (7.5 [6.4-8.3] mmol L1 ; P¼0.026) and insulin bolus groups (7.6 [6.4-8.9] mmol L1 ; P¼0.006), respectively.
另外两组包括葡萄糖-胰岛素-钾输注队列和胰岛素队列。主要结果是术后1小时血糖中位数的差异。他们发现，利拉鲁肽组术后1小时的中位（IQR[范围]）血糖（6.6[5.6-7.7]mmol L1）分别低于胰岛素输注组（7.5[6.4-8.3]mmol L 1；P¼0.026）和胰岛素推注组（7.6[6.4-8.9]mmol L.1；P 1/4 0.006）。
A multicentre, randomised, blind, placebo-controlled superiority trial in adult patients undergoing cardiac surgery examined the use of subcutaneous liraglutide as an adjunct to improve glycaemic control. The primary endpoint was the difference between groups for any intravenous insulin given in the operating theatre to maintain blood glucose >8-10 mmol L1 . They found that (43%) patients from the liraglutide group needed insulin compared with that (61%) in the placebo group -a difference of 18% (95% CI, 5.9e30.0; P¼0.003).
一项针对接受心脏手术的成年患者的多中心、随机、盲、安慰剂对照优越性试验检查了皮下利拉鲁肽作为辅助药物的使用，以改善血糖控制。主要终点是在手术室静脉注射胰岛素以维持血糖>8-10 mmol L1的组间差异。他们发现利拉鲁肽组（43%）的患者需要胰岛素，与安慰剂组（61%）相比，差异为18%（95%CI，5.9e30.0；P¼0.003）。
iptin (5 mg), a dipeptidyl dipeptidase-4 (DPP-4) inhibitor combined with a fast-acting supplemental insulin, would result in non-inferior glycaemic control compared with a basal-bolus insulin regimen in T2DM patients undergoing noncardiac surgery. A basal-bolus regimen consists of a combination of a once daily long-acting or intermediate-acting insulin along with very rapid-acting insulin used at mealtime.
iptin（5mg）、与速效补充胰岛素联合的二肽基二肽酶-4（DPP-4）抑制剂，在接受非心脏手术的T2DM患者中，与基础推注胰岛素方案相比，将导致血糖控制不差。基础推注方案包括每天一次的长效或中效胰岛素与用餐时使用的非常速效胰岛素的组合。
Usually the basal dose consist of approximately 50% of the total daily insulin dose.They found that the mean daily blood glucose was higher in the linagliptin group (9.5 [2.3] mmol L1 ) compared with the basal-bolus group (8.8 [2.3] mmol L1 ; P¼0.03). However, patients with linagliptin experienced fewer hypoglycaemic events (1.6% vs 11%, P¼0.001) and needed fewer daily insulin injections (2.0 [3.3] vs 3.1 [3.3]; P<0.001).
通常基础剂量约占每日胰岛素总剂量的50%。他们发现，与基础推注组（8.8[2.3]mmol L 1；P¼0.03）相比，利格列汀组的平均每日血糖更高（9.5[2.3]mol L 1）。然而，利格列汀患者的低血糖事件较少（1.6%对11%，P¼0.001），并且需要较少的每日胰岛素注射（2.0[3.3]对3.1[3.3]；P<0.001）。
A single-centre RCT examined the use of oral sitagliptin (a DPP-4 inhibitor) in patients with T2DM undergoing coronary artery bypass grafting (n¼182). The primary outcome was the difference in the proportion of patients with postoperative hyperglycaemia (defined as >10 mmol L1 ). They noted that the frequency of hyperglycaemia in intensive care postoperatively was not significantly different between groups (75% and 84%, P¼0.14; difference¼e9%; 95% CI, e21%e3%) for patients on sitagliptin and placebo, respectively.
一项单中心随机对照试验检查了口服西他列汀（DPP-4抑制剂）在接受冠状动脉搭桥术的T2DM患者中的使用情况（n¼182）。主要结果是术后高血糖（定义为>10 mmol L1）患者比例的差异。他们注意到，在接受西格列汀和安慰剂治疗的患者中，术后重症监护中的高血糖发生率在各组之间没有显著差异（分别为75%和84%，P¼0.14；差异¼e9%；95%CI，e21%e3%）。
SGLT-2 inhibitors are being increasingly prescribed for patients with T2DM in the community, because of their beneficial cardiorenal properties. It is expected that, in the near future, the main indication for prescribing SGLT-2 inhibitors will be for cardiorenal protection among DM patients.
由于SGLT-2抑制剂有益的心肾特性，社区中越来越多地为T2DM患者开具SGLT-2药物处方。预计在不久的将来，开具SGLT2抑制剂的主要适应症将是对DM患者的心肾保护。
转诊:标准化转诊表，包括:■转诊3个月内的糖化血红蛋白■合并症的控制■所有药物
手术前:评估和优化:■糖尿病■合并症利用手术作为教育时机:■体重管理、锻炼、戒烟。如果HbA1c超过69 mmol mol-1(8.5%)，参考优化
个性化计划：术前和术后用药变更■日间手术或住院手术■手术时机■与患者、全科医生及所有相关人员沟通计划
入院时:确保药物协调■使用术前计划■将CBG维持在6 - 12mmol■记录急症患者的CBG、肾脏特征、乳酸、酮类■确保T1DM患者从不拒绝胰岛素
在医院:尽量减少饥饿期■将CBG维持在6-12 mmol L-1■以早期治疗为目标■明确糖尿病管理交接。
回到病房时:■确保药物协调、鼓励早期治疗、保护压力区、确保T1DM患者从不拒绝胰岛素治疗、将CBG维持在6-12 mmol L-1、根据标准转诊糖尿病专家小组。
放电:与患者和全科医生沟通:■所有药物变化■未来糖尿病护理计划■自我管理的重要性
糖尿病患者围手术期护理指南(经围手术期护理中心许可转载;https://cpoc.org.uk/sites/cpoc/files/documents/2023-02/CPOC-Diabetes-Guideline-Updated2022_0.pdf;查阅于2023年2月7日)。CBG，毛细血管血糖;做梦、喝酒、吃饭、动员;血红蛋白A1c;T1DM，即1型糖尿病。糖尿病围手术期管理的现行指南- 5
Although rare, a concern with SGLT-2 inhibitors is their association with euglycaemic ketoacidosis (euDKA). It has been suggested that surgery may precipitate euDKA, as the surgical stress response increases ketone production. A retrospective review of 1307 patients on SGLT-2 inhibitors who underwent surgical procedures found that the incidence of euglycaemic diabetic ketoacidosis was 0.2% in non-emergent procedures and 1.1% for emergent procedures, owing to adherence to preoperative instructions to stop the SGLT-2 inhibitor preoperatively in the former group. Studies are ongoing on the potential cardiorenal protective properties in the perioperative period.
SGLT-2抑制剂虽然罕见，但其与低血糖酮症酸中毒（euDKA）的关系令人担忧。有人认为，手术可能会导致euDKA，因为手术应激反应会增加酮的产生。对1307名接受SGLT-2抑制剂手术的患者进行的回顾性审查发现，在非紧急手术中，糖尿病酮症酸中毒的发生率为0.2%，由于前一组患者在术前遵守了停止SGLT-2抑制剂的术前指示。目前正在对围手术期潜在的心肾保护特性进行研究。
Although guidelines from the Centre for Perioperative Care (CPOC) recommend that SGLT-2 inhibitors are omitted both on the day before surgery and the day of surgery itself,in contrast, latest guidelines from the European Society of Cardiology (ESC) and European Society of Anaesthesiology and Intensive Care (ESAIC) recommend withholding SGLT-2 inhibitors for 3 days before scheduled surgery, reflecting the increasing concern for euDKA.
尽管围手术期护理中心（CPOC）的指南建议在手术前一天和手术当天都省略SGLT-2抑制剂，相比之下，欧洲心脏病学会（ESC）和欧洲麻醉师和重症监护学会（ESAIC）的最新指南建议在计划手术前3天内停用SGLT-2抑制物，反映出对欧盟DKA的日益关注。
This lack of consensus highlights the dearth of clinical research informing these guidelines. Indeed, a consensus statement from the Society for Ambulatory Anaesthesia highlights this: ‘there is insufficient evidence regarding preoperative management of oral antidiabetics’.
这种缺乏共识的情况凸显了缺乏为这些指南提供信息的临床研究。事实上，门诊麻醉学会的一份共识声明强调了这一点：“关于口服抗糖尿病药物的术前管理，没有足够的证据”。
Therefore, until more data are available, a conservative approach may be advisable. When a patient using SGLT-2 inhibitors undergoes surgery without interrupting the medication, ketones should be measured in case of ketoacidosis and treatment with insulin by variable rate IV insulin infusion (VRIII) should be initiated intraoperatively to control ketone production. The decision to proceed with the surgery is a riskebenefit estimate, taking the ketone plasma level and other blood gas parameters into account, including pH and base-excess/bicarbonate.
因此，在获得更多数据之前，采取保守的方法可能是可取的。当使用SGLT-2抑制剂的患者在不中断药物治疗的情况下进行手术时，应测量酮体以防止酮症酸中毒，术中应开始通过可变速率IV胰岛素输注（VRIII）进行胰岛素治疗，以控制酮体的产生。考虑到酮血浆水平和其他血气参数，包括pH值和碱过量/碳酸氢盐，进行手术的决定是一个风险评估。
In summary, there seems no clear benefit in continuing metformin or sulphonylureas. The continuation or even initiation of GLP-1 agonists or DPP-4 inhibitors in the perioperative period may be beneficial but pending further studies, SGLT2 inhibitors should be withheld for 2 days among DM patients undergoing elective surgery.
总之，继续服用二甲双胍或磺脲类药物似乎没有明显的益处。在围手术期继续甚至开始使用GLP-1激动剂或DPP-4抑制剂可能是有益的，但在等待进一步研究之前，在接受择期手术的DM患者中，SGLT2抑制剂应停用2天。
Insulin胰岛素
There are several ways to manage a patient’s insulin in the preoperative period (Table 2). The most common are (1) continuation of the patient’s normal multiple daily injections of insulin but at a reduced dose before surgery; (2) commencement of a VRIII; (3) continuation of continuous subcutaneous insulin infusion (CSII) -usually via a pump; or (4) fixed rate intravenous insulin infusion (FRIII) - the latter only used for management of diabetic ketoacidosis or hyperosmolar hyperglycaemic non-ketotic (HHONK) state.
有几种方法可以在术前管理患者的胰岛素（表2）。最常见的是（1）继续患者正常的每天多次注射胰岛素，但在手术前剂量减少；（2） VRIII的启动；（3） 持续皮下胰岛素输注（CSII）-通常通过泵；或（4）固定速率静脉注射胰岛素（FRII），后者仅用于治疗糖尿病酮症酸中毒或高渗性高血糖非酮症酸血症（HHONK）状态。
The VRIII was advocated as a replacement for Alberti’s ‘glucoseeinsulinepotassium’ (GIK) in the 1990s.Although Alberti’s regimen was a significant improvement in the perioperative management of the patient with diabetes, it had inherent limitations, including high risk of error owing to the number of additives to the fluid bag, and was also wasteful.
20世纪90年代，VRIII被提倡作为Alberti的“葡萄糖胰岛素钾”（GIK）的替代品。尽管Alberti方案在糖尿病患者的围手术期管理方面有显著改进，但它有固有的局限性，包括由于液袋添加剂的数量而导致错误的高风险，而且也是浪费。
However, all guidelines caution on the inherent risks of VRIII unless used in a highly monitored environment, such as intraoperatively or in a critical care environment, because of the risk of hypoglycaemia or diabetic ketoacidosis (DKA) if inappropriately managed.Of note, patients with T1DM always need insulin to avoid the development of DKA.
然而，所有指南都对VRIII的固有风险提出警告除非在高度监控的环境中使用，如手术中或重症监护环境中，因为如果管理不当，有低血糖或糖尿病酮症酸中毒（DKA）的风险。值得注意的是，T1DM患者总是需要胰岛素来避免DKA的发展。
Guidelines differ somewhat in insulin dose adjustments before surgery for patients using multiple daily injections of insulin and these guidelines are summarised in Table 2. Most guidelines recommend reducing the long-acting insulin dose the day before and the day of surgery 20-30%, depending on the timing of insulin and once or twice daily use.
对于每天多次注射胰岛素的患者，手术前的胰岛素剂量调整指南有所不同，表2中总结了这些指南。大多数指南建议在手术前一天和手术当天将长效胰岛素剂量减少20-30%，具体取决于胰岛素的使用时间和每天使用一到两次。
For premixed and short-acting insulin, there are usually no dose adjustments required the day before surgery. On the day of surgery, most guidelines recommend halving the dose for premixed insulins and withholding short-acting insulins without meals (Table 2)
对于预混和短效胰岛素，通常不需要在手术前一天进行剂量调整。在手术当天，大多数指南建议将预混胰岛素的剂量减半，并在不吃饭的情况下停止使用短效胰岛素（表2）
CSII has been a mainstay of treatment in patients with T1DM for many years and approximately 15% of patients with T1DM use one. It delivers a fixed hourly rate of a rapid-acting insulin analogue which acts as a patient’s basal insulin. To supplement this, patients can give bolus doses of insulin to match their carbohydrate intake.
多年来，CSII一直是T1DM患者的主要治疗方法，大约15%的T1DM患者使用CSII。它提供固定的每小时速的速效胰岛素类似物，作为患者的基础胰岛素。为了补充这一点，患者可以给予大量的胰岛素，以匹配他们的碳水化合物摄入量。
It offers improved glycaemic control over multiple daily injections of insulin and a lower risk of hypoglycaemia.A retrospective observational study demonstrated that patients with T1DM maintain lower haemoglobin A1c (HbA1c) values on CSII over a 1-10-year period compared with pre-CSII values. The CPOC (Fig. 1) recommends that patients continue their CSII in the perioperative period provided that they have a short fasting time (no more than one missed meal).
它比每天多次注射胰岛素改善了血糖控制，并降低了低血糖风险。一项回顾性观察性研究表明，与CSII前的值相比，T1DM患者在1年-10年的CSII中保持较低的血红蛋白A1c值。CPOC（图1）建议患者在围术期继续进行CSII前提是他们禁食时间短（不超过一顿饭）。
It is felt that CSII is safer as it avoids the potential risks of VRIII. Of note, most insulin pumps have not been developed for the perioperative setting and dislocation of the pump or interaction with electrocautery should be monitored.The user manual of most CSII pumps will state that the pump has not been developed for use in the operating theatre. The CPOC guideline has included a section recommending a shared decision-making riskebenefit discussion with the patient for the perioperative use of CSII (Fig.1)
人们认为CSII更安全，因为它避免了VRIII的潜在风险。值得注意的是，大多数胰岛素泵尚未开发用于围手术期设置，应监测泵的错位或与电凝止血的相互作用。大多数CSII泵的用户手册将说明该泵尚未开发为用于手术室。CPOC指南包括一节，建议与患者讨论围手术期使用CSII的共同决策风险（图。1）
As part of the preoperative workup for a patient with T1DM using a CSII pump, it is recommended that a basal test is performed a few days or weeks before surgery.This means observing the rate of insulin infusion which is necessary to maintain blood glucose 5-10 mmol L1 on the CSII, while the patient is fasting.
作为使用CSII泵对T1DM患者进行术前检查的一部分，建议在手术前几天或几周进行基础测试。这意味着观察胰岛素输注速率，这是在患者禁食时维持CSII血糖5-10mmol L 1所必需的。
This allows the patient and the medical team to establish the correct basal infusion rate in the fasted state. Some guidelines recommend continuing the CSII basal rate at 80% of normal whereas others recommend continuing it as normal to counteract the hyperglycaemia that results from the stress response to surgery.
这允许患者和医疗团队在禁食状态下建立正确的基础输注率。一些指南建议将CSII基础发病率保持在正常的80%，而另一些指南则建议将其保持正常，以抵消手术应激反应引起的高血糖。
A recent single-centre, open-label, RCT compared the use of closed-loop subcutaneous insulin delivery devices with standard insulin therapy in insulin-requiring patients in the perioperative period undergoing elective surgery. A closedloop subcutaneous insulin delivery device incorporates a continuous glucose monitoring device which communicates real-time glucose data to the CSII which autonomously delivers insulin to maintain blood glucose within a desired range.
最近的一项单中心开放标签随机对照试验比较了在接受择期手术的围手术期需要胰岛素的患者中，闭环皮下胰岛素输送装置与标准胰岛素治疗的使用。闭环皮下胰岛素输送装置包括连续葡萄糖监测装置，该装置将实时葡萄糖数据传送到CSII，CSII自主输送胰岛素以将血糖维持在所需范围内。
Patients were randomised to a closed-loop group or a control group who received standard insulin management as per local policy. The primary endpoint was the proportion of time in which sensor glucose was in the target range of 5.6-10.0 mmol L1 . The study found that the mean proportion of time that the sensor glucose was in the target range was 76% (10%) in the closed-loop group and 55% (21%) in the control group (mean difference¼22.0 percentage points; 95% CI, 12-32%; P¼0.001)
患者被随机分为闭环组或对照组，根据当地政策接受标准胰岛素管理。主要终点是传感器葡萄糖在5.6-10.0 mmol L 1的目标范围内的时间比例。研究发现，闭环组传感器葡萄糖在目标范围内的平均时间比例为76%（10%），对照组为55%（21%）（平均差异¼22.0个百分点；95%CI，12-32%；P¼0.001）
There were no episodes of hypoglycaemia in either group. The study concluded that, in insulin-requiring patients undergoing surgery, closed-loop subcutaneous insulin delivery devices improve glycaemic control with no increase in risk of hypoglycaemia.
两组均未出现低血糖发作。该研究得出结论，在需要胰岛素的手术患者中，闭环皮下胰岛素输送装置可以改善血糖控制，而不会增加低血糖风险。
Fasting 禁食
There are several studies which examine the optimal fasting times for the patient with diabetes. This is of particular interest as there is a risk of gastroparesis, which is often undiagnosed.Prospective cohort studies showed that the prevalence of incomplete gastric emptying, measured by ultrasound, was higher in the patient with diabetes (48% vs 8%, P¼0.001) compared with the patient without diabetes, despite adherence to local fasting guidelines.
有几项研究考察了糖尿病患者的最佳禁食时间。这一点尤其令人感兴趣，因为胃轻瘫的风险通常无法诊断。前瞻性队列研究表明，尽管遵守了当地禁食指南，但糖尿病患者的胃排空不完全的发生率（48%对8%，P¼0.001）高于非糖尿病患者。
Another study observed that the prevalence of full stomach was 5% (95% CI, 2e9%) in elective patients and 56% (95% CI, 50-62%) in emergency patients (P<0.0001), with DM as an independent factor predictive of a full stomach (odds ratio [95% CI], 2.3 [1.2-4.6]; P¼0.012)
另一项研究观察到，择期患者的饱腹发生率为5%（95%CI，2e9%），急诊患者为56%（95%CI，50-62%）（P<0.0001），糖尿病是预测饱腹的独立因素（比值比[95%CI]，2.3[1.2-4.6]；P¼0.012）
There is also an association between the severity of gastrointestinal symptoms and the level of glycaemic control. A scoping review notes that the ‘true risk of aspiration in fasting patients with diabetes is unknown’. The review identified that there are few studies addressing the issue of whether the patient with diabetes is at increased risk of gastric aspiration.
胃肠道症状的严重程度与血糖控制水平之间也存在关联。一项范围界定综述指出，“糖尿病禁食患者误吸的真正风险尚不清楚”。该综述发现，很少有研究涉及糖尿病患者是否存在胃误吸风险增加的问题。
Preoperative optimisation
术前优化
Most institutions have guidelines in place for the perioperative management of the patient with diabetes. Unfortunately, these are not always adhered to. A region-wide prospective audit which looked at 17 hospitals in the UK found that compliance with national guidelines was poor. For instance, they found that the mean (standard deviation [SD]) fasting time was 12 (4) h.
大多数机构都制定了糖尿病患者围手术期管理指南。不幸的是，这些并不总是得到遵守。一项针对英国17家医院的全地区前瞻性审计发现，遵守国家指导方针的情况很差。例如，他们发现平均（标准差[SD]）禁食时间为12（4）小时。
There was a failure to commence a VRIII in 25 patients who missed two or more meals.Furthermore, only 8% of patients received the recommended substrate fluid (5% glucose in 0.45% saline) alongside VRIII, and although 87% of DM patients were seen in a preoperative assessment clinic, only 71% had their HbA1c recorded.
25名错过两次或两次以上用餐的患者未能开始VRIII。此外，只有8%的患者在接受VRIII的同时接受了推荐的基质液（5%葡萄糖在0.45%盐水中），尽管87%的糖尿病患者在术前评估诊所就诊，但只有71%的患者记录了HbA1c。
Audits demonstrate that the preoperative optimisation of patients with diabetes is lacking in elective cases.Indeed, the optimum care pathway for the patient with diabetes in the perioperative period for emergency surgery continues to create debate. One guideline recommends that the patient with diabetes be placed on a VRIII while awaiting emergency surgery and should have a capillary blood glucose of 6-10 mmol L1 on arrival to the operating theatre.
审计表明，在选择性病例中，糖尿病患者缺乏术前优化。事实上，糖尿病患者在急诊手术围手术期的最佳护理途径仍在引发争议。一项指南建议糖尿病患者在等待紧急手术时接受VRIII治疗，并且在到达手术室时毛细血管血糖应为6-10 mmol L 1。
A retrospective observational study (n¼48) observed that a HbA1c level taken on the day of emergency surgery was consistent with patients’ pre-morbid HbA1c levels -despite the stress response and inflammation associated with emergency surgery.
一项回顾性观察性研究（n¼48）观察到，尽管存在与急诊手术相关的应激反应和炎症，但急诊手术当天测得的HbA1c水平与患者发病前的HbA1c水平一致。
A post-hoc observational analysis of the Surgical Site Infection (SSI) Trial reported that there is a significant population of patients who have undiagnosed DM, based on their HbA1c levels. They noted that 65% (n¼45) of a preoperative patient group (n¼69) who self-reported no diabetes did in fact have HbA1c levels >42 mmol mol1 , consistent with prediabetes or T2DM.Furthermore, they noted that this cohort had the highest percentage of infections (39%) after major surgery.
一项对手术部位感染（SSI）试验的事后观察性分析报告称，根据HbA1c水平，有相当一部分患者患有未确诊的糖尿病。他们注意到，65%（n¼45）的术前患者组（n 1/4 69）自我报告没有糖尿病，事实上HbA1c水平>42 mmol mol 1，与糖尿病前期或T2DM一致。此外，他们还注意到，这一队列术后感染率最高（39%）。
These studies highlight the association between preoperative glycaemic control and postoperative outcome. Although preoperative glycaemic optimisation (e.g. HbA1c lowering) seems sensible, studies on the feasibility and efficacy are lacking and needed to substantiate this recommendation.
这些研究强调了术前血糖控制与术后结果之间的关系。尽管术前血糖优化（如降低HbA1c）似乎是明智的，但缺乏对可行性和疗效的研究，需要证实这一建议。
Perioperative management Glucose control
围手术期管理血糖控制
There principal objective for the anaesthetist caring for the patient with diabetes is to prevent hyperglycaemia and hypoglycaemia, maintaining blood glucose in the range 5-10 mmol L1 . Glucose usually peaks early after surgery, and this postoperative hyperglycaemia is a clear risk factor for complications. In a large retrospective cohort study (n¼11 633), examining the relationship between perioperative hyperglycaemia and insulin administration on outcomes in elective colorectal and bariatric surgery, patients with hyperglycaemia perioperatively had a significantly increased risk of postoperative infection (odds ratio [OR]¼2.0; 95% CI, 1.63e2.44), whether or not there was a pre-existing diagnosis of diabetes.
麻醉师护理糖尿病患者的主要目的是预防高血糖和低血糖，将血糖维持在5-10mmol L1的范围内。血糖通常在手术后早期达到峰值，这种术后高血糖是并发症的明显风险因素。在一项大型回顾性队列研究（n¼11 633）中，研究了围手术期高血糖和胰岛素给药对选择性结直肠和减肥手术结果的影响，围手术期患有高血糖的患者术后感染风险显著增加（比值比[OR]¼2.0；95%CI，1.63e2.44），无论是否有糖尿病的预先诊断。
This is further emphasised by a multicentre prospective observational study (n¼224) which noted that severe intraoperative hyperglycaemia (>10 mmol L1 ) is independently associated with new-onset infections in patients undergoing craniotomy, either elective and emergency (OR [95% CI]: 4.2 [1.5-11.5]; P¼0.006).
一项多中心前瞻性观察性研究（n¼224）进一步强调了这一点，该研究指出，严重的术中高血糖（>10 mmol L1）与开颅手术患者的新发感染独立相关，无论是择期还是急诊（OR[95%CI]:4.2[1.5-11.5]；P¼0.006）。
The CPOC guidelines recommend that blood glucose is maintained at 6-12 mmol L .
CPOC指南建议将血糖维持在6-12 mmol L 。
There are conflicting data regarding the optimal treatment of the patient with diabetes in the perioperative period. One randomised multicentre trial of T2DM patients undergoing elective or emergency surgery demonstrated that a basalbolus insulin regimen is superior to an insulin sliding scale (mean daily blood glucose concentration of 8.7 [1.8] vs 9.8 [2.4] mmol L1 ; P¼0.001) in the perioperative management of glycaemic control, also showing a reduction of postoperative complications.
关于糖尿病患者围手术期的最佳治疗，有相互矛盾的数据。一项针对接受择期或紧急手术的T2DM患者的随机多中心试验表明，在血糖控制的围手术期管理方面，基础推注胰岛素方案优于胰岛素滑动量表（平均每日血糖浓度为8.7[1.8]vs 9.8[2.4]mmol L1；P¼0.001），也显示出术后并发症的减少。
However, it has been demonstrated in other studies that over-zealous control of blood glucose can lead to harmful outcomes such as hypoglycaemia and increased morbidity and mortality.This must be balanced with data that higher blood glucose levels (>10 mmol L1 ) increase the risk of postoperative nosocomial infection. A prospective observational analysis noted that a serum glucose level >12.2 mmol L1 on Day 1 postoperatively was a sensitive (87.5%) but relatively non-specific (33.3%) predictor of the development of postoperative nosocomial infection.
然而，其他研究表明，过度控制血糖会导致低血糖、发病率和死亡率增加等有害后果。这必须与较高血糖水平（>10 mmol L1）增加术后医院感染风险的数据相平衡。一项前瞻性观察分析指出，术后第1天血糖水平>12.2 mmol L 1是术后医院感染发展的敏感（87.5%）但相对非特异性（33.3%）预测因素。
An RCT consisting of patients with (n¼152) and without (n¼150) diabetes undergoing coronary artery bypass graft (CABG) surgery evaluated the optimal level of glycaemic control to improve outcomes in cardiac surgery patients. Patients with hyperglycaemia were randomised into two groups -an intensive glucose control (target glucose 5.6-7.8 mmol L1 [n¼151] or a more conservative target of 7.8-10.0 mmol L1 [n¼151]).
一项由接受冠状动脉搭桥术（CABG）的糖尿病患者（n¼152）和非糖尿病患者（n¼150）组成的随机对照试验评估了改善心脏手术患者预后的最佳血糖控制水平。高血糖患者被随机分为两组，即强化血糖控制组（目标血糖5.6-7.8 mmol L 1[n¼151]或更保守的目标血糖7.8-10.0 mmol L 1[n¼]。
The primary outcome was a composite of complications including mortality, wound infection, pneumonia, bacteraemia, respiratory failure, acute kidney injury, or major cardiovascular events. Although median blood glucose was lower 7.3 (IQR, 6.9-7.7 mmol L1 ) in the intensive control group vs 8.6 (0.9) mmol L1 (IQR, 7.9e9.1 mmol L1 ) in the conservative group (P¼0.001), no significant difference in the composite outcome was observed (42 vs 52%, P¼0.08).
主要结果是并发症的复合，包括死亡率、伤口感染、肺炎、菌血症、呼吸衰竭、急性肾损伤或主要心血管事件。尽管强化对照组的中位血糖低于保守组的8.6（0.9）mmol L 1（IQR，7.9-9.1 mmol L）（P¼0.001），但综合结果没有显著差异（42%对52%，P¼0.08）。
A meta-analysis which examined the association between hyperglycaemia and SSI found a significant benefit for an intensive glucose control protocol vs a conventional protocol in SSIs (OR¼0.43; 95% CI, 0.29-0.64; P¼0.001). Unsurprisingly, there was a significantly higher risk of hypoglycaemic events in the intensive group compared with the conventional group (OR¼5.6; 95% CI, 2.6-11.9). They concluded that blood glucose <8.3 mmol L1 reduced the risk of SSI.
一项研究高血糖与SSI之间关系的荟萃分析发现，在SSI中，强化血糖控制方案与传统方案相比有显著益处（OR¼0.43；95%CI，0.29-0.64；P¼0.001）。不出所料，与常规组相比，强化组发生低血糖事件的风险显著更高（OR¼5.6；95%CI，2.6-11.9）。他们得出结论，血糖<8.3 mmol L1降低了SSI的风险。
A post-hoc cost analysis of the Intensive versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery (GLUCO-CABG) trial examined the financial cost of intensive (5.5-7.8 mmol L1 ) vs conservative (7.9-10 mmol L1 ) blood glucose control in the ICU in patients with and without diabetes undergoing CABG. They found that median hospitalisation costs were lower in the intensive group ($39 366 vs $42 141, P¼0.040) than in the conservative group. Data from ICU studies show that hyperglycaemia may be more harmful in patients with lower admission HbA1c,suggesting that future perioperative studies could explore personalised glucose targets.
冠状动脉旁路移植术（GLUCO-CABG）患者强化血糖控制与保守血糖控制试验的事后成本分析检查了ICU中接受CABG的糖尿病患者和非糖尿病患者强化血糖（5.5-7.8 mmol L1）与保守血糖（7.9-10 mmol L 1）控制的财务成本。他们发现，重症监护组的中位住院费用（39 366美元vs 42 141美元，P¼0.040）低于保守组。ICU研究的数据表明，高血糖对入院HbA1c较低的患者可能更有害，这表明未来的围手术期研究可以探索个性化的葡萄糖靶点。
A small single-centre prospective observational study (n¼52) consisting of patients with diabetes undergoing open nephrectomy surgery evaluated the association between longterm glycaemic control and postoperative analgesic requirements. Patients were divided into two cohorts -those with good glycaemic control (HbA1c <6.5%) and those with poor glycaemic control (HbA1c 6.5%). They found that, in the first 48 h postoperatively, fentanyl consumption was 20% higher in the cohort with poor glycaemic control (P¼0.007).
一项由接受开放性肾切除术的糖尿病患者组成的小型单中心前瞻性观察性研究（n¼52）评估了长期血糖控制与术后镇痛需求之间的关系。患者被分为两组，即血糖控制良好（HbA1c<6.5%）和血糖控制不佳（HbA1c 6.5%）的患者。他们发现，在术后的前48小时，血糖控制不佳的患者芬太尼的消耗量高出20%（P¼0.007）。
This cohort also reported higher rates of inadequate analgesia (89% vs 67% on movement, P¼0.03), suggesting that preoperative HbA1c level may be useful in anticipating postoperative analgesic requirements. Intermediate (up to 30 days) and longer-term outcomes in the postoperative patient with diabetes are not well researched. A small RCT (n¼151) examined the effect of continued follow-up care by a hospital diabetes team on HbA1c levels 1 yr after discharge in patients with diabetes who underwent elective surgery.
该队列还报告了更高的镇痛不足率（89%对67%的运动，P¼0.03），这表明术前HbA1c水平可能有助于预测术后镇痛需求。术后糖尿病患者的中期（长达30天）和长期结果尚未得到充分研究。一项小型随机对照试验（n¼151）研究了医院糖尿病团队在接受择期手术的糖尿病患者出院后1年继续随访对HbA1c水平的影响。
Patients were randomised into a continued care (CC) group or a usual care (UC) group. The research team found that the HbA1c at 1 yr in the continued group was 8.2 (1.4) vs 8.5 (1.5) in the UC group (P¼NS), indicating that continued follow-up by a hospital diabetes team did not have an additional impact on long-term glycaemic control; however, this study may have been underpowered.
患者被随机分为持续护理（CC）组或常规护理（UC）组。研究团队发现，持续治疗组1年时的HbA1c为8.2（1.4），而UC组为8.5（1.5）（P¼NS），这表明医院糖尿病团队的持续随访对长期血糖控制没有额外影响；然而，这项研究可能动力不足。
However, in terms of postoperative care, research is again scarce, and evidence mostly comes from small, underpowered studies. The ideal glucose target is not yet clearly elucidated.The adequate guidance and treatment of patients with diabetes in the postoperative period eagerly awaits larger trials. Personalised glucose targets, taking account of a given patient’s preoperative control, co-morbidities, and predilection to hypo- or hyperglycaemia, may be more appropriate.
然而，就术后护理而言，研究再次匮乏，证据大多来自小型、动力不足的研究。理想的葡萄糖靶点尚未明确阐明。糖尿病患者术后的充分指导和治疗迫切需要更大规模的试验。考虑到特定患者的术前控制、合并症和低血糖或高血糖的偏好，个性化的葡萄糖靶点可能更合适。
Adjuvant drugs and impact on glucose control Dexamethasone
辅助药物及其对血糖控制的影响地塞米松
A randomised stratified multi-centre trial examined the effects of dexamethasone on perioperative blood glucose levels (PADDAG trial). They evaluated patients (n¼302) undergoing general anaesthesia for elective noncardiac surgery who received either intravenous placebo, 4 or 8 mg of dexamethasone. Patients were stratified into non-diabetic,T1DM, and T2DM.
一项随机分层多中心试验研究了地塞米松对围手术期血糖水平的影响（PADDAG试验）。他们评估了接受全身麻醉进行选择性非心脏手术的患者（n¼302），这些患者接受了静脉注射安慰剂、4或8 mg地塞米松。将患者分为非糖尿病患者，
T1DM和T2DM。
The primary outcome was the perioperative blood glucose profile up to 24 h after surgery. They found that a single dose of dexamethasone (4 or 8 mg) did not significantly affect the maximal blood glucose in the 24h period after surgery, 10.3 (8.1-12.4), 12.6 (10.3-18.3), and 13.6 (11.2-20.1) mmol L1 in the placebo, dexamethasone 4 mg, and dexamethasone 8 mg groups, respectively (P¼0.15).In contrast, a retrospective study (n¼1037) compared the change in postoperative blood glucose from preoperative values in patients with T2DM after elective surgery who received 4, 8, or 10 mg of dexamethasone for the prophylaxis of postoperative nausea and vomiting (PONV).
主要结果是术后24小时的围手术期血糖状况。他们发现，单剂量地塞米松（4或8 mg）对手术后24小时内的最大血糖没有显著影响，安慰剂组、地塞米松4 mg组和地塞米松8 mg组分别为10.3（8.1-12.4）、12.6（10.3-18.3）和13.6（11.2-20.1）mmol L 1（P¼0.15）。相反，一项回顾性研究（n¼1037）比较了择期手术后接受4、8或10 mg地塞米松预防术后恶心呕吐（PONV）的T2DM患者术后血糖与术前值的变化。
They found that the patients who received 8 or 10 mg had a greater increase in blood glucose level compared with the 4 mg dose in the PACU (mean [SD], 3.2 [2.8] vs 2.4 [2.5] mmol L1 ; P<0.0001) over 24 h. Higher doses of dexamethasone are associated with greater perioperative increase in blood glucose levels compared with a 4 mg dose.
他们发现，在24小时内，与PACU中的4 mg剂量相比，接受8或10 mg剂量的患者血糖水平增加更大（平均[SD]，3.2[2.8]vs 2.4[2.5]mmol L1；P<0.0001）。与4 mg剂量的地塞米松相比，更高剂量的地塞米松与更大的围手术期血糖水平增加有关。
A definitive multi-centre, randomised, controlled, noninferior trial examined the effects of perioperative intravenous dexamethasone administration on postoperative surgical site infection rates in patients undergoing elective noncardiac surgery (Perioperative Administration of Dexamethasone and Infection [PADDI] trial).Their primary endpoint was the occurrence of SSI within 30 days of the day of surgery.
一个明确的多中心、随机、对照，非劣效试验研究了围手术期静脉注射地塞米松对择期非心脏手术患者术后手术部位感染率的影响（围手术期注射地塞米松和感染[PADDI]试验）。他们的主要终点是手术后30天内SSI的发生。
More than 8880 patients were randomised to receive either intravenous dexamethasone 8 mg or placebo during anaesthesia. Of this group, 13% had diabetes. SSI occurred in 8.1% in the dexamethasone group and 9.1% in the placebo group (risk difference adjusted for diabetes status, -0.9 percentage points; 95.6% CI, -2.1 to 0.3; P<0.001 for noninferiority). Of note, PONV in the first 24 h after surgery occurred in 42% in dexamethasone and in 54% in placebo (risk ratio¼0.78; 95% CI, 0.75e0.82).
超过8880名患者被随机分配在麻醉期间接受8 mg地塞米松静脉注射或安慰剂治疗。在这一组中，13%患有糖尿病。地塞米松组SSI发生率为8.1%，安慰剂组为9.1%（根据糖尿病状况调整的风险差异，-0.9个百分点；95.6%CI，-2.1至0.3；非劣效性P<0.001）。值得注意的是，在手术后的前24小时，地塞米松组和安慰剂组分别有42%和54%的患者出现PONV（风险比¼0.78；95%CI，0.75-0.82）。
It is important in the patient with diabetes that normal diet is resumed as soon as possible. The occurrence of PONV can delay resumption of normal eating and drinking which, in the patient with diabetes, can lead to further derangement of blood glucose control, increased risk of ketoacidosis and duration of insulin infusions, and delayed hospital discharge.
对于糖尿病患者来说，尽快恢复正常饮食是很重要的。PONV的发生会延迟恢复正常饮食，这对糖尿病患者来说可能会导致血糖控制进一步紊乱，酮症酸中毒的风险和胰岛素输注的持续时间增加，并延迟出院。
Magnesium sulphate
硫酸镁
It is hypothesised that magnesium decreases blood glucose through several mechanisms -increasing the affinity of insulin to its receptors, increasing secretion of insulin by the pancreas, potentiating insulin mediated glucose uptake, regulation of glycogenolysis and glucose output in the liver, decreasing release of catabolic hormones, and regulating glucose translocation into the cell.
据推测，镁通过几种机制降低血糖，如增加胰岛素对其受体的亲和力，增加胰腺分泌胰岛素，增强胰岛素介导的葡萄糖摄取，调节肝脏中的糖原分解和葡萄糖输出，减少分解代谢激素的释放，以及调节葡萄糖转运到细胞中。
A double-blinded RCT (n¼122) examined the efficacy of magnesium sulphate in reducing the blood glucose in diabetic patients undergoing cardiac surgery. The intervention group received a continuous infusion of magnesium sulphate at 15 mg kg1 h1 which was commenced 20 min before induction and continued for the first 24 h postoperatively. The control group received normal saline. They found that blood glucose and insulin requirements decreased in the magnesium patients. At ICU admission postoperatively, the patients receiving magnesium had a mean blood glucose of 8.8 (1.5) vs 9.7 (1.5) mmol L1 in the control group (P¼0.003)
双盲随机对照试验（n¼122）检查了硫酸镁在接受心脏手术的糖尿病患者中降低血糖的疗效。干预组在诱导前20分钟开始连续输注硫酸镁15 mg kg 1 h 1，并在术后前24小时持续输注。对照组接受生理盐水。他们发现镁患者的血糖和胰岛素需求降低。术后入住ICU时，接受镁治疗的患者的平均血糖为8.8（1.5）mmol L 1，而对照组为9.7（1.5）mol L 1（P¼0.003）
Regional anaesthesia
局部麻醉
It can be beneficial to consider regional anaesthesia in the patient with diabetes mellitus. Some of the benefits include the avoidance of airway complications, reduced incidence of PONV, earlier resumption of diet, decreased duration on insulin infusions, earlier mobilisation, opioid sparing, and reduced length of stay.
对糖尿病患者进行区域麻醉是有益的。其中一些好处包括避免气道并发症、降低PONV的发生率、更早恢复饮食、缩短胰岛素输注时间、更早动员、节省阿片类药物和缩短住院时间。
Reviews have concluded that patients with diabetes have an increased risk for the occurrence of difficult intubation -the most important contributing factors were found to be obesity, increased neck circumference, and stiff joint syndrome.
综述得出结论，糖尿病患者发生插管困难的风险增加，最重要的因素是肥胖、颈围增加和关节僵硬综合征。
A small prospective RCT (n¼68) examined the effect of spinal anaesthesia vs general anaesthesia on the surgical stress response and perioperative hyperglycaemia in patients with and without diabetes mellitus undergoing elective total hip replacement. A significant increase in glucose levels in both diabetic and non-diabetic patients who underwent a general anaesthetic compared with spinal anaesthesia was observed. They concluded that spinal anaesthesia attenuates the hyperglycaemic response to surgical stimuli both in patients with and without diabetes mellitus.
一项小型前瞻性随机对照试验（n¼68）研究了脊柱麻醉与全身麻醉对接受择期全髋关节置换术的糖尿病患者和非糖尿病患者的手术应激反应和围手术期高血糖的影响。与脊髓麻醉相比，接受全身麻醉的糖尿病和非糖尿病患者的血糖水平均显著升高。他们得出的结论是，无论是否患有糖尿病的患者，脊髓麻醉都会减弱对手术刺激的高血糖反应。
Some differences for patients with diabetes as compared with patients without diabetes may apply and are relevant for both the patient and anaesthetist, including longer block duration, a theoretical increased risk of neuropathy, and when using a catheter a possible increased infection risk.
与非糖尿病患者相比，糖尿病患者的一些差异可能适用，并且与患者和麻醉师都相关，包括阻滞持续时间更长、理论上神经病变风险增加，以及使用导管时可能增加的感染风险。
Preventable harms
可预防的危害
Whenever possible, hospital admission for patients with diabetes mellitus should be limited. The NHS National Diabetes Inpatient Audit (NaDIA) Harms 2020 reported 4605 serious events with harm for patients with diabetes mellitus. The most common event was hypoglycaemia, followed by inhospital DKA, foot ulcer, and hyperosmolar hyperglycaemic state (HHS). Recommendations from the NaDIA included participation in the Getting It Right First Time (GIRFT) program to optimise the surgical pathway, proper identification, and referral of patients with diabetes mellitus (including type) and aiming for avoidance of DKA and HHS.
在可能的情况下，应限制糖尿病患者住院。NHS全国糖尿病住院患者审计(NaDIA)危害2020报告了4605例糖尿病患者的严重危害事件。最常见的事件是低血糖，其次是院内DKA、足部溃疡和高渗性高血糖状态(HHS)。NaDIA的建议包括参与“正确的第一次”(GIRFT)计划，以优化手术途径，正确识别和转诊糖尿病患者(包括类型)，并以避免DKA和HHS为目标。
Limiting hospital admission, for example by ambulatory surgical treatment, has the potential of reducing iatrogenic harm, such as insulin administration errors, as described in the GIRFT diabetes workstream. Standardised perioperative care pathways have proven beneficial for patients with diabetes mellitus, although it should be noted that diabetes mellitus remains a risk factor for re-admission after ambulatory surgery.
如GIRFT糖尿病工作流程所述，限制住院，例如通过门诊手术治疗，有可能减少医源性伤害，如胰岛素给药错误。标准化的围手术期护理路径已被证明对糖尿病患者有益，但需要注意的是，糖尿病仍然是门诊手术后再次入院的危险因素。
Future research
未来的研究
One of the challenges facing future research of this topic is the lack of consistency in defining diabetes mellitus itself. This makes it difficult to identify trends, associations, and perioperative outcomes in this large cohort of patients. It is also evident that many of the available recommendations and guidelines are written based on consensus and expert opinions rather than on Level I or Level II clinical evidence.
该课题未来研究面临的挑战之一是对糖尿病本身的定义缺乏一致性。这使得在这一大群患者中很难确定趋势、关联和围手术期结果。同样明显的是，许多现有的建议和指南是基于共识和专家意见编写的，而不是基于一级或二级临床证据。
Furthermore, medications available to patients with DM are constantly evolving with new types of medications, especially GLP-1 agonists, DPP-4 inhibitors, and SGLT-2 antagonists; therefore, there is a lack of available clinical data evaluating these to optimise the perioperative course of the diabetic patient.
此外，糖尿病患者可用的药物也在不断发展，出现了新的药物类型，特别是GLP-1激动剂、DPP-4抑制剂和SGLT-2拮抗剂;因此，缺乏可用的临床数据来评估这些以优化糖尿病患者的围手术期的过程。
Next to new drugs, evolving wearable technology may also be of use for diabetes patients in the in-hospital setting, especially continuous glucose sensors, which could contribute to discharging patients to a virtual ward. It is possible that personalised treatment targets and the perioperative application of new antidiabetic medicines will be the study focus the coming years.
除了新药，不断发展的可穿戴技术也可能用于医院内的糖尿病患者，特别是连续血糖传感器，这可能有助于患者出院到虚拟病房。个性化治疗目标和新降糖药物的围手术期应用可能是未来几年的研究重点。
The ongoing ‘Management and outcomes of the perioperative care of European diabetic patients’ (MOPED) study will provide the largest prospective observational data on the perioperative journey of patients with diabetes mellitus, up to 30 days after undergoing surgery.This may generate hypotheses for RCTs on whether patients with poorly controlled DM preoperatively benefit from increased glycaemic control postoperatively, and whether any particular anaesthetic technique or perioperative glycaemic management favours preferred postoperative outcomes.
正在进行的“欧洲糖尿病患者围手术期护理的管理和结果”(mped)研究将提供糖尿病患者围手术期长达30天的最大前瞻性观察数据。这可能会对随机对照试验产生假设，即术前控制不良的糖尿病患者是否能从术后血糖控制中获益，以及是否有任何特定的麻醉技术或围手术期血糖管理有利于术后更好的结果。
It is likely that coordinated research networks focused on optimising perioperative management of patients with diabetes mellitus will be needed to generate sufficient power in clinical RCTs to inform best practice.
很可能需要集中于优化糖尿病患者围手术期管理的协调研究网络，以在临床随机对照试验中产生足够的力量，以告知最佳实践。
Authors’ contribution
作者的贡献
KC: Literature search and screening for relevant material, drafting manuscript for intellectual content, checking references.
PO’S: Literature search and screening for relevant material, proof-reading manuscript for intellectual content.
JH: Literature search and screening for relevant material, drafting and redrafting manuscript for intellectual content, checking references.
DJB: Instigator and identification of need within existing literature; Literature search and screening for relevant material, drafting and proof-reading manuscript for intellectual content.
KC:文献检索和筛选相关材料，为知识内容起草手稿，检查参考文献。
PO’s:文献检索和筛选相关材料，校对知识内容的手稿。
JH:文献检索和筛选相关材料，为知识内容起草和重新起草手稿，检查参考文献。
DJB:在现有文献中提出和确定需求;文献检索和筛选相关材料，起草和校对知识内容稿件。
Declaration of interest
利益申报书
None of the other authors have any conflict of interest.
其他作者都没有任何利益冲突。
Appendix A. Supplementary data
附录A.补充数据
Supplementary data to this article can be found online at https://doi.org/10.1016/j.bja.2023.02.039.
本文的补充资料可在https://doi.org/10.1016/j.bja.2023.02.039网站上找到。
