Effects Of Glucose-insulin-potassium On Ventricular Arrhythmias And Heart Rate Variability Of Perioperative Period In The Elderly Patient

World Health Organization(WHO) report showed the life span of our country has already approached 73 years old.National census indicated that the proportion of 65 years old person to our population is 8.51%rencently.With age increasing,the changes of cordis electricity physiology in the aged people could be frequently associated with various cardiacarrhythmia(CA).Frequent multi-sources ventricular ectopic beats(FVEB),coupled rhythm or trigeminy of ventricular ectopic beats(VEB) and ventricular tachycardia(VT) etc. may change haemodynamics.Some patients were unwell,even were caused cardiac function broken compensation and urged myocardial ischemia.Those CA could result in serious consequence.It was one of the important factors that the aged people was caused death.It was necessary to examine early and give treatment in time.Compared with the youth,the aged patient who was carried out emergency or big and medium-sized surgical operations, was much easy to induct and aggravate various cardiac risk event(CRE),being up to 12.8%.It was the main factor that threaten the aged life safety of perioperative period seriously.Therefore,many clinical workeres pay attention how to predict the preoperative risk factors of CRE and to adopt corresponding measures during operation and after operation,as to insure they smoothly passed through perioperative period.Some studies expressed thatβ-receptor blockers,alpha(2)-adrenergic agonists and statins could prevent perioperative period heart ischemia affairs from generating and reducing mortality. Among them,Mangano et al still considered that the treatment withβ-receptor blockers during hospitalization could reduce mortality and the incidence of cardiovascular complications for as long as two years after surgery.Glucose-insulin-potassium(GIK,or called polarized solution) was a traditional classic old medicine,which mainly nursed one's health through metabolic modulation to protect ischemic myocardial cell and myocardial functions.This concept was introduced first time by the Sodi-pallares et al in 1962. Through a great deal of clinic observation and studying,Opie further elaborated theoretically in 1970 and believed that GIK could promote myocardial cell glycolysis and reduce serum free fatty acids(FFA).Its rationale foundation included:â‘ to provide ischemic myocardium more energies,to let insulin promote myocardial cell uptake and make use of glucose,to promote the function instauration of ischemic myocardium at last;â‘¡insulin stimulated myocardial cell Na⁺-K⁺-ATP enzyme,promoted myocardial cell uptake K⁺,thus stabilized polarization state of cytolemma,reduced the occurrence of cardiac arrhythmia. However,alonged with the clinical data review analysis on GIK and a great deal of foundational clinic studies of that realm in recent years,it was suggested that GIK had many new pharmacological characteristic,such as anti-inflammatory,anti-Apoptosis,promoted repair,reduction of low output syndromes(LOS) and cardiac arrhythmia,improvement of microcirculation and raise of HRV(heart rate variability) et al.cardiovascular protection effectiveness.In addition,Ranasinghe et al discovered that GIK improved hemodynamic performance after coronary artery bypass grafting(CABG).The beneficial increased cardiac index(CI) of GIK therapy was associated with increased ADRB1 and SERCA2a mRNA expression.HRV analysis was a new method of quantitative assessment on cordis automatic nervous system function in recent years.The application and study in cardiovascular disease was increasingly extensive.Many studies have enunciated that HRV abaissement was the independent estimate index of sudden cardiac death.This anticipation had some thing to do with fatal ventricular arrhythmia(VA).Many heart pathological change processes, especially VA and myocardial ischemia(MI) et al were often accompanied with changes of HRV.These clinic studies that GIK infusion could protect myocardium at a long time were all concentrated on heart surgical operation or myocardial infarction,and existed a good deal of dispute.However,effects that GIK transient infusion on VA and HRV had no accepted argument.This study wants to do some approach in this aspect.Objective To observe the influence of GIK application during the period of operation on VA and HRV of gerontal patient,we explored whether GIK was beneficial to the elderly people live through perioperative period steadily or not.Methods1.patients and groupsThis study was approved by the institutional review board and informed written consent was obtained from each subject.Between January 2008 and October 2008,a total of 50 consecutive patients entered in the Guangzhou General Hospital of Guangzhou Military Command to force-progress stomach intestines,vertebra lumbalis internal fixation, extremitas inferior surgical operation were adopted preoperative evaluation,ASA gradeâ… orâ…¡,age≥65 years old.Standard of depletion included:preoperative electrocardiogram check discovered that the left or right bundle branch conduction blockade,atrial fibrillation or atrial flutte,pacing cardiac rhythm,limb lead low tension;preoperative biochemistry check acquired hyperpotassaemia or hypoglycaemia;received insulin,β-receptor blocker,digoxin or conchine treatment perioperatively;hypersensitiveness history in investigative drug.All patients were divided into control group(group C) and GIK group(group G).2.anaesthesiaAtropine 0.01mg/kg and phenobarbital sodium 2mg/kg were given i.m.approximately 30 minutes before anaesthisa.Electrocardiogram(ECG),noninvasive blood pressure,pulse blood oxygen saturation(SpO₂) were monitored after going into operating room and quieting 10 minutes.Abdomen or lumbar vertebrae operation was adopted endotracheal intubation anesthesia.Anaesthesia was induced i.v.one by one with innovar(droperidol and fentanyl were admixed by 50:1) 4ml,propofol 1.0～1.5mg/kg,benzenesulfonic acid cisatracurium 0.2mg/kg.Patients were ventilated by anaeshetic machine with tidal volume 8～10ml/kg, respiratory rate 12～14 breaths/min,and P_ETCO₂ was controlled at 30～40mmHg.Anaesthesia was maintained with propofol(4～6 mg·kg^-1·h^-1) and remifentanil(0.1～0.2μg·kg^-1·h^-1). Lower limbs operation was adopted combined spinal and epidural anaestesia(CSEA).An epidural transfixion pin was inserted at L3/4 or L4/5 interspace,cavitas subarachnoidealis was infused into 0.5%bupivcaine 7～12 mg,then epidural catheter was inserted into cavitas epiduralis approximately 3.0～5.0cm.Anaesthesia blockage plane was controlled about T₁₀. The mixed liquor contained 1%lidocaine and 0.25%laevo-bupivcaine 3.0～5.0ml was reasonably infused into cavitas epiduralis according to demand.Balanced solution and colloid were dripped into maintaining blood volume.GIK therapy(50%dextrose 50ml, regular insulin 10 IU,and potassium chloride 4mmol) at a dose of 0.4 ml·kg^-1·h^-1 was administered from anesthesia beginning until operation ending after measuring blood glucose.All patients were detected peripheral blood glucose by ACCU-CHEK Active respectively before anaesthesia,surgical operation beginning and ending.50%dextrose 20～40ml was given through intravenous injection when blood glucose level≤3.0mmol/L.3.postoperative analgesiaDuring postoperative forty-eight hours,every patient received patient-controlled analgesia(PCA) through either the i.v.route(general anaesthesia patients) or epidural route (CSEA patients).Admixture of flurbiprofen axeyil 1.5 mg/ml and pentazocine 0.9 mg/ml was contained in PCIA pump.Laevo-bupivcaine 0.125%with butorphanol 0.05 mg/ml was contained in PCEA pump.All parameters of PCA pump were 1.5～2.0ml/h,PCA is 1.5～2.0 ml,caging time is 30 minutes.After surgery,the initial rate and bolus volume of PCA pump were adjusted by the special anaesthetist according to clinical situation to make patient calm.Pain scores were recorded at 6h,12h,24h,36h,48h after surgery.Recording of pain scores and parameters adjustment of PCA were performed by one of the authors blind to the group allocation.A standard visual analogue(VAS) for pain,0 score,1～3 score,4～6 score,7～9 score,10 score means no pain,mild pain,moderate pain,severe pain,agonia respectively.If the VAS score was more than 4,the PCA pump speed was increased by one third and a bonus of 3.0～5.0 ml was given.If the score remains high,i.v.pentazocine 30 mg was given.4.ECG analysisMulti-channel dynamic electrocardiographic(DCG) data of preoperative 12h and postoperative 48h,all patients were acquired and transfered for computerized analysis by software(DMS Holter 5.0 program,USA).The decisions made automatically by the computer were reviewed and reported by an experienced technician blind to group allocating. Frequent ventricular arrhythmias consist of ventricular ectopic beats,ventricular couplets, frequent ventricular ectopic beats,ventriculartachycardia.The analytical method of HRV included time domain analysis and frequency domain analysis.Time domain index contained(1) SDNN);(2) SDNNindex;(3)SDANNindex;(4)rMSSD;(5)PNN50.Frequency domain index contained total power(TP:0.01～0.4Hz),high frequency power(HF:0.15～0.4 Hz),low frequency power(LF:0.04～0.15Hz),very low frequency power(VLF:0.003～0.04 Hz) and LF/HF.Results1.Comparison of general numerical data between two groups.There were no significant differences of sex,age,operative site,anaesthesia method etc. between two groups.2.There was no significant difference of VAS scores between two groups.3.Changes of blood glucose each moment between two groups during operation(P= 0.000 and P=0.000) were significant differences.The blood glucose levels of three times were on the increased in Control group,blood glucose levels of operation started and operation finished were much higher than that of before anesthesia(P=0.024).In GIK group,the blood glucose level steped up first,then cut down,but the blood glucose level of operation finished was no obviously slower than that of operation beginning.The blood glucose level between two groups was significant differences(F=6.360,P=0.017).4.Comparison of perioperatively ventricular arrhythmias(VA) occurrence between two groups.VA was almost appeared in overall patients perioperatively(93.75%,excepted for two patients),ventricular flutter and ventricular fibrillation did not appear.There was significant difference of VEB in GIK group(χ²=18.072,P=0.001),their mean Rank was 4.06 vs 3.53 vs 2.63 vs 2.66 vs 2.13,but no significant difference in Control group perioperatively.There were significant difference of patient number that VEB appeared and its frequency increase at postoperative 24h,36h,48h between two groups(10/1 vs 3/8,χ²=9.214,P=0.008 and 8/4 vs 2/8,χ²=4.791,P=0.043 and 10/1 vs 2/5,χ²=7.418,P=0.013),those of Control group was more than those of GIK group.5.Comparison of HRV perioperatively between two groups.There were significant differences of SDNN,SDANNindex,SDNNindex,rMSSD,TP, HF,LF and VLF perioperatively between two group(P=0.000 and P=0.000 and P=0.000 and P=0.002 and P=0.000 and P=0.000 and P=0.000 and P=0.000),those of before operation were lower than those of after operation.SDNN,SDANNindex,SDNNindex,rMSSD and TP were no significant differences between the first day and the second day after operation. They cut down gradually in Control group,but opposite in GIK group.There was significant difference of SDNN between two groups(F=4.518,P=0.042).That of GIK group was much higher than control group.ConclusionApplication of this component GIK could control stress hyperglycemia properly,decrease the occurrence of VA(ventricular arrhythmias) in two days after operation and prevent HRV from going down in two days after operation.It was beneficial to the elderly people live through perioperative period safely.