摘要 背景： 冠状动脉旁路移植术是治疗冠心病的主要手段，患者术后容易出现高血糖并导致较大的血糖波动。尤其在冠心病合并糖尿病患者中，因其血糖自我调节受损的生理特点，需要依靠药物来维持血糖。围术期血糖管理不当会增加患者高血糖或低血糖的风险，血糖波动较大，维持稳态较为困难。目前，冠心病合并糖尿病患者围术期规范化血糖护理管理方案较少，内容不够明确。且临床实践差异大，多从维持血糖水平、预防血糖异常角度进行，对于患者血糖波动关注较少，缺乏患者术前、术后血糖综合性护理管理方案。 目的： 1. 描述冠心病合并糖尿病患者冠状动脉旁路移植术后血糖波动水平并分析其相关因素；2. 构建冠心病合并糖尿病患者冠状动脉旁路移植术术前、术后血糖护理管理方案。 方法： 本研究包括两个部分。第一部分，采用横断面调查研究方法，便利抽样2022年9月～2023年2月于中国医学科学院阜外医院成人外科病区行择期冠状动脉旁路移植术的冠心病合并糖尿病患者，通过收集患者住院期间一般资料和临床资料，描述冠心病合并糖尿病患者冠状动脉旁路移植术后血糖波动水平及变化趋势，通过单因素分析、多元线性回归，分析患者术后血糖波动相关因素；第二部分，通过文献回顾、小组讨论、专家会议法，结合患者术后血糖波动相关因素构建冠心病合并糖尿病患者冠状动脉旁路移植术术前、术后血糖护理管理方案。 结果： 1. 第一部分研究结果：（1）冠心病合并糖尿病患者冠状动脉旁路移植术后血糖标准差为2.85 ± 0.85 mmol/L，术后单日血糖标准差呈逐渐上升趋势，于术后第4天趋于平稳；日间血糖平均绝对差为2.58 ± 0.94 mmol/L，术后第2天与术后第1天之间的日间血糖平均绝对差最大，后趋于平稳；最大血糖波动幅度为 11.89 ± 3.94 mmol/L，术后单日最大血糖波动幅度呈逐渐上升趋势，于术后第4天趋于平稳。（2）患者术后血糖标准差的独立相关因素有糖尿病病程（t= 2.040 ; P=0.042）、常规胰岛素治疗（t= 2.080 ; P=0.038）、常规口服联合胰岛素治疗（t= 2.500 ; P=0.013）、糖化血红蛋白（t= 2.062 ; P=0.040）、静脉泵入胰岛素（t= -2.670 ; P=0.008）。（3）术后日间血糖平均绝对差的独立相关因素有性别（t= 2.574; P=0.011）、糖尿病病程（t= 2.100 ; P=0.037）、糖化血红蛋白（t=2.366; P=0.019）、血清肌酐（t= 2.377 ; P=0.018）、静脉泵入胰岛素（t= -2.815 ; P=0.005）、使用肠外营养（t=-2.137 ; P=0.033）。（4）术后最大血糖波动幅度的独立相关因素有常规口服降糖药治疗（t= 1.997 ; P=0.047）、常规胰岛素治疗（t= 2.395 ; P=0.017）、常规口服联合胰岛素治疗（t= 2.463 ; P=0.014）、手术时间（t= 1.986 ; P=0.048）、糖化血红蛋白（t= 1.409 ; P=0.160）、静脉泵入胰岛素（t=-2.140 ; P=0.033）、使用肠外营养（t=-3.211 ; P=0.001）。 2. 第二部分研究结果：（1）13名临床医学及护理专家判断系数为 0.95，专家熟悉程度为 0.92，专家权威程度为 0.93 ；（2）冠心病合并糖尿病患者冠状动脉旁路移植术术前、术后血糖护理管理方案包含了患者术前、术后两个阶段的血糖护理管理内容，从血糖特点及重点人群、血糖监测、药物管理、营养支持治疗管理、运动管理、心理护理、健康教育七个主题构建。 结论： 1. 冠心病合并糖尿病患者冠状动脉旁路移植术后血糖波动水平较大。术后单日血糖标准差呈逐渐上升趋势，于术后第4天趋于平稳；术后第2天与术后第1天之间的日间血糖平均绝对差最大，后趋于平稳；术后单日最大血糖波动幅度呈逐渐上升趋势，于术后第4天趋于平稳。 2. 患者糖化血红蛋白越高、糖尿病病程越长、术后血清肌酐越高，患者术后血糖波动水平越高。女性血糖波动水平高于男性，术后使用静脉泵入胰岛素患者的术后血糖波动水平高于未使用者，术后使用肠外营养支持患者的术后血糖波动水平高于未使用者。在术后不同常规降糖治疗方案中，使用口服联合胰岛素治疗、单纯胰岛素治疗的患者术后血糖波动水平高于单纯口服降糖药治疗与未使用药物治疗的患者。 3. 通过专家会议法构建的冠心病合并糖尿病患者冠状动脉旁路移植术术前、术后血糖护理管理方案，较为可靠、科学，有一定的临床实用性。 关键词：冠心病；糖尿病；冠状动脉旁路移植术；血糖波动；护理管理方案

Abstract Background ： Coronary artery bypass grafting is the main treatment for coronary artery atherosclerotic heart disease, and patients are prone to induce hyperglycemia and lead to high glycemic variability after surgery. Especially in patients with coronary artery disease complicated with diabetes mellitus, they need to rely on drugs to maintain blood glucose because of their physiological characteristics of impaired glycemic self-regulation. Improper perioperative glucose management increases the risk of hyperglycemia or hypoglycemia in patients, with large glycemic variability and more difficulty in maintaining blood glucose homeostasis. At present, there are few standardized perioperative blood glucose nursing management programs for patients with coronary artery disease complicated with diabetes, and the content lacks detail. Moreover, the blood glucose management in clinical nursing practice varies greatly, mostly from the perspective of maintaining blood glucose level, and preventing abnormal blood glucose , with less attention paid to postoperative glycemic variability, and lacking a comprehensive nursing management program of preoperative and postoperative blood glucose. Objective ： 1.Describe the level of glycemic variability after coronary artery bypass grafting in patients with coronary artery disease complicated with diabetes and analyze its related factors; 2. to Construct a preoperative and postoperative blood glucose nursing management program for coronary artery bypass grafting in patients with coronary artery disease complicated with diabetes. Methods ： The research consists of two parts. In part one, a cross-sectional survey study of 327 patients with coronary artery disease complicated with diabetes mellitus who underwent elective coronary artery bypass grafting in the adult surgery ward of Fu Wai Hospital, Chinese Academy of Medical Sciences from September 2022 to February 2023. Describing the level and trend of glycemic variability after coronary artery bypass grafting in patients with coronary heart disease complicated with diabetes by collecting general and clinical data during the patients' hospitalization, and analyzing the factors related to postoperative glycemic variability by univariate analysis and multiple linear regression. In part two, the preoperative and postoperative blood glucose nursing management program for patients with coronary artery disease complicated with diabetes mellitus undergo coronary artery bypass grafting was constructed, through literature review, group discussion, and expert meeting method and combining factors related to postoperative glycemic variability. Results ： 1. The results of part one: (1) The standard deviation of blood glucose after coronary artery bypass grafting in patients with coronary artery disease complicated with diabetes was 2.85 ± 0.85 mmol/L. The standard deviation of blood glucose on a single day after surgery tended to rise gradually and leveled off on postoperative day 4; the mean of daily differences was 2.58 ± 0.94 mmol/L, the mean of daily differences between postoperative day 2 and day 1 was the highest and leveled off afterwards; The largest amplitude of glycemic excursion was 11.89 ± 3.94 mmol/L, and the largest amplitude of glycemic excursion on a single day after surgery tended to rise gradually and leveled off on the fourth postoperative day. (2) The independent factors associated with the standard deviation of blood glucose were the duration of diabetes (t= 2.040; P=0.042), conventional insulin therapy (t=2.080; P=0.038), conventional oral combined insulin therapy (t= 2.500; P=0.013), glycated hemoglobin (t= 2.062; P=0.040), intravenous insulin pump (t= -2.670; P=0.008). (3) The independent factors associated with the mean of daily differences were gender (t= 2.574; P=0.011), duration of diabetes (t= 2.100; P=0.037), glycosylated hemoglobin (t=2.366; P=0.019), serum creatinine (t= 2.377; P=0.018), intravenous insulin pump (t= -2.815 ; P=0.005), and parenteral nutrition (t=-2.137 ; P=0.033). (4) The independent factors associated with the largest amplitude of glycemic excursion were conventional oral hypoglycemic therapy(t= 1.997 ; P=0.047), conventional insulin therapy (t= 2.395 ; P=0.017), conventional oral combined insulin therapy (t= 2.464 ; P=0.014), duration of surgery (t= 1.986 ; P=0.048), glycated hemoglobin (t= 1.409 ; P=0.160), use of intravenous insulin pump (t=-2.140 ; P=0.033), and parenteral nutrition (t=-3.211 ; P=0.001). 2. The results of part two: (1) The judgment coefficient of 13 clinical medicine and nursing experts was 0.95, the familiarity of experts was 0.92, and the authority of experts was 0.93. (2) the preoperative and postoperative blood glucose nursing management program after coronary artery bypass grafting in patients with coronary heart disease complicated with diabetes mellitus included the preoperative and postoperative two nursing phase blood glucose nursing management. This blood glucose nursing management program includes seven themes: glucose characteristics and key populations, blood glucose monitoring, medication management, nutrition support therapy management, exercise management, psychological nursing, and health education. Conclusions： 1. The glycemic variability after were high in patients with coronary artery disease complicated with diabetes mellitus. The postoperative single-day standard deviation of blood glucose tended to rise gradually and leveled off on postoperative day 4; the largest mean of daily difference between postoperative day 2 and day 1 was the highest and then leveled off; the postoperative single-day largest amplitude of glycemic excursion tended to rise gradually and leveled off on postoperative day 4. 2. The higher the glycosylated hemoglobin, the longer the duration of diabetes, and the higher the postoperative serum creatinine, the higher the postoperative glycemic variability. Glycemic variability was higher in women than in men, and postoperative glycemic variability was higher in patients with postoperative intravenous insulin pumps than in patients without postoperative intravenous insulin pumps, and postoperative glycemic variability was higher in patients with postoperative parenteral nutrition support than in patients without postoperative parenteral nutrition support. Among the different conventional postoperative glucose-lowering regimens, the postoperative glycemic variability was higher in patients treated with oral combined insulin therapy and insulin alone than in patients treated with oral therapy alone and without drug therapy. 3. The preoperative and postoperative blood glucose nursing management program after coronary artery bypass grafting in patients with coronary artery disease complicated with diabetes mellitus, constructed through the expert meeting method, is reliable, scientific, and clinically practical. Keywords：Coronary Heart Disease；Diabetes Mellitus；Coronary Artery Bypass Grafting；Glycemic Variability; Nursing Management Program