胰岛素严格控制血糖对脓毒症患者的影响及其机理的初步探讨  

Influence and mechanism of a tight control of blood glucose by intensive insulin therapy on human sepsis

作　　者：虞文魁[1] 李维勤[1] 王晓东[1] 燕晓雯[1] 祁晓平[1] 李宁[1] 黎介寿[1] 

机构地区：[1]南京军区南京总医院全军普通外科研究所,210002

出　　处：《中华外科杂志》2005年第1期29-32,共4页Chinese Journal of Surgery

基　　金：军队"十五"科研基金重点项目 (0 1Z0 11)

摘　　要：目的　探讨用胰岛素严格控制血糖对脓毒症患者预后和并发症的影响及其可能的机理。方法　将 5 5例脓毒症患者随机分为严格控制血糖组 (用胰岛素控制血糖在 4 4～ 6 1mmol/L)和常规治疗组 (血糖控制在 10 0～ 11 1mmol/L)。在入院后的 2 4h、3d、5d和 7d、10d、14d用流式细胞仪测定外周血单核细胞HLA DR的变化 ,并同时收集炎症反应指标 ,包括血肿瘤坏死因子α(TNF α)、白细胞介素 6 (IL 6 )和C 反应蛋白 (CRP) ,以及病情严重度 (APACHEⅡ评分、SOFA评分 )、感染并发症和预后等资料 ,在两组之间进行比较。结果　相对于常规治疗组 ,严格控制血糖组体温异常持续时间、发热时间以及呼吸机辅助呼吸时间均显著缩短 (P <0 0 5 ) ,同时住院期间的ΔSOFA也显著降低(P <0 0 5 )。在严格控制血糖组有 3例 (11% )患者并发了低血糖 ,经过及时治疗未出现明显的不良后果。在感染初期单核细胞表面HLA DR表达降低、血CRP浓度增加 ,随着病程的推移HLA DR表达逐渐恢复 ,血CRP也逐渐降低。严格控制血糖组HLA DR表达的恢复较常规治疗组更快 ,入院后 3d、5和 7d存在显著差异 (P <0 0 5 ) ;同时血CRP浓度的下降也有更明显的趋势 ,在入院后 10d有显著差异 (P <0 0 5 )。结论　用胰岛素严格控制血糖能加快感染患者恢复。Objective To investigate the effect of a tight control of blood glucose by intensive insulin therapy on human sepsis, and to explore the potential mechanism of the intensive insulin therapy. Methods Eligible patients were randomized by a blinded pharmacist to receive tight control of blood glucose by intensive insulin therapy (maintenance of blood glucose at a level between 4 4 and 6 1 mmol/L) or to receive conventional treatment (maintenance of glucose at a level between 10 0 and 11 1 mmol/L). The expression of HLA DR on peripheral monocytes was measured in 54 patients by flow cytometry on 24 h、3 d、5 d、7 d、10 d and 14 d of intensive care in parallel with serum c reactive protein (CRP), severity of the disease (APACHE II score, SOFA score) and clinical data collection. Results Patients receiving intensive insulin therapy were less likely to require prolonged mechanical ventilation. Tight control of blood glucose significantly reduced the number of days during which leukopenia or leukocytosis and the days with hypo or hyperthermia ( P <0 05). Hypoglycemia occurred in 3 patients (10 7%) in the tight control of blood glucose group. There were no instance of hemodynamic deterioration or convulsions. Compared with the conventional treatment, tight control of blood glucose also increased the HLA DR expression of peripheral monocytes, and there were significantly difference on 3 d, 5 d and 7 d ( P <0 05). Whereas it suppressed the elevated serum CRP concentrations, there was significantly difference on 7 d ( P <0 05). Conclusions Tight control of blood glucose by intensive insulin therapy expedited healing of human sepsis, and increased the HLA DR expression of peripheral and suppressed the elevated serum CRP. So, it is necessary to use insulin to strict control the glucose levels in human sepsis.

关 键 词：控制血糖 患者 胰岛素 CRP 脓毒症 常规治疗 严格 表达 快感 恢复 

分 类 号：R631[医药卫生—外科学]