实施每日唤醒对多发伤患者血糖波动和病死率影响的临床研究  

Clinical study of the influence of daily sedation interruption on fluctuation of blood glucose level and mortality of critical patients with multiple trauma

作　　者：李勇[1] 金兆辰[1] 蔡燕[1] 吉木森[1] 孔宪如[1] 刘竟[1] 杨宏锋[1] 王成龙[1] 

机构地区：[1]江苏大学附属人民医院重症医学科,镇江212002

出　　处：《中华危重病急救医学》2014年第4期233-238,共6页Chinese Critical Care Medicine

基　　金：卫生部国家临床重点专科建设项目（2011-872）

摘　　要：目的 评估实施每日唤醒对多发伤患者血糖波动和病死率的影响.方法 采用前瞻性研究方法,观察68例危重症患者入重症监护病房（ICU）实施每日唤醒计划后首个24 h内的血糖情况,每2h检测1次,计算血糖平均值（MEAN）、标准差（SD）、变异系数（CV）、血糖不稳定指数（GLI）、日内平均血糖波动幅度（MAGE）、最大血糖波动幅度（LAGE）;记录30 d病死率.根据MEAN和GLI的中位数将患者分为低MEAN＋低GLI组（A组,34例）、低MEAN＋高GLI组（B组,14例）、高MEAN＋低GLI组（C组,12例）、高MEAN＋高GLI组（D组,8例）4组,比较各组间血糖水平、血糖波动情况及转归水平.结果 68例患者中共死亡5例,总体病死率为7.4％,其中A组预后最佳[病死率为0（0/34）],D组预后最差[病死率为37.5％（3/8）].血糖水平指标MEAN（mmol/L）以A、B组较低（6.7±1.3、7.6±0.8）,C、D组较高（9.3±1.4、10.7±1.3）.血糖波动指标SD（mmol/L）、CV、GLI、LAGE （mmol/L）、MAGE （mmol/L）以A、C组较低（SD：1.6±0.4、1.7±0.6,CV：0.2±0.1、0.2±0.1,GLI：26.5±19.5、40.1±17.6,LAGE：4.6±2.3、6.5±1.9,MAGE：2.7±0.8、3.1±0.8）,B、D组较高（SD：2.9±0.7、3.9±0.8,CV：0.4±0.1、0.4±0.1,GLI：120.5±33.2、184.6±98.4,LAGE：9.5±2.0、12.7±4.0,MAGE：6.2±1.2、7.6±1.8）.低血糖发生率以D组最高[5.8％（6/104）],B组次之[1.6％（3/182）],A、C组较低[0.9％（4/442）,0.1％（2/256）].高血糖发生率以C、D组较高[67.3％（105/156）、69.2％（72/104）],B组次之[33.5％（61/182）],A组最低[15.4％（68/442）].A组的机械通气时间[（3.4±3.3）d]、多器官功能衰竭发生率[44.1％（15/34）]、连续性肾脏替代治疗（CRRT）使用率[11.8％（4/34）]、ICU住院时间[（5.1±3.9）d]均为最佳,D组最差[分别为（9.4±5.2）d、87.5％（7/8）、75.0％（4/8）、（10.3±7.4）d].结论 每日唤醒可以减少多发伤患者血糖波动,改善患者预后.Objective To assess the influence of a protocol of routine daily interruption of sedation on fluctuation of blood glucose level and mortality of critical patients with multiple trauma.Methods A prospective study involving 68 critical patients with multiple trauma admitted to intensive care unit （ICU） was performed.Finger blood glucose level was measured after the implementation of daily interruption of sedation,and the results were recorded every 2 hours during the first 24 hours.Mean （MEAN）,standard deviation （SD） and coefficient of variability （CV） of blood glucose level,glycemic liability index （GLI）,mean amplitude of glycemic excursion （MAGE） and largest amplitude of glycemic excursions （LAGE） were calculated respectively,and 30-day mortality was recorded.The patients under study were divided into four groups according to the median values of MEAN and GLI,group A with patients of low MEAN ＋ low GLI （n=34）,group B with patients of low MEAN ＋ high GLI （n=14）,group C with patients of high MEAN ＋ low GLI （n =12）,and group D with patients of high MEAN ＋ high GLI （n =8）.Glucose levels,their range of fluctuation,and the prognosis were compared among groups.Results Five of the 68 patients died,with a gross mortality rate of 7.4％.Group analysis demonstrated that the patients in group A had the best prognosis with the 30-day mortality rate of 0 （0/34）,while that of the group D was worst with the 30-day mortality rate of 37.5％ （3/8）.The MEAN levels of glucose （mmol/L） were relatively lower in groups A and B （6.7 ± 1.3,7.6 ±0.8） and higher in groups C and D （9.3 ± 1.4,10.7 ± 1.3）.Indicators of glucose level fluctuation,including SD （mmol/L）,CV,GLI,LAGE （mmol/L）,and MAGE （mmol/L）,were lower in groups A and C （SD：1.6 ±0.4,1.7 ±0.6; CV：0.2 ±0.1,0.2 ±0.1; GLI：26.5 ± 19.5,40.1 ± 17.6; LAGE：4.6 ± 2.3,6.5 ± 1.9; MAGE：2.7 ± 0.8,3.1 ± 0.80）,and higher in groups B and D （SD：2.9 ± 0.7,3.9 ±0.8; CV：0.4 ±0.1,0.

关 键 词：血糖波动 多发伤 每日唤醒 

分 类 号：R459.7[医药卫生—急诊医学]