强化胰岛素治疗对严重胸部创伤伴应激性高血糖患者免疫功能及预后的影响  

Effect of intensive insulin therapy on immune function and prognosis in severe chest trauma patients with stress hyperglycemia

作　　者：张兰 余坷坪 胡维书 吴建梅 陈小华 Zhang Lan;Yu Keping;Hu Weishu;Wu Jianmei;Chen Xiaohua(Department of Endocrinology, Chongqing Hospital (Chongqing People's Hospital), University of Chinese Academy of Sciences, Chongqing 400013, China;Department of Intensive Care Unit, Chongqing Hospital (Chongqing People's Hospital), University of Chinese Academy of Sciences, Chongqing 400013, China;Department of Orthopedics, Chongqing Hospital (Chongqing People's Hospital), University of Chinese Academy of Sciences, Chongqing 400013, China)

机构地区：[1]中国科学院大学重庆医院(重庆市人民医院)内分泌科,400013 [2]中国科学院大学重庆医院(重庆市人民医院)ICU,400013 [3]中国科学院大学重庆医院(重庆市人民医院)骨科,400013

出　　处：《中华创伤杂志》2019年第10期924-929,共6页Chinese Journal of Trauma

基　　金：重庆市科委技术预见与制度创新基金(2018017).

摘　　要：目的探讨强化胰岛素治疗对严重胸部创伤伴应激性高血糖患者免疫功能及预后的影响。方法采用回顾性病例对照研究分析2016年10月—2018年10月重庆市人民医院收治的60例严重胸部创伤伴应激性高血糖患者临床资料,其中男31例,女26例;年龄25~61岁[(46.1±4.0)岁]。简明损伤定级(AIS)3~5分。30例接受常规胰岛素治疗(常规治疗组),30例接受强化胰岛素治疗(强化治疗组)。分别于治疗前、治疗后1,3,5和7 d抽取两组患者静脉血,检测肿瘤坏死因子-α(TNF-α)、白细胞介素-6(IL-6)和C-反应蛋白(CRP)水平和淋巴细胞计数(CD14+、CD4+、CD4+/CD8+)的变化。比较两组患者院内感染发生率、机械通气时间、住院病死率、低血糖发生率。结果治疗前两组间血浆TNF-α、IL-6和CRP水平差异无统计学意义(P>0.05)。治疗后1~7 d,强化治疗组血浆TNF-α水平、IL-6和CRP水平均低于常规治疗组(P<0.05或0.01)。与治疗前比较,治疗后两组血浆TNF-α、IL-6和CRP水平均不同程度升高,第3天均达到高峰,随后逐步下降(P<0.05)。治疗前和治疗后1 d,两组CD14+、CD4+、CD4+/CD8+淋巴细胞计数差异均无统计学意义(P>0.05)。治疗后3,5,7 d强化治疗组CD14+淋巴细胞计数[3 d:(0.61±0.08)×10^9∶(0.55±0.09)×10^9,5 d:(0.68±0.05)×10^9∶(0.63±0.05)×10^9,7 d:(0.77±0.07)×10^9∶(0.71±0.06)×10^9]、CD4+淋巴细胞计数[3 d:(0.29±0.04)×10^9∶(0.25±0.03)×10^9,5 d:(0.32±0.04)×10^9∶(0.30±0.05)×10^9,7 d:(0.34±0.03)×10^9∶(0.32±0.06)×10^9]、CD4+/CD8+淋巴细胞计数[3 d:(0.28±0.04)×10^9∶(0.26±0.06)×10^9,5 d:(0.33±0.03)×10^9∶(0.31±0.06)×10^9,7 d:(0.35±0.03)×10^9∶(0.32±0.06)×109]均高于常规治疗组(P<0.05或0.01)。与治疗前比较,治疗后第3天两组CD14^+、CD4^+、CD4^+/CD8^+淋巴细胞计数均不同程度升高(P<0.05或0.01)。与常规治疗组比较,强化治疗组院内感染发生率降低[57%(17/30)∶30%(9/30)],机械通气时间缩短[(12.8±2.4)d∶(7.Objective To investigate the effect of intensive insulin therapy on the immune function and prognosis of severe thoracic injuries patients with stress hyperglycemia. Methods A retrospective case control study was performed to analyze the clinical data of 60 patients with severe chest trauma and stress-induced hyperglycemia admitted to Chongqing People's Hospital from October 2016 to October 2018. There were 31 males and 26 females, aged 25-61 years [(46.1±4.0)years]. The abbreviated injury scale (AIS) range was 3-5 points. Thirty patients received routine insulin therapy (routine treatment group) and thirty patients received intensive insulin therapy (intensive treatment group). Venous blood was collected from two groups of patients before treatment, 1 day, 3 days, 5 days and 7 days after treatment respectively. Level of inflammatory cytokines [tumor necrosis factor-α(TNF-α), interleukin-6 (IL-6) and C-reactive protein (CRP)], and lymphocyte count (CD14^+, CD4^+ and CD4^+/CD8^+) were detected respectively. The incidence of nosocomial infection, length of hospital stay, mortality and incidence of hypoglycemia were compared between the two groups. Results There were no significant differences in plasma TNF-α, IL-6 and CRP levels between the two groups before treatment (P>0.05). After treatment (1-7 days), the levels of serum TNF-α, IL-6 and CRP in the intensive treatment group were lower than those of routine treatment group (P<0.05 or 0.01). Compared with these before treatment, the levels of TNF-α, IL-6 and CRP in both groups increased to varied degrees, reaching a peak on day 3, followed by a gradual decline (P<0.05 or 0.01). There were no statistically significant differences in CD14^+, CD4^+、CD4+/CD8^+ lymphocyte counts between the two groups before treatment (P>0.05). On days 3, 5, and 7 after treatment, the counts of CD14+ lymphocytes [3 d:(0.61±0.08)×10^9vs.(0.55±0.09)×10^9, 5 d:(0.68±0.05)×10^9vs.(0.63±0.05)×10^9, 7 d:(0.77±0.07)×10^9vs.(0.71±0.06)×10^9], CD4+ lymphocytes [3 d:(0.29±0.

关 键 词：胸部损伤 高血糖症 强化胰岛素治疗 

分 类 号：R587.1[医药卫生—内分泌] R655[医药卫生—内科学]