重症脓毒症患者血糖控制与炎症因子变化及临床意义

柳学; 林晓军; 何楷然; 林晓; 曾文新

doi:10.3760/cma.j.issn.1671-0282.2017.12.021

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中华急诊医学杂志

• 临床研究 •

ENGLISH ABSTRACT

重症脓毒症患者血糖控制与炎症因子变化及临床意义

作者及单位信息

出版日期： 2017 -12 -10 ·

DOI： 10.3760/cma.j.issn.1671-0282.2017.12.021

Glycemic control and changes of inflammatory factors in severe sepsis patients and their clinical significance

Authors Info & Affiliations

Liu Xue

The Emergency and Critical Care Department, Guangdong General Hospital (Guangdong Academy of Medical Science), Guangzhou 510080, China

Lin Xiaojun

He Kairan

Lin Xiao

Zeng Wenxin

Published： 2017 -12 -10 ·

DOI： 10.3760/cma.j.issn.1671-0282.2017.12.021

APP内阅读

摘要

目的探讨重症脓毒症患者血糖控制与炎症因子TNF-α、IL-6变化的关系及临床意义。

方法将103例血糖异常升高的重症脓毒症患者分为强化胰岛素治疗组(intensive insulin therapy, IIT)( n＝51)及常规胰岛素治疗组(conventional insulin therapy, CIT)( n＝52)；再根据患者糖化血红蛋白水平分别将两个治疗组各分为应激性高血糖和糖尿病两个亚组，比较其病死率及低血糖发生率。采用酶联免疫吸附法检测患者治疗0、3、7 d后的炎症因子TNF-α、IL-6变化。

结果IIT组中，糖尿病组病死率显著高于应激性高血糖组(66.7% vs.30.8%, P<0.05)；CIT组中，应激性高血糖组病死率明显高于糖尿病组(54.1% vs.25.0%, P<0.05)。多变量Logistic回归分析，强化胰岛素治疗在糖尿病组死亡风险更高( OR＝1.221，95% CI：1.075～1.434)，但在应激性高血糖组，强化胰岛素治疗降低了死亡风险( OR＝0.872，95% CI：0.714～0.975)。IIT组低血糖发生率显著高于CIT组(13.7% vs.1.9%, P<0.05)。治疗前，两组中应激性高血糖患者血清肿瘤坏死因子-α(TNF-α)、白介素-6(IL-6)水平均明显高于糖尿病患者( P<0.01)；治疗7 d后，两组中，应激性高血糖患者血清TNF-α、IL-6均明显下降( P<0.01)，其中IIT组下降幅度较CIT组更为明显( P<0.05)。

结论重症脓毒症伴有应激性高血糖患者，接受强化胰岛素治疗严格控制血糖，能更有效抑制炎症因子。

关键词：脓毒血症;应激性高血糖;2型糖尿病;强化胰岛素治疗;常规胰岛素治疗;炎症因子;糖化血红蛋白;预后

ABSTRACT

ObjectiveTo investigate glycemic control, changes of inflammatory factors and their clinical significance in severe sepsis patients.

MethodsOne hundred and three severe sepsis patients with abnormal hyperglycemia were randomly divided into the two groups and receive intensive insulin therapy (IIT) and conventional insulin therapy (CIT) respectively. According to glycosylated hemoglobin level, the two groups were further divided into stress hyperglycaemia and diabetes mellitus subgroups. The mortality and incidence of hypoglycemia were compared between the groups and subgroups. Enzyme linked immunosorbent assay was used to detect TNF-α, IL-6 levels before treatment, 3 and 7 days after treatment.

ResultsIn IIT group, the mortality in diabetes mellitus subgroup was significantly higher than that in stress hyperglycaemia subgroup (66.7% vs. 30.8%, P<0.05), while the mortality in stress hyperglycaemia subgroup significantly higher than that in diabetes mellitus subgroup (54.1% vs. 25.0%, P<0.05) in CIT group. Multivariate Logistic regression analysis revealed IIT increased the risk for death in diabetes mellitus subgroup( OR=1.221, 95% CI: 1.075-1.434), while decreased the risk for death in stress hyperglycaemia subgroup( OR=0.872, 95% CI: 0.714-0.975). The incidence of hypoglycemia was significantly higher in IIT group than that in CIT group(13.7% vs. 1.9%, P<0.05). Before treatment, the levels of TNF-α, IL-6 in stress hyperglycaemia patients were significantly higher than those in diabetes mellitus patients. After 7 day treatment, The levels of TNF-α, IL-6 decreased significantly in stress hyperglycaemia patients ( P<0.01), and decreased more significantly in IIT group than that in CIT group.

ConclusionSevere sepsis patients with stress hyperglycaemia can attain better glycemia control and inhibition of inflammatory factors, and clinical benefit from IIT.

KEYWORDS： Severe sepsis;Stress hyperglycemia;Type 2 diabetes melittus;Intensive insulin therapy;Conventional insulin therapy;Inflammatory factors;Glycosylated hemoglobin;Prognosis

Corresponding author: Corresponding Author: Zeng Wenxin, Email: mocdef.6ab21xwgneZ

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引用本文

柳学,林晓军,何楷然,等. 重症脓毒症患者血糖控制与炎症因子变化及临床意义[J]. 中华急诊医学杂志,2017,26(12)：1438-1441.

DOI:10.3760/cma.j.issn.1671-0282.2017.12.021

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脓毒症患者并发异常血糖升高有不同的原因，部分患者有明确的糖尿病病史，有的仅为单纯的应激性高血糖 ^{[
1
]} 。近年来临床研究表明 ^{[
2
]} ，同样的血糖控制在不同原因高血糖重症患者有不同的临床获益，提示个体化血糖控制的重要性。脓毒症的本质，是机体促炎、抗炎反应的失控，炎症因子是促发、增强脓毒症病理生理过程的核心之一，尤其炎症因子TNF-α、IL-6参与了脓毒症的发生、发展过程，可以反应疾病的严重程度 ^{[
3
,

4
]} 。本研究旨在探讨个体化血糖控制的过程中，炎症因子如何相应变化。

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摘要
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备注信息

通信作者：曾文新，Email: mocdef.6ab21xwgneZ

基金项目：

广东省医学科学技术研究基金资助项目 (A2014023) 查看更多基金信息

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