降钙素原、白介素6、瓜氨酸和肠三叶因子水平对严重多发伤伴发急性胃肠损伤有预测价值

摘要 目的：探讨降钙素原(PCT)、白介素（IL）-6、瓜氨酸、肠三叶因子（ITF）对多发伤患者并发急性胃肠损伤（AGI）的预测价值。方法：分析130例严重多发伤患者临床资料,按照入院72h内是否出现AGI,分为AGI组（71例）和无AGI组（59例）。比较2组血清PCT、IL-6、瓜氨酸和ITF水平变化。采用多因素Logistic回归分析影响严重多发伤患者并发AGI的危险因素。结果：2组患者伤后第1、3、5天的PCT、IL-6、瓜氨酸及ITF水平比较,差异均有统计学差异（P均<0.05）。多因素Logistics回归分析显示,血清IL-6、瓜氨酸是影响严重多发伤患者并发AGI的独立危险因素（P均<0.05）。结论：严重多发伤并发AGI患者的血降钙素原、IL-6和ITF水平明显升高,瓜氨酸水平逐渐降低再升高,这些指标是影响AGI发生的危险因素。     

急性胃肠道损伤分级联合序贯器官衰竭评分对脓毒症患者28天预后有评估价值

摘要 目的：探讨急性胃肠损伤（AGI）分级联合序贯器官衰竭评分(SOFA) 对脓毒症患者28 d预后的预测价值。方法：以192例脓毒症患者为研究对象,根据患者28 d是否存活分为存活组和死亡组,比较2组的临床特征。入院1周内每日记录AGI分级,并分析不同AGI分级患者的临床特征。分别绘制AGI分级、SOFA评分、急性生理学及慢性健康状况（APACHEⅡ）评分以及AGI分级联合SOFA评分对患者28 d预后的受试者工作特征(ROC）曲线,计算相应的曲线下面积（AUC）,并进行比较。结果：192例脓毒症患者28 d死亡率为38.0%（73/192）,AGI的发生率为89.1%（171/192）,其中1级患者69例,2级72例,3级26例,4级4例。AGI分级越高,患者危重症评分、28 d死亡率越高（P均<0.01）。多元回归分析显示,年龄、乳酸、机械通气（MV）、AGI分级以及APACHEⅡ评分是脓毒症患者28 d死亡的独立危险因素（P均<0.05）。ROC曲线分析提示,AGI分级、SOFA评分对患者28 d死亡的预测能力均低于APACHEⅡ评分,但两者相结合的预测能力与APACHEⅡ评分相当（P>0.01）。结论：脓毒症患者AGI发生率高,AGI分级联合SOFA评分对脓毒症患者28 d预后有预测价值。     

住院危重症行肠内营养患者腹泻的危险因素

目的:探讨住院危重症行肠内营养患者腹泻的危险因素.方法:选取2014-01/2015-12于龙泉市人民医院重症监护室收治的185例危重患者为研究对象,根据Hart腹泻计分法分为观察组(发生腹泻)和对照组(未发生腹泻).比较两组患者的一般资料、肠内营养输注情况及治疗情况,采用多因素Logistics回归分析筛选出患者出现腹泻的危险因素.结果:总共185例患者中有105例(56.8%)符合腹泻的诊断标准,且多数发生在肠内营养开始第1-2天,多持续1-2 d.观察组的住院时间、低蛋白血症发生率、肠内营养输注时间、输注量、肠内营养前禁食的比例、应用抗生素的时间、是否应用多种抗生素、应用抑酸药、口服钾制剂的比例均显著高于对照组,肠内营养逐渐增量的比例显著低于对照组,差异有统计学意义(P0.05).两组的输注速度比较,差异有统计学意义(P0.05).合并低蛋白血症、肠内营养前禁食、应用抑酸药、口服钾制剂是患者出现腹泻的独立危险因素(P0.05),肠内营养逐渐增量是其独立保护因素(P0.05).结论:对于行肠内营养的危重症患者而言,合并低蛋白血症、肠内营养前禁食、应用抑酸药、口服钾制剂可显著增加腹泻风险,对此建议在肠内营养时逐渐增量,以降低其风险.     

老年腹腔镜胃癌患者术后早期肠内营养不耐受的高危因素分析

[目的]分析老年腹腔镜胃癌患者术后早期肠内营养不耐受的高危因素。[方法]回顾性分析经病理确诊且均行早期肠内营养支持的286例老年腹腔镜胃癌手术患者的临床资料。应用单因素分析老年腹腔镜胃癌患者术后早期肠内营养不耐受的危险因素，对有差异的统计学资料纳入多因素Logistic回归分析。[结果]286例老年腹腔镜胃癌手术患者中，178例发生术后早期肠内营养不耐受(不耐受组),占比62.24%;耐受组108例，占37.76%。单因素分析显示，2组患者性别、年龄、TNM分期、BMI、合并基础疾病、胃癌根治方法、手术时间、术中出血量和麻醉时间上相比，差异无统计学意义(P>0.05);而2组患者在营养途径、肠内营养开始时间及使用营养泵上对比，差异有统计学意义(P<0.05)。多因素Logistic分析表明，营养途径、肠内营养开始时间及使用营养泵为影响老年腹腔镜胃癌患者术后早期肠内营养不耐受的危险因素。[结论]老年腹腔镜胃癌患者术后早期肠内营养不耐受的危险因素为营养途径、肠内营养开始时间和使用营养泵。     

重症急性胰腺炎急性胃肠损伤的危险因素分析及相关预测模型的构建

目的 探讨重症急性胰腺炎(severe acute pancreatitis, SAP)患者并发急性胃肠损伤(acute gastrointestinal injury, AGI)的危险因素及建立相关预测模型。方法 回顾性收集2016年4月至2020年4月期间河池市人民医院和广西医科大学第二附属医院收治的SAP患者126例作为研究对象,分为AGI组(n=79)和非AGI组(n=47)。对两组患者各项指标进行单因素筛选,再行Logistic多因素回归分析,建立预测模型并应用受试者工作特征曲线(Receiver OperatingCharacteristic, ROC)曲线检测其区分度,应用拟合优度检验评价其校准度。结果 单因素分析结果显示,天门冬氨酸氨基转移酶(Aspartate aminotransferase, AST)、Ca²⁺、胰淀粉酶、脂肪酶、尿淀粉酶、肌钙蛋白Ⅰ、肠型脂肪酸结合蛋白(intestinal fatty acid-binding protein, I-FABP)、D-乳酸、二胺氧化酶(diamine oxidase, DAO)、三叶因子-2(...     

危重症患者肠内营养喂养不耐受的影响因素及对策

目的探讨危重症患者肠内营养不耐受率及其相关影响因素。方法 442例进行肠内营养的危重症患者,依据喂养不耐受判断标准分为耐受组和不耐受组,采用单因素比较法和多因素Logistic回归法分别筛选肠内营养喂养不耐受的影响因素。结果危重症患者肠内营养喂养不耐受率为39.82%(176/442);多因素Logistic回归分析结果显示,喂养不耐受的危险因素为急性生理与慢性健康评分(APACHE)Ⅱ(OR=2.645)、开始肠内营养时间(OR=2.675)、低白蛋白血症(OR=2.961)、使用抗生素种类(OR=2.294)、口服钾制剂(OR=3.630)等,而保护因素包括添加膳食纤维(OR=0.255)及早期使用促胃动力药(OR=0.374)。结论危重症患者肠内营养期间具有较高的喂养不耐受发生率;医护人员应根据以上高危因素,采取针对性干预措施,降低肠内营养期间的喂养不耐受发生率。     

重症急性胰腺炎肠内营养不能耐受危险因素的临床研究

[目的]探讨重症急性胰腺炎(SAP)肠内营养不能耐受的危险因素。[方法]选取2014年1月~2018年5月收治的重症急性胰腺炎行肠内营养治疗患者295例,根据患者是否出现肠内营养不能耐受,分为耐受组(174例)及非耐受组(121例),比较2组患者临床资料,对有统计学差异的指标采用多因素Logistic回归分析判断肠内营养不能耐受独立危险因素。[结果]295例患者中121例出现肠内营养不能耐受,其发生率为41.02%。多因素分析显示:腹内压20cmH2O(OR=6.834,P=0.001,95%CI:1.441,21.292),APACHEⅡ20分(OR=6.247,P=0.003,95%CI:1.436,20.572),禁食时间72h(OR=6.013,P=0.009,95%CI:1.391,19.347),血清白蛋白25g/L(OR=5.435,P=0.013,95%CI:1.043,14.179),是SAP患者肠内营养不能耐受发生独立危险因素,添加可溶性纤维(OR=0.258,P=0.010,95%CI:0.048,0.739)是SAP患者肠内营养不能耐受发生独立保护因素。而机械通气(OR=1.762,P=0.145,95%CI:0.598,6.018),CVP11cmH2O(OR=2.106,P=0.085,95%CI:0.609,8.678)非SAP患者肠内营养不能耐受发生独立危险因素。[结论]SAP患者行肠内营养不能耐受的独立危险因素为腹内压及APACHEⅡ评分增高,禁食时间延长及严重低蛋白血症,而肠内营养过程中合理添加可溶性纤维饮食是其保护因素,针对上诉因素应早期识别,进而降低肠内营养不能耐受的风险。     

肠外营养与肠内营养联合治疗重症胰腺炎临床研究

目的 评价全胃肠外营养(TPN)和肠内营养(EN)联合应用对重症急性胰腺炎(SAP)的治疗效果,明确全胃肠外营养与肠内营养在重症急性胰腺炎中的作用.方法 采用前瞻性、对照、开放式临床研究,将确诊为重症急性胰腺炎的患者分为TPN治疗组和TPN EN联合治疗组,共有101例患者按要求完成试验,其中TPN治疗组56例,TPN EN联合治疗组45例.重症急性胰腺炎的诊断依据采用1992年亚特兰大国际会议分类标准.重症急性胰腺炎严重度评估依据:Ranson标准、APACHE:Ⅱ评分、Balthazar CT积分.结果 两组患者人院时年龄、性别及重症急性胰腺炎严重度评分诸方面均无显著性差异.与TPN治疗组相比,TPN EN联合治疗组患者的APACHElI评分及Binder合并症积分明显改善;并发症和平均住院时间明显缩短,住院费用明显降低,病死率降低(0% vs 7.5%).但血清淀粉酶和乳酸脱氢酶活性治疗前后无明显变化.结论 全胃肠外营养和肠内营养联合应用可显著改善重症急性胰腺炎患者的营养状况及预后,缩短住院时间.降低住院费用.     

AGI评分、甘油三酯联合hs-CRP/Alb比值评估高甘油三酯血症性急性胰腺炎患者疾病严重程度及复发情况的临床应用研究

目的 探讨采用急性胃肠损伤(AGI)评分、甘油三酯(TG)联合高敏C反应蛋白/白蛋白(hs-CRP/Alb)比值评估高甘油三酯血症性急性胰腺炎(HTG-AP)患者疾病严重程度及复发情况的应用效能。方法 招募2019年6月至2022年6月电子科技大学医学院附属绵阳医院收治的HTG-AP患者89例,其中轻度急性胰腺炎(MAP)32例(MAP组),中重度急性胰腺炎(MSAP)38例(MSAP组)和严重急性胰腺炎(SAP)19例(SAP组)。随访观察患者出院3个月内病情复发情况,采用多因素Cox回归分析探讨影响疾病复发的因素,采用受试者工作特征(ROC)曲线评估AGI、TG联合hs-CRP/Alb比值预测疾病复发的效能。结果 SAP组AGI评分、hs-CRP、hs-CRP/Alb比值水平显著高于MSAP组和MAP组(P<0.05),Alb水平显著低于MSAP组和MAP组(P<0.05)。MSAP组AGI评分、hs-CRP、hs-CRP/Alb比值水平显著高于MAP组(P<0.05),Alb水平显著低于MAP组(P<0.05)。89例患者失访5例,在随访期间复发29例,未...     

肠内营养在重症急性胰腺炎治疗中的应用价值

重症急性胰腺炎(severe acute pancreatitis,SAP)是临床上较为常见的危重急症,近年来其发生率有上升趋势.因为种种原因导致胰腺内胰酶的活化和自身消化,随之发生全身性炎症反应综合征(systemic inflamation response syndrome, SIRS)、局部及全身感染和多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS),临床经过凶险,死亡率高.营养治疗是SAP治疗中的重要一环,由于经口饮食有刺激胰液分泌、导致胰腺炎恶化之嫌,既往一直采用深静脉插管、全胃肠外营养(total parenteral nutrition, TPN)的方式进行营养治疗,直至腹部压痛消退、腹痛缓解、肠鸣音恢复才逐渐开始经口饮食.但TPN有较多并发症,包括肠道黏膜屏障功能障碍,从而引起感染.随着对胰腺炎研究的深入及肠内营养治疗在其它危重疾病治疗中的应用[1,2],近年来,许多学者主张应早期对患者进行肠内营养(enteral nutrition, EN),对SAP 患者进行EN已有诸多文献报道.     

Severity of acute gastrointestinal injury grade is a good predictor of mortality in critically ill patients with acute pancreatitis

BACKGROUND Gastrointestinal(GI)dysfunction is a common and important complication of acute pancreatitis(AP),especially in patients with severe AP.Despite this,there is no consensus means of obtaining a precise assessment of GI function.AIM To determine the association between acute gastrointestinal injury(AGI)grade and clinical outcomes in critically ill patients with AP.METHODS Patients with AP admitted to our pancreatic intensive care unit from May 2017 to May 2019 were enrolled.GI function was assessed according to the AGI grade proposed by the European Society of Intensive Care Medicine in 2012,which is mainly based on GI symptoms,intra-abdominal pressure,and feeding intolerance in the first week of admission to the intensive care unit.Multivariate logistic regression analysis was performed to assess the association between AGI grade and clinical outcomes in critically ill patients with AP.RESULTS Among the 286 patients included,the distribution of patients with various AGI grades was 34.62%with grade I,22.03%with grade II,32.52%with grade III,and 10.84%with grade IV.The distribution of mortality was 0%among those with grade I,6.35%among those with grade II,30.11%among those with grade III,and 61.29%among those with grade IV,and AGI grade was positively correlated with mortality(χ2=31.511,P<0.0001).Multivariate logistic regression analysis showed that age,serum calcium level,AGI grade,persistent renal failure,and persistent circulatory failure were independently associated with mortality.Compared with the Acute Physiology and Chronic Health Evaluation II score(area under the curve:0.739 vs 0.854;P<0.05)and Ranson score(area under the curve:0.72 vs 0.854;P<0.01),the AGI grade was more useful for predicting mortality.CONCLUSION AGI grade is useful for identifying the severity of GI dysfunction and can be used as a predictor of mortality in critically ill patients with AP.     

ICU危重病人使用短肽肠内营养剂不同鼻饲时间对血糖影响的研究

目的探讨使用短肽肠内营养剂对重症医学科(ICU)危重病患者血糖的影响。方法对60例进行肠内营养支持的ICU危重症患者随机分为两组:两组在积极治疗原发病的基础上,A组30例病人:营养液每日鼻饲持续时间16 h肠内营养泵匀速泵入;B组30例病人:营养液每日间断鼻饲12 h肠内营养泵匀速泵入进行临床随机对照研究,时间为7~27天,绝大多数为10~14天。治疗过程中,监测血糖、生化等指标,找出适合ICU患者的最佳鼻饲持续时间。结果 A组:每日鼻饲持续时间16 h的ICU危重症患者,血糖能较平稳控制;B组:每日间断鼻饲12 h的ICU危重症患者,血糖波动较大。结论通过临床观察,对ICU危重症患者进行肠内营养支持以持续泵入肠内营养液时间在10 h,使用营养液7-14天,血糖波动较小,胃肠道并发症的发生率,生化学指标改善与间断泵入营养液比较对血糖影响较大,胃肠道并发症的发生率、生化学指标改善差异有意义(P0.05),APACHEⅡ评分与血糖有相关性,持续泵入营养液血糖控制较稳定,两组比较差异有意义,(P0.05)。经过我们研究说明肠内营养液支持治疗以持续泵入疗效较好,可缩短在ICU的住院时间,预后较好,因病例较少有待进一步研究。     

Outcomes in critically ill patients before and after the implementation of an evidence-based nutritional management protocol

OBJECTIVE: To determine whether the implementation of a nutritional management protocol in the ICU leads to the increased use of enteral nutrition, earlier feeding, and improved clinical outcomes in patients. DESIGN: Prospective evaluation of critically ill patients before and after the introduction of an evidence-based guideline for providing nutritional support in the ICU. SETTING: The medical-surgical ICUs of two teaching hospitals. PATIENTS: Two hundred critically ill adult patients who remained npo > 48 h after their admission to the ICU. One hundred patients were enrolled into the preimplementation group, and 100 patients were enrolled in the postimplementation group. INTERVENTION: Implementation of an evidence-based ICU nutritional management protocol. MEASUREMENT AND RESULTS: Nutritional outcome measures included the number of patients who received enteral nutrition, the time to initiate nutritional support, and the percent caloric target administered on day 4 of nutritional support. Clinical outcomes included the duration of mechanical ventilation, ICU and in-hospital length of stay (LOS), and in-hospital mortality rates. Patients in the postimplementation group were fed more frequently via the enteral route (78% vs 68%, respectively; p = 0.08), and this difference was statistically significant after adjusting for severity of illness, baseline nutritional status, and other factors (odds ratio, 2.4; 95% confidence interval [CI], 1.2 to 5.0; p = 0.009). The time to feeding and the caloric intake on day 4 of nutritional support were not different between the groups. The mean (+/- SD) duration of mechanical ventilation was shorter in the postimplementation group (17.9 +/- 31.3 vs 11.2 +/- 19.5 days, respectively; p = 0.11), and this difference was statistically significant after adjusting for age, gender, severity of illness, type of admission, baseline nutritional status, and type of nutritional support (p = 0.03). There was no difference in ICU or hospital LOS between the two groups. The risk of death was 56% lower in patients who received enteral nutrition (hazard ratio, 0.44; 95% CI, 0.24 to 0.80; p = 0.007). CONCLUSION: An evidence-based nutritional management protocol increased the likelihood that ICU patients would receive enteral nutrition, and shortened their duration of mechanical ventilation. Enteral nutrition was associated with a reduced risk of death in those patients studied.     

Risk factors for upper gastrointestinal rebleeding in critically ill patients

BACKGROUND/AIMS: To determine the risk factors for rebleeding after upper gastrointestinal bleeding in critically ill patients. METHODOLOGY: We retrospectively analyzed the medical records of consecutive 60 patients undergoing bedside esophagogastroduodenoscopy between January 2000 and December 2004 for upper gastrointestinal bleeding that developed while in the ICU. RESULTS: Eight of the 60 patients died within 7 days after initial bleeding and two of the eight died due to upper gastrointestinal bleeding. Seven-day rebleeding rate was 34.6% (18/52). An additional 7 patients died within 30 days, none of whom died of upper gastrointestinal bleeding. Thirty-day rebleeding rate was 51.1% (23/45). In multiple logistic regression using selected significant variables, anemia (Hb < 9.0g/dL), and hypoalbuminemia (albumin < 3.0g/dL) for 7-day rebleeding, and hypoxia (PaO2 < 80mmHg), anemia (Hb < 9.0g/dL), and units of blood transfused (> or = 3) for 30-day rebleeding were the significant independent risk factors in critically ill patients. CONCLUSIONS: The results of this study suggest that underlying patients' conditions or the severity of initial upper gastrointestinal bleeding affect rebleeding in the ICU setting. Adequate general ICU care including the prevention of initial bleeding and correction of hypoxia, anemia, and hypoalbuminemia after bleeding could reduce the rebleeding risk.     

Enteral nutrition by endoscopic means; I. Techniques, indications, types of enteral feed

Enteral nutritional support plays a major role in the management of patients who are critically ill in intensive care units (ICU), those with poor volitional intake, persons with chronic neurological or mechanical dysphagia, and individuals with gut dysfunction. Part I of this review will briefly discuss the principles governing nasoenteral feeding and will describe in detail the endoscopic-assisted methods for placing enteral feeding tubes. These include percutaneous endoscopic gastrostomy, jejunal extension through a percutaneous endoscopic gastrostomy or direct endoscopic jejunostomy, and the "one-step button". In addition, the types of enteral food with focus on disease-specific enteral diets will be discussed. Finally, the latest innovations in enteral feeding including immune-enhancing nutrients such as arginine, omega-3 fatty acids, glutamine, and nucleotides advocated for critically ill patients will be discussed. Questions regarding possible complications and long-term results of the various methods of enteral feeding will be discussed separately in part II.     

St?rungen der gastrointestinalen Motilit?t

Inhibition of gastrointestinal motility is a major problem in critically ill patients. Impaired gastrointestinal motility leads to a multitude of subsequent complications in critically ill patients, with intolerance of enteral feeding as one of great importance. The pharmacological treatment of impaired gastrointestinal motility is difficult to handle, because the underlying mechanisms are complex and not fully understood and the number of pharmacological treatment options available is limited. A standardized concept for the use of prokinetic agents in the treatment of impaired gastrointestinal motility in critically ill patients involves the early use of baseline therapeutic options followed by goal-directed therapy. The early use of enemas and of laxatives which promote water secretion and prevent excessive water absorption, such as bisacodyl or sodium picosulfate, is highly recommended. The first line medication in patients with impaired gastric emptying is erythromycin given intravenously. Patients suffering from gastroparesis and impaired intestinal motility may benefit from erythromycin followed hours later by the combination of metoclopramide plus neostigmine.     

Nutrition support in the acutely ventilated patient

Although the nutrition support literature is limited and therefore does not provide robust evidence to promote grade A or strong recommendations, there is a "signal" from all of these studies taken a a whole that critically ill patients may benefit from nutritional manipulation. The acutely ventilated patient that is likely to still be intubated by day three is a classic example of the critically ill patient who has the potential to achieve positive outcomes with nutritional support. Initiating nutrition support early improves the chances of benefit. However, nutrition cannot be provided in a vacuum. It is only one part of a multitude of treatments and therapies that must be optimally applied by a multidisciplinary team of professionals dedicated to the care of ICU patients. The exact makeup of the enteral (or parenteral) formula that is most likely to improve survival is unclear. More research is needed. Further study may demonstrate the possibility for nutritional manipulation to be one of the most important treatments physicians can offer to critically ill ventilated patients. Nutrition may have as much survival benefit as activated protein C, a drug costing over $7000 per course of therapy. No longer can it be said that nutrition makes no difference.     

Clinical significance of increased lipase levels on admission to the ICU

STUDY OBJECTIVES: To examine the incidence, risk factors, and sequelae associated with asymptomatic hyperlipasemia in the ICU. SETTING: Medical and surgical ICUs. PATIENTS: Two hundred forty-five adult critically ill patients admitted to an ICU for > 72 h with a diagnosis other than pancreatitis were studied prospectively. MEASUREMENTS: Serum amylase and lipase were measured on ICU admission and every third day until normalized. Clinical parameters including the incidence of ileus, the ability to tolerate enteral feeds, and the results of radiologic studies were also recorded. RESULTS: Hyperlipasemia was present in 40% of patients (peak, 1,183 +/- 175 U/L; range, 209 to 8,620 U/L) [mean +/- SEM]. Increased multiple-organ dysfunction scores, hypotension, anemia, mechanical ventilation (MV), bacteremia, elevated liver function test results, and elevated creatinine and triglyceride levels were all associated with increased lipase levels. In multivariate analysis, hypotension, anemia, elevated serum bilirubin, and MV were independently associated with higher lipase levels. Although mortality was not different, ICU length of stay and the duration of MV were significantly greater in patients with increased lipase levels (p < 0.05). Fifty patients underwent imaging studies. Pancreatitis was confirmed in 11 patients. The mean peak lipase value was significantly increased in patients with a positive study finding as compared to those with negative findings: 2,231 +/- 715 U/L and 900 +/- 234 U/L, respectively (p < 0.01). Enteral feedings, when initiated, were tolerated in 94% of patients with increased lipase levels and 97% of patients with normal lipase levels. CONCLUSIONS: Elevated serum lipase levels are frequently encountered in critically ill patients. In the majority of these patients, enteral feedings are well tolerated and there are minimal clinical sequelae. Extremely high lipase levels may be associated with radiologic evidence of pancreatitis. Hypoperfusion and inflammatory processes associated with multiple-organ failure appear to be contribute to these increases.     

危重患者血糖波动与血清炎症因子水平及病情预后的相关性

目的探讨重症监护病房（ICU）危重患者的血糖波动与血清炎症因子c反应蛋白（CRP）、肿瘤坏死因子-α．（TNF-d）、白细胞介素-6（IL-6）和患者病情及预后的相关性。方法选择2010年1月至2011年1月入住北京军区总医院ICU病房的非糖尿病危重患者共60例，其中男38例、女22例，平均年龄（55±9）岁，急性生理学及慢性健康状况评估Ⅱ（APACHEII）评分〉10分，符合应激性高血糖诊断且糖化血红蛋白为4％-6％。患者入科12h内佩戴动态血糖监测系统（CGMS），监测平均血糖波动幅度（MAGE），测定空腹血清CRP、TNF．0l和IL-6水平，分析MAGE与炎症因子水平变化及与APACHEⅡ评分的关系；追踪观察患者28d预后。组间比较采用t检验。结果Pearson相关分析显示危重患者入科24h内MAGE与炎症因子CRP、TNF-d、IL-6及APACHERⅡ评分显著相关（r=0．622、0．505、0．509、0．597，均P〈0．01）。多元线性回归分析结果显示，MAGE和IL-6及性别对ICU患者APACHERlI评分的影响作用较大（β=0．155、0．768、-0．209，t=2．879、8．375、-3．170，均P〈0．05）。死亡病例MAGE及APACHEII评分均明显高于存活病例[MAGE分别为（3．34-1．0）、（5．1±2．0）mmol／L，APACHEⅡ分别为（21±3）、（26±5）分，均P〈0．01）]。多元logistic回归分析显示，MAGE可影响患者预后（OR=4．401，95％CI：2．185-6．618，P〈0．05）。结论危重患者血糖波动幅度与血清炎症因子水平及病重程度密切相关；血糖变异度高可作为ICU危重患者预后的独立预测因子。     

两类达标血糖控制对急危重患者预后的影响

目的 观察两类达标血糖控制对急危重患者预后的影响. 方法 选取2011年1月至2013年9月我院急诊重症监护室（EICU）急性生理学与慢性健康评分（APACHEⅡ）＞15分且合并高血糖的危重患者200例,分为胰岛素强化治疗（IIT）组和常规控制（CIT）组,比较两组近期死亡率、3d及7d后APACHEⅡ、严重并发症、低血糖、院内感染发生率、住院时间和费用等指标. 结果 IIT组住院时间和费用、院内感染发生率、呼吸衰竭、心功能不全、3d及7d后APACHEⅡ较CIT组低（P＜0.05）.两组低血糖总发生率比较差异有统计学意义（29％ vs 13％,P＜0.01）,严重低血糖发生率、死亡率比较差异无统计学意义. 结论 IIT可能为临床带来较多益处,但增加急危重患者低血糖风险,对降低总死亡率可能无明显影响.