危重病患者抢救中胰岛素强化治疗的探讨

目的观察胰岛素强化治疗能否改善重症监护室（ICU）危重患者的预后。方法将116例危重患者随机分为传统治疗组（CT组）和胰岛素强化治疗组（IT组），每4h监测1次床旁血糖。当CT组血糖＞11．9mmol／L时，皮下注射中性可溶性胰岛素控制血糖在10．0～11．1mmol／L；当IT组血糖＞6．1mmol／L时，皮下注射胰岛素控制血糖在4．4～6．1mmol／L。记录患者ICU住院时间、使用呼吸机时间、气管插管或气管套管留置时间、每日早6时平均血糖、每日提供的平均热量、每日胰岛素用量、每日简化治疗干预评分系统-28（TISS-28）评分、人白细胞DR抗原（HLA—DR）、CD4^＋／CD8^＋，死亡、低血糖、肾功能损害（血肌酐＞221／μmol／L）和高胆红素血症（总胆红素＞34．2μmol／L）、输红细胞及发热（口温＞38．5℃）例数。结果CT组病死率（44．83％）远远高于IT组（12．07％），差异有显著性（P＜O．01）；患者ICU住院时间、使用呼吸机时间、气管插管留置时间、每日早6时平均血糖、每日TISS-28评分均明显高于IT组（P＜0．05或P＜0．01）；每日胰岛素用量、HLADR、CD4^＋／CD8^＋均明显低于IT组（P＜0．05或P＜0．01）。两组并发症比较，CT组患者发生肾功能损害、输注红细胞及发热例数均明显高于IT组（P均＜0．01）。结论胰岛素强化治疗控制危重患者血糖在4．4～6．1mmol／L水平确能降低患者的病死率。

Intensive insulin therapy in critically ill patients

OBJECTIVE: To observe the effect of intensive insulin therapy on improving the condition of critically ill patients. METHODS: A prospective, randomized, controlled study involving adults receiving mechanical ventilation was performed. On admission, critically ill patients were randomly assigned to receive intensive insulin therapy (infusion of insulin only if the blood glucose level exceeded 6.1 mmol/L and maintenance of blood glucose at a level 4.4-6.1 mmol/L, IT group) and conventional treatment (infusion of insulin only if the blood glucose level exceeded 11.9 mmol/L and maintenance of blood glucose at a level 10.0-11.1 mmol/L, CT group). The blood glucose was detected every 4 hours. The days of stay in the intensive care unit (ICU), time of the ventilatory support needed, the time for retention of tracheal intubation, the morning blood glucose level (6 am), the intake of nonprotein calories per day, the dosage of required insulin per day,therapeutic intervention scoring system-28 (TISS-28) score,human leukocyte antigen (locus) DR (HLA-DR), CD4+/CD8+, the mortality rate,acute renal failure (serum creatine >221 micromol/L), bilirubinemia (total bilirubin >34.2 micromol/L),the number of patients who received red-cell transfusions,fever (temperature in mouth >38.5 centigrade) and the rate of hypoglycemia were determined and registered. RESULTS: In a total of 116 patients enrolled, intensive insulin therapy reduced mortality rate (44.83 % with conventional treatment, compared with 12.07 % with intensive insulin therapy,P< 0.01). Intensive insulin therapy reduced the days of stay in ICU, TISS-28 score per day, time of the ventilatory support needed, time for retention of tracheal intubation, mean morning blood glucose levels (6 am) compared with those in CT group (P<0.05 or P<0.01), and patients receiving intensive insulin therapy were less likely to require intensive care. Intensive insulin therapy also raised consumption of insulin per day, HLA-DR and CD4+/CD8+ obviously (P<0.05 or P<0.01). Compare with the morbidity between two groups, the incidence of fever due to infection, acute renal failure and red-cell transfusions were higher in CT group (all P<0.01). CONCLUSION: Intensive insulin therapy maintaining blood glucose at a level 4.4-6.1 mmol/L reduces mortality rate among critically ill patients.