96例危重新生儿高血糖症及胰岛素治疗

目的　 观察危重症新生儿高血糖的发生及胰岛素治疗的临床意义。 方法 　对 16 8例危重症新生儿进行血糖监测。轻中度高血糖患儿采用限糖治疗 ,重度高血糖患儿随机分为限糖治疗组 ( 30例 )及小剂量胰岛素治疗组 ( 2 9例 ) ,观察血糖下降速度及预后。 结果 　发生高血糖症 96例 ,患病率为 5 7 1%,且危重症评分越高 ,其血糖值也越高。轻中度高血糖症患儿 ,限糖治疗后第 2天血糖下降正常者达 75 7%,而重度高血糖症患儿应用胰岛素组与未用胰岛素组相比 ,入院 2 4h时血糖控制情况分别为 ( 5 2 3± 1 5 )mmol/L与 ( 7 79± 1 38)mmol/L(P <0 0 1) ,病死率明显下降 ,分别为 13 8%与 40 0 %(P <0 0 5 )。 结论 　危重症新生儿病情越重 ,血糖水平越高。轻中度高血糖症经限糖治疗即可有效控制血糖水平 ,而重度高血糖症应用小剂量胰岛素治疗后可有效阻止血糖的进一步升高 ,减少危重症新生儿的病死率。     

危重新生儿血糖和胰岛素水平的变化及其临床意义

目的 探讨危重新生儿血糖和血清胰岛素的变化及其临床意义.方法 选择2006年12月-2009年1月在本院住院的危重新生儿60例.男36例,女24例;体质量2 300～4 200 g;胎龄35～41周;日龄1～27 d.采用微量血糖仪测定危重新生儿标本中血糖水平;对于高血糖和低血糖新生儿给予相应治疗;用化学发光免疫法检测危莺患儿血清胰岛素水平.健康对照组30例按上述同样方法测定相应指标.并进行二组比较.结果 危重60例患儿中糖代谢紊乱26例(43%),其中高血糖21例,低血糖5例.危重新生儿血糖、胰岛素水平[(6.37±4.11)mmol/L、(25.73±14.32)mIU/L]较健康足月新生儿[(4.13±1.73)mmol/L、(4.01±1.73)mIU/L]显著升高(t=2.32,4.76 Pa<0.01),经治疗后血糖均恢复正常.结论 危重新生儿可出现糖代谢紊乱及高胰岛素血症,对危重患儿应密切监测血糖变化,尽早发现血糖异常,及时诊断并合理处理.     

丙戊酸钠对癫患者体质量、体质量指数、血糖、血清胰岛素水平的影响

目的探讨丙戊酸钠(VPA)对癫患儿体质量、体质量指数(BMI)、血糖、血清胰岛素水平的影响。方法以VPA治疗3个月的30例癫患者作为研究对象,进行治疗前后自身对比研究,检测患者治疗前及治疗后3个月时体质量、BMI、身高、血糖、血清胰岛素水平,比较治疗前后体质量、BMI、血糖、血清胰岛素、胰岛素抵抗指数变化。利用放射免疫分析法检测其血胰岛素水平。采用SPSS10.0软件进行统计学分析。结果癫患儿治疗后体质量[(15.68±3.82)kgvs(19.64±4.75)kg,t=3.56P<0.01]、BMI[(18.29±2.91)kg/m2vs(20.16±2.71)kg/m2,t=2.13P<0.05]、胰岛素(4.42±0.39)mU/Lvs(6.89±0.41)mU/L,t=24.7P<0.01)、胰岛素抵抗指数(0.96±0.19vs1.45±0.21,t=9.4P<0.01)均较VPA治疗前明显增高。而血糖水平较治疗前无明显增高[(4.42±0.23)mmol/Lvs(4.39±0.35)mmol/L,t=0.39P<0.05]。结论VPA治疗可引起癫患儿体质量、BMI、血清胰岛素水平增高,并导致胰岛素抵抗;诱导胰岛素抵抗可能是VPA患儿体质量增加的原因之一。但对其血糖无直接影响。     

丙戊酸钠对癫(癎)患者体质量、体质量指数、血糖、血清胰岛素水平的影响

目的 探讨丙戊酸钠(VPA)对癫(癎)患儿体质量、体质量指数(BMI)、血糖、血清胰岛素水平的影响.方法 以VPA治疗3个月的30例癫(癎)患者作为研究对象,进行治疗前后自身对比研究,检测患者治疗前及治疗后3个月时体质量、BMI、身高、血糖、血清胰岛素水平,比较治疗前后体质量、BMI、血糖、血清胰岛素、胰岛素抵抗指数变化.利用放射免疫分析法检测其血胰岛素水平.采用SPSS 10.0软件进行统计学分析.结果 癫(癎)患儿治疗后体质量[(15.68±3.82) kg vs (19.64±4.75) kg,t=3.56 P＜0.01]、BMI[(18.29±2.91) kg/m2 vs (20.16±2.71) kg/m2,t=2.13 P＜0.05]、胰岛素(4.42±0.39) mU /L vs (6.89±0.41) mU /L,t=24.7 P＜0.01)、胰岛素抵抗指数(0.96±0.19 vs 1.45±0.21,t=9.4 P＜0.01)均较VPA治疗前明显增高.而血糖水平较治疗前无明显增高[(4.42±0.23) mmol/L vs (4.39±0.35) mmol/L,t=0.39 P＜0.05].结论 VPA治疗可引起癫(癎)患儿体质量、BMI、血清胰岛素水平增高,并导致胰岛素抵抗;诱导胰岛素抵抗可能是VPA患儿体质量增加的原因之一.但对其血糖无直接影响.     

新生儿缺氧缺血性脑病血胰岛素和血糖变化

目的　探讨新生儿缺氧缺血性脑病 (HIE)患儿血胰岛素和血糖变化的临床意义。方法　对 70例HIE和 4 0例正常新生儿进行血胰岛素和血糖监测 ,并进行对比观察。结果　HIE患儿入院时高血糖 19例 ,低血糖 5例。HIE组血糖、血胰岛素均显著高于正常对照组 (P均 <0 .0 1) ,且以重度HIE组更甚。结论　HIE患儿可出现糖代谢紊乱 ,对HIE患儿应密切监测血胰岛素和血糖变化 ,及早发现和尽快纠正高血糖或低血糖 ,以免加重脑损伤     

53例危重新生儿高血糖症

目的：　报道53例危重新生儿血糖监测结果,对危重新生儿高血糖的发生因素及与预后进行分析。方法：　 53例按有无器官功能衰竭分为单衰组,多衰组,无衰组;微量全血血糖>7mmol/L诊断高血糖。对检出的高血糖病例,在控制原发病的同时,降低葡萄糖输入浓度及速度,复查血糖,如未恢复正常予正规胰岛素治疗,直至血糖水平恢复正常。并对高血糖症的新生儿行头颅B超检查。结果：　单衰组与多衰组患儿血糖水平明显高于无衰组,多衰组血糖为(22.4±3.78)mmol/L ,单衰组血糖为(19.9±9.53)mmol/L ,无衰组血糖为(11.1±2.73)mmol/L ,单衰组、多衰组与无衰组比较均P<0.05。血糖越高,死亡率亦越高。 43例高血糖患儿中血糖24h之内恢复正常的有31例,其中24例治愈或好转,好转率77.4%,>24h恢复的有12例,5例好转,好转率41.7%,两者比较P<0.05。共有11例患儿发生颅内出血,其中1例血糖>10mmol/L,10例血糖>15mmol/L。结论：　危重症患儿血糖的变化可作为判断其病情及预后的辅助指标。     

危重新生儿高渗血症临床探讨

目的观察危重新生儿高渗血症的发生及其临床意义。方法对所有入院的危重新生儿即进行电解质、血糖、尿素氮、血气等测定,按公式计算出血渗透浓度。结果152例危重新生儿发生高渗血症48例,极危重组(新生儿危重症评分≤70分)的高渗血症患儿有19例,一般危重组(新生儿危重症评分70~90分)有29例,极危重组患儿血糖、血渗透浓度和病死率较一般危重组患儿明显升高,P<0.01,而其pH值比一般危重组低,P<0.05,两组比较有统计学意义。血渗透浓度>320 mmol/L组病死率为66.67%,较290~320 mmol/L组明显升高,P<0.01。结论危重新生儿高渗血症有其临床特点,高糖血症参与的高渗血症比例高,极危重组高渗血症及血渗透浓度>320 mmol/L的患儿预后差。     

218例无追赶生长的小于胎龄儿儿童期糖代谢分析

目的 探索无追赶生长的小于胎龄儿在儿童期的胰岛素敏感性.方法 收集2008年8月至2016年8月于北京大学第三医院儿科门诊就诊的身材矮小患儿439例,分为小于胎龄儿组(small for gestational age,SGA)218例和特发性矮小组(idiopathic short stature,ISS)221例.比较两组之间的空腹胰岛素、空腹血糖、空腹血糖与胰岛素比值、胰岛β细胞功能(HOMA%)和胰岛素抵抗指数(HOMA-IR)特点.结果 两组患儿均根据青春期分期及性别分组,SGA组与ISS组,青春期前男性患儿的空腹血糖分别为(4.7±0.6)mmol/L和(4.8±0.6)mmol/L,P=0.678,空腹胰岛素(5.1±4.0)mU/L和(4.3±4.7)mU/L,P=0.345,血糖胰岛素比值、HOMA%及HOMA-IR的差异均无统计学意义;青春期前女性患儿的空腹血糖分别为(4.5±0.5)mmol/L和(4.6±0.5)mmol/L,P=0.828,空腹胰岛素分别为(4.7±3.5)mU/L和(4.5±3.3)mU/L,P=0.603,血糖胰岛素比值、HOMA%及HOMA-IR的差异均无统计学意义;青春期男性患儿的空腹血糖分别为(5.0±0.8)mmol/L和(4.9±0.5)mmol/L,P=0.176,空腹胰岛素分别为(5.9±4.3)mU/L和(6.0±4.5)mU/L,P=0.958,血糖胰岛素比值、HOMA%及HOMA-IR的差异均无统计学意义;青春期女性患儿的空腹血糖分别为(4.9±0.6)mmol/L和(4.8±0.4)mmol/L,P=0.141,空腹胰岛素分别为(7.5±6.4)mU/L和(7.4±8.6)mU/L,P=0.448,血糖胰岛素比值、HOMA%及HOMA-IR的差异均无统计学意义.     

激素敏感型肾病综合征患儿血、尿血管内皮细胞生长因子的变化

目的观察激素敏感型肾病综合征(SSNS)患儿活动期及缓解期血清和尿血管内皮细胞生长因子(VEGF)水平的变化,并探讨其临床意义。方法以SSNS患儿30例为研究对象,年龄、性别匹配的正常健康儿童作对照,用液相芯片分析技术检测患儿在活动期与缓解期及正常健康儿童30例血清和晨尿VEGF水平,分析VEGF在SSNS患儿活动期及缓解期的变化。结果SSNS患儿活动期血VEGF水平[(186.62±106.21)ng/L]明显高于缓解期[(118.75±73.08)ng/L],同时也高于正常对照组[(108.64±54.75)ng/L](P均<0.05);缓解期与正常对照组相比,血VEGF无明显差异(P>0.05);SSNS患儿活动期晨尿VEGF水平[(201.66±100.46)ng/L]明显高于缓解期[(116.35±55.99)ng/L],也高于正常对照组[(99.94±42.07)ng/L](P均<0.05);缓解期与正常对照组相比,尿VEGF无明显差异(P>0.05)。结论VEGF在SSNS发生发展过程中起一定病理生理作用。     

脓毒症并发多器官功能障碍综合征患儿血浆凝溶胶蛋白水平的变化

目的 研究脓毒症并发多器官功能障碍综合征(MODS)患儿血浆凝溶胶蛋白水平的变化及意义.方法 检测并比较脓毒症并发MODS组、脓毒症组、对照组血浆凝溶胶蛋白水平,检测并比较脓毒症患儿中死亡者与存活者凝溶胶蛋白水平.结果 脓毒症合并MODS组患儿血浆凝溶胶蛋白水平为(29.0±11.4)mg/L,明显低于脓毒症组[(63.5±21.2)mg/L,P＜0.001]和健康对照组[(157.3±31.8)mg/L,P＜0.001];死亡脓毒症患儿的血浆凝溶胶蛋白水平为(20.8±3.5)mg/L,明显低于存活脓毒症患儿水平[(41.2±6.3)mg/L,P＜0.001].结论 凝溶胶蛋白可能参与了MODS发病机制,检测血浆凝溶胶蛋白水平有助于临床医生对患儿病情危重程度进行评估,从而采取有效治疗措施.     

A protocolized approach to identify and manage hyperglycemia in a pediatric critical care unit

INTRODUCTION: Hyperglycemia is a risk factor for poor outcome in critically ill patients, and glycemic control may decrease morbidity and mortality in adults. There is limited information regarding hyperglycemia and its control in pediatric intensive care. OBJECTIVE: To determine prevalence and risk factors for hyperglycemia and evaluate our approach to glycemic control in critically ill children. DESIGN, SETTING, PATIENTS, AND MAIN OUTCOMES: A pediatric-specific protocol to identify and manage hyperglycemia was developed and instituted as standard practice in our pediatric intensive care unit, and was applicable to patients >6 months and >5 kg, without end-stage liver disease or type 1 diabetes mellitus. Triggers for routine blood glucose assessment were based on supportive measures including mechanical ventilation, vasopressor/inotrope infusions, and antihypertensive infusions. Hyperglycemic patients, defined by two consecutive blood glucose readings of >140 mg/dL (7.7 mmol/L), were treated with infused insulin to maintain blood glucose levels 80-140 mg/dL (4.4-7.7 mmol/L). We performed retrospective analysis 6 months after instituting this approach. Main outcomes were prevalence and risk factors for hyperglycemia, and effectiveness of our approach to achieve glycemic control. INTERVENTIONS: None. MEASUREMENTS/MAIN RESULTS: One hundred forty-five of 477 patients had blood glucose actively assessed, and 74 developed hyperglycemia and were managed with insulin. This approach to identify patients with hyperglycemia had a positive predictive value of 51% and negative predictive value of 94%. Hyperglycemia prevalence was 20%. Mechanical ventilation, vasopressor/inotropic infusion, continuous renal replacement therapy, high illness severity scores, and longer lengths of stay were associated with hyperglycemia. The average blood glucose of patients with hyperglycemia was 200 mg/dL (11 mmol/L), and on average, patients were treated with insulin for 6.3 days with 2.4 units/kg/day. Blood glucose levels were <160 mg/dL (8.8 mmol/L) in 70% of insulin-treated days, 80-140 mg/dL (4.4-7.7 mmol/L) in 49% of insulin-treated days, and 4% of insulin-treated patients had any blood glucose measurements <40 mg/dL (2.2 mmol/L). CONCLUSIONS: Hyperglycemia is prevalent in pediatric intensive care units and may be effectively identified and managed using a protocolized approach.     

Glucose control, organ failure, and mortality in pediatric intensive care.

OBJECTIVE: In ventilated children, to determine the prevalence of hyperglycemia, establish whether it is associated with organ failure, and document glycemic control practices in Australasian pediatric intensive care units (PICUs). DESIGN: Prospective inception cohort study. SETTING: All nine specialist PICUs in Australia and New Zealand. PATIENTS: Children ventilated > 12 hrs excluding those with diabetic ketoacidosis, on home ventilation, undergoing active cardiopulmonary resuscitation on admission, or with do-not-resuscitate orders. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: All blood glucose measurements for up to 14 days, clinical and laboratory values needed to calculate Paediatric Logistic Organ Dysfunction (PELOD) scores, and insulin use were recorded in 409 patients. Fifty percent of glucose measurements were > 6.1 mmol/L, with 89% of patients having peak values > 6.1 mmol/L. The median time to peak blood glucose was 7 hrs. Hyperglycemia was defined by area under the glucose-time curve > 6.1 mmol/L above the sample median. Thirteen percent of hyperglycemic subjects died vs. 3% of nonhyperglycemic subjects. There was an independent association between hyperglycemia and a PELOD score > or = 10 (odds ratio 3.41, 95% confidence interval 1.91-6.10) and death (odds ratio 3.31, 95% confidence interval 1.26-7.7). Early hyperglycemia, defined using only glucose data in the first 48 hrs, was also associated with these outcomes but not with PELOD > or = 10 after day 2 or with worsening PELOD after day 1. Five percent of patients received insulin. CONCLUSIONS: Hyperglycemia is common in PICUs, occurs early, and is independently associated with organ failure and death. However, early hyperglycemia is not associated with later or worsening organ failure. Australasian PICUs seldom use insulin.     

Disturbance of Glucose Homeostasis After Pediatric Cardiac Surgery

This study aimed to evaluate the time course of perioperative blood glucose levels of children undergoing cardiac surgery for congenital heart disease in relation to endogenous stress hormones, inflammatory mediators, and exogenous factors such as caloric intake and glucocorticoid use. The study prospectively included 49 children undergoing cardiac surgery. Blood glucose levels, hormonal alterations, and inflammatory responses were investigated before and at the end of surgery, then 12 and 24 h afterward. In general, blood glucose levels were highest at the end of surgery. Hyperglycemia, defined as a glucose level higher than 8.3 mmol/l (>150 mg/dl) was present in 52% of the children at the end of surgery. Spontaneous normalization of blood glucose occurred in 94% of the children within 24 h. During surgery, glucocorticoids were administered to 65% of the children, and this was the main factor associated with hyperglycemia at the end of surgery (determined by univariate analysis of variance). Hyperglycemia disappeared spontaneously without insulin therapy after 12–24 h for the majority of the children. Postoperative morbidity was low in the study group, so the presumed positive effects of glucocorticoids seemed to outweigh the adverse effects of iatrogenic hyperglycemia.     

Pilot study of a model-based approach to blood glucose control in very-low-birthweight neonates

ABSTRACT: BACKGROUND: Hyperglycemia often occurs in premature, very low birthweight infants (VLBW) due to immaturity of endogenous regulatory systems and the stress of their condition. Hyperglycemia in neonates has been linked to increased morbidities and mortality and occurs at increasing rates with decreasing birthweight. In this cohort, the emerging use of insulin to manage hyperglycemia has carried a significant risk of hypoglycemia. The efficacy of blood glucose control using a computer metabolic system model to determine insulin infusion rates was assessed in very-low-birth-weight infants. METHODS: Initial short-term 24-hour trials were performed on 8 VLBW infants with hyperglycemia followed by long-term trials of several days performed on 22 infants. Median birthweight was 745g and 760g for short-term and long-term trial infants, and median gestational age at birth was 25.6 and 25.4 weeks respectively. Blood glucose control is compared to 21 retrospective patients from the same unit who received insulin infusions determined by sliding scales and clinician intuition. RESULTS: Reduction in hyperglycemia towards the target glucose band was achieved safely in all cases during the short-term trials with no hypoglycemic episodes. Lower median blood glucose concentration was achieved during clinical implementation at 6.6 mmol/L (IQR: 5.5 - 8.2mmol/L, 1,003 measurements), compared to 8.0 mmol/L achieved in similar infants previously (p < 0.01). No significant difference in incidence of hypoglycemia during long-term trials was observed (p = 0.51). Percentage of blood glucose within the target range was increased by 83% compared to the retrospective cohort (p < 0.01). CONCLUSIONS: A computer model that accurately captures the dynamics of neonatal metabolism can provide safe and effective blood glucose control without increasing hypoglycemia.     

Hyperglycemia is associated with morbidity in critically ill children with meningococcal sepsis

OBJECTIVE: To determine the association between hyperglycemia and outcome in children ventilated for meningococcal sepsis. DESIGN: Retrospective case notes review. SETTING: Eight bedded pediatric intensive care unit in London. PATIENTS: Consecutive children ventilated for meningococcal sepsis 2001-2004. INTERVENTIONS: None. MEASUREMENTS: Peak glucose for the entire admission was determined and mean glucose was calculated for the following three epochs: 1) first 24 hrs, 2) second 24 hrs, and 3) the entire pediatric intensive care unit admission. Patients were also grouped according to whether their blood glucose rose to >7 mmol/L (126 mg/dL), >10 mmol/L (180 mg/dL), or remained below these levels during the pediatric intensive care unit admission. Outcome measures were predicted mortality (based on pediatric risk of mortality score), ventilator free days at 30 days, nosocomial infection, use of renal replacement therapy, use of inotropes, and skin necrosis. MAIN RESULTS: Ninety-seven patients were identified with a median age of 2.1 yrs and a median length of stay of 4 days. Four patients died. Peak glucose significantly correlated with predicted mortality and negatively correlated with ventilator free days at 30 days (p < 0.001 and p < 0.001, respectively). Patients who received renal replacement therapy or inotropic support, or developed a nosocomial infection or skin necrosis had significantly higher peak glucose than those who did not (p = 0.006, p < 0.0001, p = 0.022, and p < 0.0001, respectively). Patients who received renal replacement therapy or who developed skin necrosis had significantly higher mean blood glucose in the second 24 hrs of admission (p = 0.017 and p = 0.004, respectively). However, mean blood glucose in the first 24 hrs and over the entire admission did not correlate with outcome. Patients defined as hyperglycemic with blood glucose either >7 mmol/L or >10 mmol/L also had a significantly worse outcome than those who maintained blood glucose below these levels. CONCLUSIONS: There was a significant association between hyperglycemia and outcome. Our results support a trial of tight glycemic control in this group of critically ill children.     

Clinical value of glycated hemoglobin and fructosamine in the long-term glycemic control of children with acute lymphoblastic leukemia

Hyperglycemia in children with acute lymphoblastic leukemia (ALL) has been well documented in the literature. The puipose of the present study was to evaluate the clinical value of glycated hemoglobin (GHb) and fructosamine (Frc) in the long-term glycemic control of ALL patients. An attempt was made to identify the risk factors for hyperglycemia in ALL patients. The study group comprised 26 newly diagnosed ALL patients admitted to hospital during1995–96. Patients with a history of blood transfusion or infection within the past 3 months were excluded from the study. White blood cell (WBC) counts, fasting blood glucose (FBG). GHb and Frc levels were analyzed in venous blood on screening day 0, before induction of chemotherapy. Frc analysis was repeated on the 21st day and GHb level on the 60th day of chemotherapy. FBG tests were performed before each dose of L-asparaginase, on days 21 and 60. None of the patients was obese. Although six children (23%) had hyperglycemia during the induction therapy, four of them had a GHb level higher than normal on admission. Only one patient who developed hyperglycemia had a family history of diabetes mellitus. Patients with a high initial WBC count (>20× 10⁹/L) had a significantly higher baseline GHb than patients with a WBC count below this level. GHb values returned to normal after achievement of complete remission. It is suggested that the leukemic process could impair glucose metabolism and baseline GHb may be used to monitor possible small changes in glucose homeostasis of ALL patients, prior to chemotherapy.     

Glycemic level in mechanically ventilated children with bronchiolitis.

OBJECTIVE: To evaluate in children with bronchiolitis requiring mechanical ventilation the association between blood glucose level and duration of mechanical ventilation and pediatric intensive care unit (PICU) stay. DESIGN: Retrospective cohort study. SETTING: University hospital PICU. PATIENTS: Children admitted to a university hospital PICU over a period of 3 yrs. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Demographic data, infection with respiratory syncytial virus, history of prematurity, mechanical ventilator settings, and use of inotrope during illness were noted. In addition, C-reactive protein, alanine transaminase, and glucose levels were recorded. Data from 50 children with median (interquartile range) age of 2.2 (1.3-4.7) months were analyzed. There were 37 boys, 21 children had been premature babies, and 30 children were positive for respiratory syncytial virus. Hyperglycemia at any time was frequent (peak glucose > or =6.1 mmol/L [110 mg/dL] in 98% and >8.3 mmol/L [150 mg/dL] in 72%). Children with sustained hyperglycemia were more likely to be boys with higher alanine transaminase and C-reactive protein, requiring inotrope (p < .05). These children are more likely to have required high-frequency oscillation ventilation, required higher airway pressures, and had longer duration of mechanical ventilation and PICU stay (p < .05). Peak glucose and sustained peak glucose were not independently associated with duration of mechanical ventilation or PICU stay. Multiple regression showed that age, C-reactive protein, the need for inotrope, and respiratory syncytial virus infection were independent factors associated with duration of PICU stay. Glucose level was not a factor. CONCLUSIONS: Our findings show that hyperglycemia is frequent in children with bronchiolitis requiring mechanical ventilation, but we failed to show that this phenomenon was independently associated with prolonged duration of mechanical ventilation or PICU stay. Our observations raise the question whether tight glycemic control should be used in children with bronchiolitis.     

婴幼儿持续性高胰岛素血症的术中冰冻诊断意义及病理分析

目的探讨婴幼儿持续性高胰岛素血症(persistent hyperinsulinemic hypoglycemia in infancy,PHHI)的病理分型以及术中冰冻病理对外科手术治疗方法选择的指导意义。方法2011年4月至2016年10月,复旦大学附属儿科医院共25例PHHI患儿经外科手术治疗,回顾性分析其相关临床资料、手术治疗经过及术后病理特征。结果25例患儿中男17例,女8例,年龄16 d至12个月,术前经内分泌科明确诊断患有PHHI,空腹血糖0.6~5.5 mmol/L,禁食实验胰岛素水平为3.1~50.1 mU/L。结合术前检查及术中冰冻结果,5例患儿诊断为局灶性病变,行胰腺病灶切除术,20例诊断为弥漫性病变,行胰腺次全切术。术后随访2~38个月,空腹血糖3.0~12.6 mmol/L,15例术后血糖恢复较好,1例仍有低血糖症状,需加用激素治疗,3例空腹时血糖偏低,进食后可恢复,另6例有术后高血糖症状,需药物治疗。1例术前疑诊为局灶性病变,行50%胰腺切除术后2周复发。术后病理检查有5例诊断为局灶型,1例为不典型型,余19例为弥漫型。结论对于内科治疗无效的PHHI以手术治疗为主,术前明确病理分型对手术方式的选择极为重要,术中快速冰冻切片结合术前辅助检查可以较为准确的指导手术方式。婴幼儿PHHI主要以弥漫型为主,但从术后病理区分弥漫型及局灶性仍存在困难,其中不典型型尚无明确的定义或分类,还有待在病理学方面进一步详细研究。     

儿童阻塞性睡眠呼吸暂停低通气综合征多系统影响的研究

目的 探讨阻塞性睡眠呼吸暂停低通气综合征(obstructive sleep apnea-hypopneasyndrome,OSAHS)对儿童多器官系统的影响.方法 选择2009年3月至2010年12月在温州医学院附属第二医院、育英儿童医院睡眠障碍诊疗中心,经多导睡眠监测仪( polysomnography,PSG)监测确诊为OSAHS的儿童89例,根据病情轻重分为轻度组59例、中重度组30例,选取同期来本院体检的健康儿童100例为正常对照组.测量身高、体重、体重指数、血压,记录腺样体面容、牙咬合情况,测定血常规、甘油三酯、总胆固醇、低密度脂蛋白胆固醇、高密度脂蛋白胆固醇、血糖和胰岛素水平,检查心电图和心脏B超,比较各组结果.结果 OSAHS轻度组、中重度组体重(kg)分别为23.3 ±10.1、21.9±8.4,身高(cm) 114.9±16.2、110.8±13.3,均低于正常组(31.8±10.1、136.1±15.1)(P ＜0.05),腺样体面容发生率23.7％、26.7％,牙咬合异常率74.6％、60.0％,明显高于正常组(0,4％)(P＜0.05);OSAHS中重度组高密度脂蛋白胆固醇[(1.20±0.30) mmol/L]、胰岛素[2.79 (0.84～16.16) mU/L]低于正常组[(1.40±0.27) mmol/L、4.92(0.76～16.80) mU/L],低密度脂蛋白胆固醇[ (2.61 ±0.75) mmol/L]高于正常组[(2.32 ±0.62) mmol/L] (P ＜0.05);OSAHS轻度组、中重度组红细胞计数(×1012/L)分别为4.93 ±0.37、5.23 ±0.22,血小板计数(×109/L) 292.92±75.64、292.50±63.05,明显高于正常组(4.70 ±0.31,255.60±69.12) (P＜ 0.05),收缩压(mm Hg,1 mm Hg =0.133 kPa)分别为98.54±10.44、99.13±19.13,高于正常组(87.88±11.37) (P ＜0.05),右室内径(mm) (14.24±1.64、13.17±2.07)小于正常组(16.10±2.96),主肺动脉内径(mm)(17.05±3.33、16.33±3.14)大于正常组(14.11 ±2.52),右室壁厚(mm) (3.43±0.26、3.57 ±0.20)大于正常组(3.32 ±0.25) (P ＜0.05),OSAHS中重度组心率[(94.43 ±10.64)次/min]比正常组[ (87.12±16.20)次/min]增快(P＜0.05);OSAHS中重度组与轻度组比较差异无统计学意义(P＞0.05).结论 儿童OSAHS颌面发育畸形明显,可以影响其他系统的功能,有生长发育减缓、代谢紊乱、血液黏度增加、血压升高、心脏结构改变的倾向.     

Glycemic Control for Postoperative Pediatric Cardiac Patients

This study aimed to determine the prevalence of hyperglycemia among pediatric postoperative cardiac patients, its impact on outcomes, and whether hyperglycemia can be controlled effectively in this population. A retrospective chart review of 100 postoperative patients admitted to the authors’ pediatric cardiac intensive care unit (ICU) was conducted. Patients were evaluated for incidence of hyperglycemia, defined as blood glucose (BG) level exceeding 7.7 mmol/l (140 mg/dl), and outcomes. The evaluation also included 20 different postoperative patients with a BG level exceeding 7.7 mmol/l (140 mg/dl) who received management with insulin via the authors’ pediatric-specific glycemic control protocol. The BG control and hypoglycemic rates in this cohort were assessed. The prevalence of hyperglycemia was 84%. The hyperglycemic patients had higher inotrope scores, longer hospital stays, more mechanical ventilation days, and higher mortality rates than those without hyperglycemia. For the patients with hyperglycemia managed via the authors’ pediatric-specific glycemic control protocol, 62% of all BG values were within the authors’ goal range, and less than 4% of BG values were less than 3.3 mmol/l (60 mg/dl). No patient had a BG level lower than 2.2 mmol/l (40 mg/dl) during glycemic management. Severe hyperglycemia is prevalent among postoperative pediatric cardiac patients and correlates with morbidity and mortality. Hyperglycemia may be controlled effectively in these patients using a pediatric-specific glycemic control protocol without increasing the incidence of hypoglycemia.