严重脓毒症患者胰岛素抵抗和胰岛素分泌功能的观察

目的探讨严重脓毒症患者入ICU后血糖、胰岛素浓度、胰岛素抵抗（IR）及胰岛素分泌功能的动态变化．与疾病的严重程度和预后的关系。方法选取严重脓毒症患者36例和正常对照20例，根据脓毒症后28d后的存活情况，分为生存组（n=20例）和死亡组（n=16）。回顾分析各组第1天、第28天空腹血糖（FBG）、胰岛素（FINS）浓度，使用稳态模式法（HOMA）计算胰岛素抵抗指数（HOMA—IR）及胰岛素分泌指数（HOMA-8）。结果严重脓毒症患者入组后第1天FBG、FINS浓度及HOMA—IR均明显高于对照组，HOMA—β明显低于对照组，差异均有统计学意义（t分别=7．46、5．64、7．07、6．73，P均〈0．05）。生存组与死亡组入组后第1天FBG、FINS浓度及HOMA—IR均高于对照组，而HOMA—β低于对照组，差异有统计学意义（t分别=5．13、4．43、5．49、4．70、6．85、3．60、5．02、8．96，P均〈0．05）；生存组第28天FBG、FINS浓度及HOMA—IR较第1天下降，而HOMA-β回升，差异均有统计学意义（t分别=3．71、2．72、4．06、2．47，P均〈0．05）；死亡组FBG和HOMA-IR高于生存组，HOMA—β低于生存组，差异有统计学意义（t分别=3．46、2．82、2．97，P均〈0．05）；而FINS浓度与生存组间差异无统计学意义（t=0．32，P〉0．05）。单个脏器功能不全患者FBG浓度、HOMA-β与对照组间比较，差异均无统计学意义（q分别=1．95、1．66，P均〉0．05）；多个脏器功能不全患者FBG、FINS浓度及HOMA—IR均高于对照组；而HOMA—β低于对照组，差异均有统计学意义（q分别=10．18、5．19、7．58、14．96，P均〈0．05）。APACHEⅡ评分与FBG、HOMA—IR呈正相关，与HOMA—β呈负相关，差异均有统计学意义（r分别=0．68、0．50、-0．66，P均〈0．05）。结论严重脓毒症患者存在IR，其中多脏器功能不全患者存在胰岛β细胞功能不全，FBG浓度、HOMA—IR及HOMA—β可作为判断严重脓毒症患者病情转归，预后的预警指标。

Insulin resistance and insulin secretion in patients with severe sepsis

Objective To observe the changes of blood glucose, serum insulin level, insulin resistance （IR） and insulin secretion of patients with severe sepsis and explore the relationship between the changes and severity of illness as well as prognosis. Methods Thirty six patients with severe sepsis and 20 healthy volunteers serving as normal controls were enrolled. Fasting blood glucose （FBG） and fasting insulin （FINS） were determined at the 1st and 28th days after the diagnosis of severe sepsis was made. Insulin resistance index （HOMA-IR） and insulin secretion index （HOMA-β） were calculated using Homeostasis Model Assessment （HOMA）. Results The levels of FBG, FINS and HOMA-IR at the 1st day after the diagnosis of severe sepsis was made were significantly higher than those in normal controls, and HOMA-β was lower than that in normal controls（t=7.46,5.64,7.07,6.73 ,P〈0.05）. FBG, FINS and HOMA-IR in the 1st day after admission not only in the survivors but also in the dead were significantly higher than those in normal controls, and HOMA-β was lower than that in normal controls （t=5.13,4.43,5.49,4.70, 6.85, 3.60, 5.02,8.96, P〈0.05）. FBG, FINS and HOMA-IR in the 28th day in the survivors were decreased and HOMA-β was increased than those in the 1st day（t=3.71,2.72,4.06,2.47, P〈0.05）. FBG and HOMA-IR in the dead were significantly higher than those in the survivors, HOMA-β in the dead was lower than that in the survivors （t=3.46,2.82,2.97 ,P〈 0.05 ）, but no difference in FINS levels was found between the two groups. No difference in FBG and HOMA-β were found between the septic patients with single organ dysfunction and normal controls （q=1.95, 1.66, P〉0.05）. FBG, FINS and HOMA-IR in the septic patients with multi-organ dysfunction were significantly higher than those in normal controls, and HOMA-β was lower than that in normal controls （q=10.18,5.19,7.58,14.96, P〈0.05）. There were a positive correlation between APACHE Ⅱ scores and FBG , HOMA-IR （r=0.68,0.50, P〈0.05）, and a negative correlation between APACHE Ⅱ scores and HOMA-β（r=-0.66, P〈0.05）. Conelusions IR was found in patients with severe sepsis. Dysfunctions of pancreatic islet β cell occurs in septic patients with multi-organ dysfunction syndrome. FBG, HOMA-IR and HOMA-β can be used to evaluate the severity of disease and prognosis in patients with severe sepsis.