卒中昏迷患者高血糖实时胰岛素滴定模式的研究

目的探讨实时胰岛素滴定模式对卒中昏迷患者并发高血糖的调控作用。方法将入院后12h内连续2次以上随机血糖〉10．0mmol／L的卒中昏迷患者110例，随机纳入对照组（35例）、治疗Ⅰ组（每1小时滴定组，37例）和治疗Ⅱ组（每2小时滴定组，38例）。对照组采用预混胰岛素，即优泌林70／30，皮下注射，治疗Ⅰ组和治疗Ⅱ组以诺和灵R加入等渗盐水中以微量泵静脉推注，按所检测的血糖值确定胰岛素用量。记录各时点的血糖值，并分析各组院内感染发生率及滴定治疗对神经功能预后的影响。结果治疗组（Ⅰ和Ⅱ组）平均血糖值低于对照组，分别为（8．9±2．5）mmol／L和（12．7±3．1）mmol／L，P=0．000；血糖达标率高于对照组，分别为58．7％和17．5％，P=0．000；而低血糖（〈3．9mmol／L）的发生率均为1．5％，差异无统计学意义，P=0．719。与治疗Ⅱ组相比，治疗Ⅰ组平均血糖值低于治疗Ⅱ组，分别为（7．9±1．7）mmoL／L和（9．3±2．7）mmol／L，P=0．000；血糖达标率高于治疗Ⅱ组，分别为65．5％和42．6％，P=0．000；低血糖率低于治疗Ⅱ组，分别为1．1％和2．2％，P=0．003。治疗组的院内感染率明显低于对照组（分别为10．7％和25．7％，χ^2=4．135，P=0．042），而治疗Ⅰ组与Ⅱ组相比差异无统计学意义（分别为8．1％和13．2％，χ^2=0．113，P〉0．05）。神经功能预后治疗组好于对照组，对照组mRS评分高于治疗Ⅰ、Ⅱ组，F=4．377，P=0．015，说明治疗Ⅰ、Ⅱ组患者神经功能预后均好于对照组。结论实时胰岛素滴定模式可及时、有效、持续地对卒中昏迷患者并发的高血糖进行调控，高频度的血糖监测和调控，是进行血糖控制的有效手段。实时胰岛素滴定模式也有利于降低院内感染率，促进神经功能的恢复。

Comatose stroke patients complicated with hyperglycemia: a study of realtime insulin titration model

Objective To investigate the regnlatory effect of a reahime insulin titration model on comatose stroke patients complicated with hyperglycemia. Methods A total of 110 stroke patients with coma whose blood glucose （BG） levels were 〉 10.0 mmol/L detected more than twice within 12 hours after admission were randomly assigned into control group （ n = 35 ） , treatment group Ⅰ （ n = 37, every one-hour titration group） and treatment group Ⅱ （ n = 38, every 2-hour titration group）. Humulin 70/30, a premixed insulin, was injected subcutaneously in the control group. Novolin R was given intravenously by minipump in both treatment group Ⅰ and Ⅱ , the dose was according to the BG values. The incidence of nosocomial infection and its effect on neurological prognosis in each group were analyzed. Results The mean values of BG in treatment group was lower than that of the control group（ 8.9 ± 2.5 mmol/L vs. 12, 7 ± 3.1 mmol/L（ [ P = 0. 000] ）. The success rate of maintaining ideal BG level was higher than the control group（57.8% vs. 17.5% [ P = 0. 000] ） , the incidence of hypoglycemia （ 〈 3.9mmol/L） were all 1.5% （P =0.719）, The mean BG value of group Ⅰ was lower than that of group Ⅱ , （7.9 ± 1.7 mmol/L and 9.3 ±2.7mmol/L[P =0. 000] ） ; The success rate of maintaining ideal BG level of group Ⅰ was higher than that of group Ⅱ （65.5% vs. 42.6% [ P = 0. 000] ） ; the rate of hypoglycemia of group Ⅰ was lower than that of group Ⅱ （ 1. 1% vs. 2.2% [ P = 0. 003 ] ）. The nosocomial infection rate in the treatment groups was significantly lower than that in the control group （ 10.7% vs. 25.7% [χ^2= 4. 135, P = 0.0421 ）, while there was no significant difference between the group Ⅰ and Ⅱ （8.1% vs. 13.2% [χ^2 =0. 113 ,P 〉 0.05 ] ）. The neurological prognosis of treatment group was better than the control group. The modified Rankin scale （mRS） scores in the control group were higher than those in the 2 treatment groups（ F = 4. 377, P = 0. 015 ） , indicating that the neurological prognosis in both treatment groups was better than that in the control group. Conclusions The continuous monitoring and regulation of BG level with every one-hour titration model is effective and superior to the two-hour titration group. The realtime insulin titration model may promptly, effectively and continuously regulate the BG level of comatose stroke patients with hyperglycemia. The realtime insulin titration model is also beneficial to reduce the nosocomial infection rate and improve neurological recovery.