【摘要】：背景與目的： 應(yīng)激性血糖升高是ICU危重患者中普遍存在的一種現(xiàn)象[1,2]，過高的血糖可能導(dǎo)致多器官功能的損害。高血糖對(duì)機(jī)體的損害主要由兩種方式來表現(xiàn)，一是持續(xù)性的高血糖，二是較大的血糖波動(dòng)幅度（也稱血糖變異度）。國內(nèi)外已經(jīng)有相關(guān)的研究指出，較大的血糖波動(dòng)比持續(xù)高血糖對(duì)糖尿病的慢性并發(fā)癥有更大影響。并且血糖波動(dòng)和高血糖狀態(tài)相互促進(jìn)，相輔相成，共同對(duì)患者的預(yù)后產(chǎn)生影響。但對(duì)于危重顱腦疾病患者，血糖波動(dòng)是否和其預(yù)后相關(guān)，，血糖波動(dòng)能否成為影響危重顱腦疾病患者預(yù)后的獨(dú)立危險(xiǎn)因素，目前尚缺乏系統(tǒng)性臨床觀察。本文通過對(duì)80例新入蘇大附一院急診科ICU以及江蘇省靖江市人民醫(yī)院集團(tuán)重癥醫(yī)學(xué)科的危重顱腦疾病患者進(jìn)行72小時(shí)的血糖監(jiān)測(cè)，計(jì)算其血糖波動(dòng)指標(biāo)，并對(duì)患者的28天預(yù)后進(jìn)行觀察，探討血糖波動(dòng)和其預(yù)后的相關(guān)性，以便早期判斷疾病的危重程度，并為此類患者的早期臨床治療提供理論依據(jù)。 研究方法： 研究對(duì)象選擇2012年09月至2013年07月入住蘇大附一院急診科重癥監(jiān)護(hù)病房（ICU）以及江蘇省靖江市人民醫(yī)院集團(tuán)ICU，當(dāng)日急性生理學(xué)與慢性健康狀況評(píng)分系統(tǒng)Ⅱ（APACHE-Ⅱ評(píng)分）≥15分，ICU住院時(shí)間≥3天，4分≤GCS≤8分的危重顱腦疾病患者進(jìn)行血糖監(jiān)測(cè)及預(yù)后觀察，排除既往有糖尿病史，或合并有嚴(yán)重的其他臟器的損傷，或者傷前有飲酒史的患者，或者有高血壓病史者，共80例，失訪2例，余78例，其中男性42例，女性36例，平均年齡49.6±11.5歲。血糖監(jiān)測(cè)終點(diǎn)為轉(zhuǎn)入ICU后72小時(shí)，預(yù)后觀察終點(diǎn)為轉(zhuǎn)入ICU后28天；計(jì)算患者轉(zhuǎn)入ICU時(shí)的平均血糖（GluAve）、血糖變異性指標(biāo)[血糖標(biāo)準(zhǔn)差（GluSD)、血糖變異系數(shù)（GluCV）、第1、2、3天以及72小時(shí)的血糖不穩(wěn)定指數(shù)（GLI-1、GLI-2、GLI-3、GLI-3d）]。按患者預(yù)后情況分為死亡組（n=38)及生存組(n=40)，比較兩組間APACHE-Ⅱ評(píng)分、血糖變異性、炎癥因子hs-CRP（超敏C反應(yīng)蛋白）及腫瘤壞死因子α (TNF-α)水平、胰島素抵抗指標(biāo)、顱腦損傷程度特異性指標(biāo)NSE（神經(jīng)元特異性烯醇化酶）及28天病死率的差異。 研究結(jié)果： （1）死亡組APACHE-Ⅱ評(píng)分明顯高于生存組[（23.8±6.5) vs (21.6±5.4)，Ρ0.05]，死亡組hs-CRP、TNF-α以及NSE均明顯高于生存組(均Ρ0.05)；NSE與APACHE-Ⅱ評(píng)分顯著相關(guān)（Ρ0.01）； （2）死亡組患者的血糖變異指標(biāo)GluSD、GluCV、GL-1、GLI-3d及低血糖發(fā)生率均明顯高于生存組（Ρ0.05），而GluAdm（初始血糖）、GluAve比較差異無統(tǒng)計(jì)學(xué)意義（均Ρ0.05）； （3）死亡組胰島素抵抗指標(biāo)HOMA-IR、HOMA-β、胰島素總用量與生存組比較差異有統(tǒng)計(jì)學(xué)意義(Ρ0.05)，且GLI-3d與HOMA-IR及hs-CRP、TNF-α均顯著相關(guān)（Ρ0.01）； （4）對(duì)反映預(yù)后的ROC曲線下面積進(jìn)行比較，GLI-3d的AUC=0.901，對(duì)預(yù)后診斷有較高的準(zhǔn)確性。 研究結(jié)論： 危重顱腦疾病患者的血糖波動(dòng)與28天死亡率密切相關(guān)，控制血糖波動(dòng)，保持血糖穩(wěn)定比控制高血糖更重要。
[Abstract]:Background & objective: stress hyperglycemia is a common phenomenon in critically ill patients with ICU [1,2]. Hyperglycemia may lead to damage to multiple organ functions. There are two main ways to show the damage of hyperglycemia to the body. One is persistent hyperglycemia and the other is the larger fluctuation of blood sugar (also known as blood glucose variation). It has been pointed out at home and abroad that large fluctuation of blood glucose has more effect on chronic complications of diabetes than persistent hyperglycemia. And blood glucose fluctuation and hyperglycemia promote each other, complement each other, and affect the prognosis of patients together. However, whether the blood glucose fluctuation is related to the prognosis and whether the blood glucose fluctuation can be an independent risk factor affecting the prognosis of critical craniocerebral disease patients is still lack of systematic clinical observation. Based on the 72-hour blood glucose monitoring of 80 newly admitted ICU patients in the emergency department of the first affiliated Hospital of Jiangsu Province and the critical craniocerebral diseases of Jingjiang people's Hospital Group in Jiangsu Province, the blood glucose fluctuation indexes were calculated. The 28-day prognosis of the patients was observed to explore the correlation between the fluctuation of blood glucose and the prognosis in order to judge the severity of the disease early and provide theoretical basis for the early clinical treatment of this kind of patients. Methods: the subjects were selected from September 2012 to July 2013 in the Emergency intensive Care Unit of the first affiliated Hospital of Jiangsu Province (ICU) and Jingjiang people's Hospital Group (ICU,), Jiangsu Province. Patients with critical craniocerebral diseases whose acute physiology and chronic health status score 鈪

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