胰岛素强化治疗对急性重型颅脑损伤患者脑脊液乳酸代谢的影响

Effect of intensive insulin therapy on cerebrospinal fluid lactic acid metabolism in patients with severe head injury

目的 评价强化治疗和血糖控制对改善合并应激性高血糖的重型颅脑损伤患者脑组织代谢和神经系统预后的意义。方法 46例发生应激性高血糖（血糖超过9mmot／L）的重型颅脑损伤患者配对后随机分为胰岛素强化治疗组和对照组，血糖分别控制在4～6mmot／L和〈11mmot／L。硬膜外置管动态监测颅内压（ICP）变化，于入院后1周内每日检测脑脊液乳酸浓度和pH值，并行哥拉斯格（GCS）评分评价中枢神经系统功能恢复情况。结果 强化治疗显著降低了恢复期脑脊液乳酸浓度和水肿高峰期颅内压峰值，治疗组GCS评分高于对照组，胰岛素治疗并缩短了ICU监护天数和总住院时间。结论 胰岛素强化治疗可改善脑外伤后脑脊液乳酸代谢，降低水肿高峰期颅内压，为神经组织细胞恢复提供稳定微环境。

Objective To evaluate whether the strict control of serum glucose can improve the prognosis for cerebral metabolism and nervous system of these patients with severe head injury. Methods A total of 46 severe head injury patients were randomly assigned to receive intensive insulin therapy or routine therapy, titrating serum glucose levels at 4 -6 mmol/L and less than 11 mmol/L respectively. All patients were treated according to neurosurgical intensive care routine including monitoring intracranial pressure （ICP）. Lactate and pH value of cerebrospinal fluid （CSF） were tested continually in a week after admission, while Glasgow Coma Scale （GCS） scores were appealed for evaluating neurological function in the two groups. Results In comparison with control group, lactate concentrations and intracranial pressure significantly decreased after insulin treatment as well as the marked elevation of GCS scores. There was no difference in pH values of CSF between the two groups. Intensive insulin therapy also reduced the ICU days and hospital stay. Conclusion As a valuable protocol for glucose management, intensive insulin therapy ameliorates the accumulation of lactate in the ischemic brain tissue after injury, depress ICP during oedema crest-time and improve neurological outcomes.