强化胰岛素治疗对脓毒性休克患者血流动力学的影响

The influence of intensive insulin therapy on hemodynamics in patients with septic shock

目的探讨强化胰岛素治疗和目标血糖控制对脓毒性休克患者血流动力学和心功能的影响。方法选择合并有心肌抑制的脓毒性休克患者27例，随机分为目标组（13例）和常规组（14例）。通过静脉持续输注胰岛素和加强血糖监测将24h平均血糖控制在目标组4．1～6．1mmol／L、常规组6．2～8．3mmol／L。采用肺动脉导管测定血流动力学参数和心功能。结果48h后与常规组比较，目标组平均血糖下降[（6．0±1．5）mmol／L比（8．2±1．9）mmol／L，P〈0．053、胰岛素用量增加[（10．3±3．7）U／h比（7．5±3．0）U／h，P〈0．05）3；氧合指数（PaO2／FiO2）、每搏量指数（SVD、心排血指数（CI）和氧输送指数（DO2I）分别增加了20．2％、23.3％、15．1％和11．7％（P均〈0．05）。两组间平均动脉压（MAP）、急性生理学与慢性健康状况评分系统I（APACHEI）评分和血乳酸比较差异无统计学意义（P均〉0．05）。与常规组比较，目标组严重低血糖发生率有所增加（38．5％比28．6％），但差异无统计学意义（P〉0．05）。结论强化胰岛素治疗进一步血糖控制可改善脓毒性休克患者的血流动力学状态，增强心功能，减轻心肌抑制。

Objective To elucidate effects of intensive insulin therapy and target glucose control on hemodynamics and cardiac function in patients with septic shock. Methods Twenty-seven patients of septic shock with myocardial depression were divided into routine group （14 cases, level of blood glucose was 4.1 to 6.1 mmol/L） and target group （13 cases, level of blood glucose was 6.2 to 8.3 mmol/L）. Hemodynamics and cardiac function parameters were obtained via pulmonary artery catheter after 48 hours. Results Mean blood glucose level in target group was lower than that in routine group [（6.0±1.5） mmol/L vs. （8.2± 1.9） mmol/L, P〈0. 05], with dosage of insulin infusion in target group increased as compared with that of routine group [（10.3 ±3.7） U/h vs. （7.5 ± 3.0） U/h, P 〈 0. 053. Furthermore, oxygenation index （PaOz/FiOz）, stroke volume index （SVI）, cardiac index （CI） and oxygen delivery index （DO2I） were increased 20. 2%, 23.3%, 15.1% and 11.7%, respectively （all P〈0. 05）. On the other hands, there was no significant difference between target and routine group in mean artery pressure, acute physiology and chronic health evaluation I （APACHE I ） score, blood lactic acid （all P〉0.05）, ahhought the incidence of severe hypoglycemia was higher in target group than the routine group （38.5% vs. 28. 6%, P〉0. 05）. Conclusion Intensive insulin therapy and blood glucose control may improve hemodynamic status and enhance cardiac function in patients with septic shock and myocardial depression.