胰岛素强化治疗对严重创伤患者炎性反应及预后的影响

Effects of intensive insulin therapy on inflammatory response and prognosis of patients with severe trauma

目的了解胰岛素强化治疗对严重创伤患者炎性反应及预后的影响。方法将80例严重创伤患者按随机配对原则分为治疗组（40例）和对照组（40例）。治疗组患者入院后立即行胰岛素强化治疗，从胰岛素泵泵人胰岛素2～4U／h，控制血糖值在6～8mmol／L；对照组按临床常规治疗，不给予胰岛素。观察2组患者的发热、器官损伤情况，统计病死率。于开始治疗后1、3、5、7d晨抽取2组患者静脉血，检测血浆TNF-α、IL-2、IL-10、C反应蛋白（CRP）水平。结果治疗组患者9例发生高热，低于对照组（29例）。治疗组和对照组各有31例和30例患者出现1个脏器功能不全。治疗组和对照组同一患者出现3个脏器功能不全的分别为10、19例，出现4个脏器功能不全的分别为7、12例。治疗组伤后3d内死亡4例，3d以后死亡1例，病死率为12．5％；对照组伤后3d内死亡5例，3d以后死亡4例，病死率为22．5％。治疗后3～7d，治疗组患者TNF-α、CRP值均低于对照组（P〈0．05或P〈0．01），而IL-2、IL-10值则均高于对照组（P〈0．05或P〈0．01）。治疗后7d，治疗组TNF—α、CRP值最低，分别为（1．3±0．6）μg／L、（55±16）mg／L，且明显低于对照组的（3．0±0．8）μg／L、（89±20）mg／L（P〈0．01）。结论严重创伤后行胰岛素强化治疗，可以减轻患者全身性炎性反应程度，改善创伤患者预后。

Objective To investigate the effects of intensive insulin therapy on inflammatory response and prognosis of patients with severe trauma. Methods Eighty severely injured patients were divided into intensive insulin therapy group （n =40, IT） and routine therapy group （n =40, RT） in random pair. At the time of admission, a continuous infusion of insulin （2 -4 U/h） was pumped into the patients of IT group to maintain blood glucose level at 6 - 8 mmol/L. Patients in RT group were given routine treatment without administration of insulin. Fever, organ injury, and mortality of patients in 2 groups were recorded. Venous blood was drawn from patients of 2 groups on the morning of post treatment day （PTD） 1, 3, 5, and 7. Values of TNF-α, C-reactive protein （CRP） , IL-2, and IL-10 in plasma were assayed. Results High fever appeared in 9 patients in IT group, and WBC exceeded 10.0× 10^9 for more than 3 days in 17 patients in this group, versus 20 and 29 patients respectively in RT group. Dysfunction of 1 organ appeared in 31 patients in IT group and 30 patients in RT group. Dysfunction of 3 organs appeared in 10 patients in IT group and 19 patients in RT group. Dysfunction of 4 organs appeared in 7 patients in IT group and 12 patients in RT group. In IT group, 4 patients died within 3 post-injury day （PID） , and 1 patient died after PID 3 （ total case fatality： 12.5% ）. In RT group, 5 patients died within 3 PID, and 4 patient died after PID 3 （total case fatality： 22.5% ）. Plasma levels of TNF-α and CRP of patients in IT group were significantly lower than those of patients in RT group on PID 3 -7 （ P 〈0.05 or P 〈0.01） , while levels of IL-2 and IL-10 of patients in IT group were significantly higher than those of patients in FIT group （ P 〈 0. 05 or P 〈 0.01 ）. Plasma levels of TNF-α （ 1.3 ±0.6 μg/L） and CRP （55 ＋ 16 mg/L） of patients in IT group on PTD 7 were lowered to the trough level, and they were significantly lower than those of patients in RT group （3.0 ± 0.8 μg/L, 89 ±20 mg/L, respectively, P 〈 0.01 ）. Conclusions Intensive insulin therapy can mitigate systemic inflammatory response and improve prognosis of patients with severe trauma.