创伤性凝血病患者血糖波动与 hs －CRP TNF－αIL －6水平及预后的关系

The relationship between glucose fluctuations with hs-CRP TNF-αIL-6 level and prognosis in patients with traumatic coagulopathy

目的：探讨创伤性凝血病患者血糖波动与血清炎症因子水平及预后的关系，为早期识别、预后判断和阐述发生机制提供新的方法或思路。方法选取创伤性凝血病患者100例，依据72 h内平均血糖波动幅度（ MAGE）分为A组（ MAGE＜3．9 mmol／L）61例、B组（ MAGE≥39． mmol／L）39例。检测24 h内凝血指标，包括凝血酶原时间（PT）、部分凝血活酶时间（APTT）、凝血酶时间（ TT）、纤维蛋白原（ Fg）、D－二聚体（ D－D）等，进行24 h内急性生理学及慢性健康状况评分Ⅱ（ APACHEⅡ）、创伤严重程度评分（ TRISS），监测72 h MAGE，检测第1、3、7天血清高敏C反应蛋白（ hs－CRP）、肿瘤坏死因子－α（ TNF－α）、白细胞介素－6（ IL－6）水平，观察4周内预后情况。对72 h MAGE与血清hs －CRP、TNF －α、IL －6水平进行Pearson直线相关分析，采用Logistic多因素回归分析各因素与患者死亡的关系。结果 B组24 h凝血功能包括PT、APTT、TT、Fg、D－D水平，24 h APACHEⅡ评分、TRISS评分及72 h MAGE水平均高于A组（ t＝3．40-5．52，P＜0．05或P＜0．01）。 A、B组血清hs－CRP、TNF－α、IL－6水平均以第3天最高，第7天降低，但低于第1天水平（t＝3．55-7．37，P＜0．05或P＜0．01）；B组血清hs－CRP、TNF－α、IL－6水平均高于A组相应时点水平（ t＝3．65-4．87，P＜0．05）。72 h MAGE与血清hs－CRP、TNF－α、IL－6水平均呈正相关性（rhs－CRP ＝0．62，rTNF－α＝0．49，rIL－6＝0．57，P＜0．05）。4周内A、B组致残率为26．23％、37．84％（χ2＝4．21，P＜0．05），死亡率为13．11％、35．14％（χ2＝5．07，P＜0．01）；多因素Logistic回归分析显示，APACHEⅡ评分、TRISS评分、72 h MAGE是创伤性凝血病患者死亡的独立危险因素。结论创伤性凝血病患者多存在较大幅度的血糖波动，且血清hs－CRP、TNF－α、IL－6呈高水平波动，72 h MAGE与血清hs－CRP、TNF－α、IL－6呈正相关性，且是患者预后不良的独立危险因素，因此推测血糖波动可能是通过炎症反应介导而对机体产生损伤作用的。

Objective To explorer the relationship between glucose fluctuations with serum inflammatory factors and prognosis in patients with traumatic coagulopathy, to provide new method or idea for its early recognition, prognosis evaluation and expounding pathogenesis.Methods One hundred patients with traumatic coagulopathy were selected, and were divided into group A with 61 patients （MAGE〈3.9 mmol/L）, and group B with 39 patients （ MAGE≥3.9 mmol/L） by mean amplitude of glycemic excursions （ MAGE ） in 72 h.Coagulation indexes in 24 h were detected, including prothrombin time （ PT） , activated partial thromboplastin time （ APTT） , thrombin time （ TT） , fibrinogen （Fg）, D-dimer （D-D）, also acute physiology and chronic health evaluation （APACHEⅡ） and trauma revised injury severity score （ TRISS） in 24 h were measured, and MAGE in 72 h were monitored.Serum high sensitivity C -reactive protein （ hs -CRP ） , tumor necrosis factor alpha （TNF-α）, interleukin-6 （IL-6） level in day 1, 3, and 7 were detected, and patients＇prognosis were observed 4 weeks later.Relationship between 72 h MAGE with serum hs -CRP, TNF-α, IL-6 were analyzed by Pearson linear correlation, and relationship between patient＇s death and various factors were analyzed by Logistic multi-factors regression analysis.Results Coagulation indexes （ PT, APTT, TT, Fg, D-D） and APACHEⅡin 24 h, TRISS score in 24 h, and MAGE in 72 h in group B were all higher than that of group A （t=3.40-5.52, P〈0.05 or P〈0.01）.Serum hs-CRP, TNF-α, IL-6 in day 3 in group A and B were all in the highest level, and decreased in day 7, yet also lower than that in day 1 （t=3.55-7.37, P〈0.05 or P〈0.01）, and level in group B were all higher than that in group A on corresponding time point （t=3.65-4.87, P〈0.05）.72 h MAGE had positive correlation with serum hs-CRP, TNF-αand IL-6 （rhs-CRP =0.62, rTNF-α=0.49, rIL-6 =0.57, P〈0.05）. Disability rate in group A and B were 26.23%and 37.84%in 4 weeks after admission （χ2 =4.21, P〈0.05）, and mortality rate were 13.11% and 35.14% （χ2 =5.07, P〈0.01）.Multivariate Logistic regression analysis showed that APACHEⅡscore, TRISS score, 72 h MAGE were all independent risk factors with patients＇death.Conclusion There are abnormal glucose fluctuations in many patients with traumatic coagulopathy, and their serum inflammatory factors of hs-CRP, TNF-α, IL-6 fluctuate in high level, and 72 h MAGE has positive correlation with inflammatory factors, also is independent risk factor with bad prognosis, so it indicates that glucose fluctuations＇damage effect may be mediated through inflammatory reaction.