胰岛素目标血糖管理对脓毒症患者心室舒缩功能的影响

Effects of target blood glucose control with insulin therapy on systolic and diastolic cardiac function in septic patients

目的 探讨强化胰岛素治疗下不同目标血糖管理对脓毒症患者心室功能的影响.方法 石河子大学医学院第一附属医院2012年10月至2013年9月重症医学科采用随机对照的临床干预研究.90例脓毒症患者按随机数字表法分为3组各30例.A组：控制血糖4.4 ～6.1 mmol/L、B组：控制血糖6.1～8.3 mmol/L、C组：控制血糖8.3～10.0 mmol/L,设对照组30例.所有患者在治疗前及治疗后1、3、7d通过经胸壁超声心动图（TTE）记录左室射血分数（LVEF）、二尖瓣口舒张早期最大流速（E）与心房收缩期最大流速（A）的比值（E/A）,采血检测B型钠尿肽（BNP）;同时记录各组患者性别、年龄、血流动力学指标、白细胞计数（WBC）、APACHEⅡ评分、治疗前血糖水平、低血糖发生率及28 d死亡率.结果 A、B、C组LVEF差异无统计学意义（P=0.184）;A、B、C组E/A依次降低,A组与C组差异有统计学意义（P=0.005）;A、B、C组BNP依次升高,A组与B、C组差异有统计学意义（PAB=0.028,PAc=0.000）.治疗后1、3d,A、B、C组LVEF差异无统计学意义（P1=0.310、P3 =0.174）,E/A、BNP差异有统计学意义（均P=0.000）;治疗后7d,A、B、C组LVEF差异无统计学意义（P=0.119）,E/A、BNP差异有统计学意义（均P=0.000）.A、B、C组E/A随时间变化趋势不同.结论 将脓毒症患者血糖控制于4.4～6.1 mmol/L,可有效改善其心室舒缩功能不全;较之收缩功能,控制血糖于4.4 ～6.1 mmol/L对脓毒症心室舒张功能不全的保护更明显.通过LVEF、E/A及BNP联合评价,控制血糖于4.4～6.1 mmol/L,对治疗后7d内连续的心功能不全的恢复有积极意义.

Objective To explore the protective effects of target blood glucose control on cardiac dysfunction in septic patients.Methods For this prospective and randomized interventional study,a total of 90 septic patients were divided into group A （blood glucose levels of 4.4 to 6.1 mmol/L）,group B （6.1 to 8.3 mmol/L） and group C （8.3 to 10.0 mmol/L） （n =30 each）.And 30 non-septic subjects were selected into control group.Serial transthoracic echocardiogram （TTEs） was performed to measure left ventricle ejection fraction （LVEF） and ratio of blood flow velocity of mitral annulus during early diastole （E） and atrial contraction （A） before and 1,3,7 days after blood glucose control with insulin therapy.The plasma level of brain natriuretic peptide （BNP） was detected by enzyme-linked immunosorbent assay （ELISA）.The patient records were reviewed to obtain information about demographics,Acute Physiology and Chronic Health Evaluation Ⅱ （APACHE Ⅱ） scores,incidence of hypoglycemia and 28-days survival rates.Results No significant inter-group improvement existed in mean values of LVEFs （P =0.184）.And E/As differed among the groups and there was statistical difference between groups A and C （P =0.005）.There was a increasing trend for the levels of BNP of groups A,B and C.And comparison of group A with group B/C had statistical variability （PAB =0.028,PAc =0.000）.LVEFs had no variation （P1 =0.310,P3 =0.174） while E/A and BNP were significantly higher or lower in group A than those in others at Day 1 and 3 （P =0.005）.The LVEFs were similar at Day 7 and E/As and BNPs of groups A,B and C showed statistical differences.The variation of E/As with time differed between groups A,B and C.Conclusion Maintaining a target blood glucose of 4.4 to 6.1 mmol/L may improve cardiac dysfunction.Furthermore,it has more significant improvement of diastolic dysfunction than systolic counterpart.Combined utilization of LVEF,E/A and BNP is better in evaluating critical ill patients with sepsis-induced cardiomyopathy under target blood glucose control.It suggests that a glucose level of 4.4 to 6.1 mmol/L may benefit cardiac consistent dysfunction in septic patients during 7 days after treatment.