重症脓毒症患者血糖控制与炎症因子变化及临床意义

Glycemic control and changes of inflammatory factors in severe sepsis patients and their clinical significance

目的探讨重症脓毒症患者血糖控制与炎症因子TNF-α、IL-6变化的关系及临床意义。方法将103例血糖异常升高的重症脓毒症患者分为强化胰岛素治疗组（ intensive insulintherapy, IIT）（n=51）及常规胰岛素治疗组（ conventional insulin therapy, CIT） （ n = 52）；再根据患者糖化血红蛋白水平分别将两个治疗组各分为应激性高血糖和糖尿病两个亚组，比较其病死率及低血糖发生率。采用酶联免疫吸附法检测患者治疗0、3、7d后的炎症因子TNF-α、IL-6变化。结果IIT组中，糖尿病组病死率显著高于应激性高血糖组（66．7％vs．30．8％，P〈0．05）；CIT组中，应激性高血糖组病死率明显高于糖尿病组（54．1％vs．25．0％，P〈0．05）。多变量Logistic回归分析，强化胰岛素治疗在糖尿病组死亡风险更高（OR=1．221，95％CI：1．075～1．434），但在应激性高血糖组，强化胰岛素治疗降低了死亡风险（OR=0．872，95％CI：0．714-0．975）。IIT组低血糖发生率显著高于CIT组（13．7％vs．1．9％，P〈0．05）。治疗前，两组中应激性高血糖患者血清肿瘤坏死因子-α（TNF-α）、白介素-6（IL-6）水平均明显高于糖尿病患者（P〈0．01）；治疗7d后，两组中，应激性高血糖患者血清TNF-α、IL-6均明显下降（P〈0．01），其中IIT组下降幅度较CIT组更为明显（P〈0．05）。结论重症脓毒症伴有应激性高血糖患者，接受强化胰岛素治疗严格控制血糖，能更有效抑制炎症因子。

Objective To investigate glycemic control, changes of inflammatory factors and their clinical significance in severe sepsis patients. Methods One hundred and three severe sepsis patients with abnormal hyperglycemia were randomly divided into the two groups and receive intensive insulin therapy （IIT） and conventional insulin therapy （CIT） respectively. According to glyeosylated hemoglobin level, the two groups were further divided into stress hyperglycaemia and diabetes mellitus subgroups. The mortality and incidence of hypoglycemia were compared between the groups and subgroups. Enzyme linked immunosorbent assay was used to detect TNF-α, IL-6 levels before treatment, 3 and 7 days after treatment. Results In IIT group, the mortality in diabetes mellitus subgroup was significantly higher than that in stress hyperglycaemia subgroup （ 66. 7% vs. 30. 8%, P 〈 0. 05 ）, while the mortality in stress hyperglycaemia subgroup significantly higher than that in diabetes mellitus subgroup （54. 1% vs. 25.0%, P 〈 0. 05 ） in CIT group. Multivariate Logistic regression analysis revealed IIT increased the risk for death in diabetes mellitus subgroup （OR = 1.221, 95% CI： 1.075-1.434 ）, while decreased the risk for death in stress hyperglycaemia subgroup （ OR = 0. 872, 95% CI： 0. 714-0. 975 ） . The incidence of hypoglycemia wassignificantly higher in liT group than that in CIT group （ 13.7% vs. 1.9%, P 〈0. 05 ） . Before treatment, the levels of TNF-α, IL-6 in stress hyperglyeaemia patients were significantly higher than those in diabetes mellitus patients. After 7 day treatment, The levels of TNF-α, IL-6 decreased significantly in stress hyperglyeaemia patients （ P 〈 0. 01 ）, and decreased more significantly in liT group than that in CIT group. Conclusion Severe sepsis patients with stress hyperglyeaemia can attain better glycemia control and inhibition of inflammatory faetors, and elinieal benefit from liT.