【摘要】 目的 寻求一种有效、简单易行、与胰岛素抵抗有关的的应激性高血糖调控模式。方法 颅脑外伤24 h内入院急症手术患者80例,以入院格拉斯哥评分(GCS)分为G1(<6)、G2(7～10)和G3(11～15)三组,每组又随机分为治疗亚组与对照亚组;术中每隔1h测定血糖1次。高血糖术中调控模式:1.用公式Ⅰ:胰岛素用量(U)=(末次血糖-正常血糖)×18×体重×0.6×10×1000-1～×2-1(胰岛素:葡萄糖=1:2),计算将入室血糖降至正常体内所需胰岛素总量M,用输液泵将M在2 h内输注完毕。2.根据公式Ⅱ:胰岛素拮抗度IR=[1-(末次血糖-正常血糖)/正常血糖]×100%,(1)IR<0,采用公式Ⅰ再次计算胰岛素值,并用2 h泵注,之后采用公式Ⅲ。(2)IR>0,直接用公式Ⅲ。3.根据公式Ⅲ:胰岛素维持量(U/h)=(末次血糖×18)/150,计算维持量。结果 GCS评分越低,血糖含量越高,胰岛素拮抗越严重;血糖含量越高,预后越差;治疗亚组与对照亚组的预后差异有显著性(P<0.05)。结论颅脑外伤应激性高血糖的三步法胰岛素调控模式安全、有效;早期、连续的胰岛素调控,有利于改善患者预后。更多还原

【Abstract】 Objective To evaluate the effectiveness of a insulin regimen for the management of stress hyperglycemia induced by head injury.Methods Eighty patients (64 male, 16 female) admitted to the hospital within 24h after head injury were enrolled in the study. The age ranged from 16-75 yr. The patients were divided into 3 groups according to the numeric values of Glasgow Coma Scale (GCS) : group Ⅰ < 6 ( n = 30) ; group Ⅱ 7-10 ( n = 22) and group Ⅲ 11-14 ( n = 28) . Each group was further divided into insulin and control subgroups. The neurologic outcome was divided into 5 groups according to Glasgow Outcome Scale (GOS) : (1) death; (2) brain death; (3) severely decapacitated; (4) moderately decapaeilated; (5) good. Anesthesia was induced with midazolam 0.1 mg· kg-1 , fentanyl 4 μg · kg-1 ; etomidate 0.2 mg· kg-1 and succinylcholine 100 mg· kg-1 and maintained with continuous infusion of 2 % procaine 250 ml + vecuronium 4 mg supplemented with intermittent i. v. boluses of fentanyl. Blood glucose level was determined before anesthesia and every hour during operation. In insulin subgroup the insulin was given during operation in 3 steps : step Ⅰ : the amount of insulin needed to reduce the elevated blood glucose to normal level was calculated using formula Ⅰ :The amount of insulin = (the last blood glucose - normal blood glucose) × 18 × body weight (kg) × 0.6 × 10 × 1000-1 × 2-1 (U) . The amount of insulin calculated was infused over 2 h with infusion pump. Step Ⅱ : the degree of insulin resistance (IR) was assessed:IR - [ 1 - (the last blood glucose - the normal blood glucose) / the normal blood glucose ] × 100 % , if IR < 0, step Ⅰ was repeated. If IR>0, the step Ⅲ was taken to maintain blood glucose at normal level using formula Ⅱ : the maintenance dose of insulin = (last blood glucose × 18) / 150 U·h-1 .Results The blood glucose levels before anesthesia were (12 ± 7) mmol (group Ⅰ ), (9 ± 3) mmol (group Ⅱ ) and (8 ± 5) mmol (group Ⅲ ) . The differences between the two groups were significant ( P < 0.01). The lower was the GCS score, the higher was the blood glucose level and more serious was the insulin resistance. The neurologic outcome was vlosely correlated with the blood glucose level before anesthesia. The higher was the blood glucose level before anesthesia the worse was the outcome. There was significant difference in neurologic outcome between the insulin and control subgroups. The survival rate was 95 .1 % in insulin subgroup and 89.7 % in control subgroup. The percentage of patients with good outcome was 80.5 % in insulin subgroup and 53.8 % in control subgroup. Conclusion The insulin regimen described above is safe and effective in the management of stress hyperglycemia and can improve the neurologic outcome.更多还原