【作者】 王艳丽；

【导师】 张胜兰；

【作者基本信息】 山东中医药大学 ， 中西医结合临床， 2008， 硕士

【摘要】 目的:观察胰岛素强化治疗对中医辨证分型高血糖危重症患者治疗作用的影响,并探讨甲状腺轴、血清β-内啡肽、白介素-6水平与中医辨证分型的关系。方法:将收入内、外科ICU监护病房的高血糖危重症患者达到危重症病情评分系统APACHE II评分分值者50例,随机分为胰岛素强化治疗组(30人)和胰岛素常规治疗组(20人)。通过胰岛素泵、静脉点滴或皮下注射胰岛素的方法配合一日多次血糖监测,胰岛素强化治疗组使血糖维持在4.4～6.1mmol/L,胰岛素常规治疗组维持血糖在10.0～11.1mmol/L。于治疗前、治疗后第1天、第3天和第7天空腹抽取肘静脉血3ml通过ELISA法对血清游离三碘甲状腺原氨酸(FT3)、游离甲状腺素(FT4)、促甲状腺素(TSH)、β-内啡肽(β-EP)及白介素-6(IL-6)表达情况进行动态监测,观察并探讨两组病人中医辨证分型与病人死亡率、APACHE II评分及甲状腺轴、β-EP、IL-6的关系。结果:①胰岛素强化治疗组死亡率明显低于胰岛素常规治疗组(6.7% vs 35% ,P<0.05)。②胰岛素强化治疗组治疗后第1天、第3天和第7天FT3表达明显升高(2.38±0.65 vs 2.03±0.45、P<0.05;2.98±0.85 vs 2.23±0.70、P<0.05;4.18±1.30 vs 3.15±1.15、P<0.05), FT4、TSH无明显变化。观察组FT3指标的异常数与APACHEII积分及病死率相关。③胰岛素强化治疗组治疗后第1天、第3天血清β-EP水平明显低于胰岛素常规治疗组(6.58±1.31 vs 7.79±2.20、P<0.05;3.63±0.88 vs5.22±1.36、P<0.01)。④胰岛素强化治疗组治疗后第1天、第3天和第7天血清IL-6表达显著低于胰岛素常规治疗组(274.69±51.66 vs 309.45±41.87、P<0.05;199.39±45.60 vs 244.13±74.87、P<0.05;109.07±23.68 vs 125.04±16.70、P<0.05)。⑤中医辨证分型中四种主要证型分布比较均匀,实热组的APACHEII评分最低(P<0.05);气滞血瘀组的APACHEII评分最高(P<0.05)。治疗后实热证、气滞血瘀证、腑气不通证、厥脱证四证型胰岛素强化治疗组与胰岛素常规治疗组APACHEⅡ评分比较都有显著差异(P<0.05)。除TSH各证型治疗前后无显著差异外(P>0.05),其他因子各证型治疗前后均有显著差异(P<0.01)。各因子治疗前后实热证、气滞血瘀证与其他证型比较,差异都有显著性(P<0.05)。结论: (1)胰岛素强化治疗较胰岛素常规治疗能够显著改善高血糖危重症患者的甲状腺功能紊乱,降低血清β-EP和IL-6水平,减轻全身炎症反应,改善机体免疫状态,从而降低死亡率,改善患者预后。(2)高血糖危重症中四种主要证型分布比较均匀,胰岛素强化治疗较胰岛素常规治疗对辨证分型各组的APACHEII评分的改善有显著差异。实热组的APACHEII评分最低,预后最好;气滞血瘀组的APACHEII评分最高,预后最差。通过APACHEII评分为临床危重症中医辨证的治疗和预后提供了理论依据。TSH各证型治疗前后无显著差异外,其他因子各证型治疗前后均有显著差异。FT3、FT4在实热证中表达最高,气滞血瘀证中表达最低,β-EP、IL-6在实热证中表达最低,气滞血瘀证中表达最高,即各因子在高血糖危重症治疗前后实热证中表现病情最轻,气滞血瘀证中表现病情最重。更多还原

【Abstract】 Objective To observe the value of intensive insulin therapy on differentiation of symptoms and signs for classification of syndrome in the critical illness with hyperglycemia and try to explain it’s relation of thyroid axis、β-EP、IL-6 and differentiation of symptoms and signs for classification of syndrome.Methods 50 eligible patients who achieve scores of APACHE II,admitted to our medical or surgical intensive care unit were allocated randomly to receive tight control of blood glucose by intensive insulin therapy (maintenance of blood glucose at a level between 4.4mmol/L and 6.1mmol/L,30patients) or to receive conventional treatment (maintenance of blood glucose at a level between 10.0 mmol/L and 11.1mmol/L,20patients). We also collected 3ml venous blood to detect FT3、FT4、TSH、β-EPand IL-6 expression of serum by the way of ELISA pretherap、on the1d,3d,7d after patients being admitted intensive care units(ICU). The relation of differentiation of symptoms and signs for classification of syndrome、mortality、APACHE IIand IL-6 of the two groups patients were observed..Results:①Mortality(6.7% vs 35%,P<0.05)of 30 patients who received intensive insulin therapy was obviously lower than that of 20 patients who received conventional treatment.②Levels of FT3 of serum (2.38±0.65 vs 2.03±0.45、P<0.05;2.98±0.85 vs 2.23±0.70、P<0.05;4.18±1.30 vs 3.15±1.15、P<0.05)on 1d,3d,7d ,of 30 patients who received intensive insulin therapy, were evidently higher to that of 20 patients who received conventional treatment.;Levels of FT4and TSH of serum have no marked change.the number of abnormality among FT3 was positively correlated to APACHEⅡscore,while a significantly correlation was seen between the number and the mortality.③β-EP activity of serum(6.58±1.31 vs 7.79±2.20、P<0.05;3.63±0.88 vs 5.22±1.36、P<0.01)on 1d, 3d, of 30 patients who received intensive insulin therapy, was obviously below to that of 20 patients who received conventional treatment.④IL-6 expression of serum on 1d, 3d,7d,,of 30 patients who received intensive insulin therapy,was obviously below to that of 20 patients who received conventional treatment(274.69±51.66 vs 309.45±41.87、P<0.05;199.39±45.60 vs 244.13±74.87、P<0.05;109.07±23.68 vs 125.04±16.70、P<0.05).⑤The distribution of the four kinds of model is quite well distributed, APACHEⅡscore of the sthenic heat syndrome is the lowes(tP<0.05),the prognosis is the best; stagnancy of Blood and Qi syndrome is the highest(P<0.05), the prognosis is the worst. They both have difference . They all have prominent difference except TSH between before and after treating (P﹤0.01). They both have difference in each type of syndrome of IL-6 . the sthenic heat syndrome and stagnancy of Blood and Qi syndrome both have difference compared with other kinds of model of each factor(P<0.05). Conclusion (1) Tight control of blood glucose by intensive insulin therapy is able to notable improve dysthyroid of critical illness with hyperglycemia,to lower the level ofβ-EP and IL-6 of serum,to relieve systemic inflammatory response syndrome and improve immune state, accordingly to lower the mortality and improve prognosis of patient.(2)In the evere case with hyperglycemia, The distribution of the four kinds of model is quite well distributed, They both have significantly difference to the improve of APACHEⅡscore in the group of differentiation of symptoms and signs for classification of syndrome between patients who received intensive insulin therapy and conventional treatment. APACHEⅡscore of the sthenic heat syndrome is the lowest,the prognosis is the best; stagnancy of Blood and Qi syndrome is the highest, the prognosis is the worst. Through APACHEⅡscore provid the theory according for the treat and prognosis of clinical traditional Chinese medicine differentiatiosymptoms and signs. They all have prominent difference except TSH between before and after treating . FT3、FT4 are the highest in the sthenic heat syndrome, are the lowest in the stagnancy of Blood and Qi syndrome;β-EP、IL-6 are the lowest in the sthenic heat syndrome, the highest in the stagnancy of Blood and Qi syndrome. Each factor in the critical illness with hyperglycemia before and after treating, patient’s condition is the best in the sthenic heat syndrome,patient’s condition is the worst in the stagnancy of Blood and Qi syndrome.更多还原