T2DM患者静点葡萄糖-胰岛素溶液对血糖影响的研究

【作者】 刘安诺； 彭巧君；

【机构】 安徽医科大学护理学院； 新疆医科大学第一附属医院护理部；

【摘要】 目的:探讨糖尿病患者静脉点滴葡萄糖胰岛素溶液血糖是否保持平稳及影响平稳的相关因素。方法:采用自身前后配对设计,自2007年8月至2008年8月选择接受静脉药物治疗的2型糖尿病住院病人180例为研究对象,纳入研究172例,试验进行七天,第一天评价患者一般情况,体格检查和实验室检查;第二天及第三天静脉输注0.9%氯化钠注射液250ml作为对照,第四天及第五天输注5%葡萄糖250ml+RI 4u(江苏万帮生化医药股份有限公司),第六天及第七天输注5%葡萄糖250ml+RI 6u作为试验,液体中所加药物均为疏血通(主要成分:水蛭.地龙)。早餐2h后即开始静脉点滴,滴速40~50滴/分,固定三餐时间、主食量和日常运动量。由专人使用快速血糖仪测量空腹、早餐后2h(点滴0h)、点滴结束、结束后2h的指端血糖,输液时测量不输液肢体的指端血糖,并记录数据。试验期内禁用其它糖类及盐类补充液体。应用SPSS13.0统计软件进行统计学处理。计量资料用表示,先进行正态性和方差齐性检验;同一溶液各时间点血糖水平差异比较用重复测量设计的方差分析;同一溶液两时间点血糖水平差异比较用多个相关样本Friedman检验;不同溶液同一时间点用配对t检验;计数资料用卡方检验;输注前后血糖的差异与研究指标的相关性用Spearman相关、偏相关及Logistic回归分析,检验水准α=0.05,采用双侧检验假设,产生结果在P<0.05时有统计学意义。结果:1.输注5%葡萄糖250ml+4u RI与0.9%氯化钠250ml,即刻、结束、结束后2h血糖水平比较差异有统计学意义(F值=6.600,P=0.011;F=6.129,P=0.014);两种溶液在结束、结束后2h血糖水平比较有统计学意义(t=-4.748,P=0.000;t=-7.120,P=0.000);70例患者在葡萄糖中结束血糖高于即刻血糖,9例患者在生理盐水结束血糖高于即刻血糖,比较有统计学意义(Х2=61.143,P=0.000);输注过程血糖水平呈下降趋势,葡萄糖溶液下降幅度较小,结束时血糖水平10.91±3.68 mmol/L,结束2h血糖水平10.16±3.60 mmol/L,均>10 mmol/L超过WHO血糖控制标准,生理盐水血糖下降幅度较大,结束时血糖水平9.56±3.76 mmol/L,结束2h血糖水平8.29±3.18 mmol/L,基本回复8 mmol/L血糖控制尚可标准。2.输注5%葡萄糖250ml+4u RI与5%葡萄糖250ml+6uRI比较,即刻、结束、结束后2h血糖水平比较差异有统计学意义(F值=25.213,P=0.000;F=3.719,P=0.045),两种溶液在结束、结束后2h血糖水平比较有统计学意义(t=2.168,P=0.032;t=4.456,P=0.000);70例患者在4u RI溶液中结束血糖高于即刻血糖,12例患者在6uRI溶液中结束血糖高于即刻血糖,比较有统计学意义(Х2=14.83,P=0.012);输注过程血糖水平呈下降趋势,6uRI葡萄糖溶液较4uRI下降幅度大,结束时血糖水平8.06±2.55 mmol/L回复到血糖控制尚可标准,结束2h血糖水平6.92±1.75 mmol/L,回复2hPBG控制理想状态。3.单因素Pearson相关分析,结束与即刻比较血糖升高的影响因素是年龄、民族、病程、糖化血清蛋白、腹围、并发症、治疗模式,其中民族、糖化血清蛋白、并发症、治疗模式是结束时血糖水平的主要影响因素。4.Logistic逐步回归分析,以点滴结束血糖为应变量,以年龄、病程、民族糖化血清蛋白、腹围、BMI、治疗模式、并发症变量为自变量,进一步讨点滴影响结束血糖水平的主要因素。最终糖化血清蛋白、民族、BMI入选,年龄和并发症以交互作用入选。结论:1.糖尿病患者静脉输注5%葡萄糖250ml+4u RI,点滴结束\结束后2h血糖水平不能回复至血糖控制尚可水平。输液过程有40.70%患者输液结束血糖高于即刻血糖。2.除糖尿病合并高血压、肾功能减退、心功能不全的T2DM患者液体治疗最好选择0.9%氯化钠溶液作为药物的溶剂,可避免因输液导致的高血糖状态,建议输液速度控制50~60 gtt/min以减少容量负荷。3.糖尿病患者静脉输注5%葡萄糖250ml+6u RI,点滴结束血糖水平能回复至血糖控制尚可水平。输液过程有7.0%患者输液结束血糖高于即刻血糖。4.输注葡萄糖时影响血糖平稳的主要影响因素为:民族、糖化血清蛋白症、BMI,年龄&并发症。5.护理措施为:加强血糖监测,输液过程应该作为监测时间段之一,防止医源性高血糖;早餐进食质和量控制;早餐后1h和点滴葡萄糖结束后嘱咐患者下床活动,增加骨骼肌对糖的利用,尽量减少高血糖;输液中间不能再次摄食;个体化输注胰岛素方案。更多还原

【Abstract】 Objective: To investigate whether blood glucose can maintain stable when diabetic was administered with glycol-insulin solutions by intravenous drip and the relative factors to affect its stability.Methods: To choose 180 type-2 diabetic inpatients who received drugs by intravenous treatment as investigating object from August of 2007 to that of 2008, analyzed by self matched-pairs design, 172 inpatients were brought to research, and the experiment lasts seven days. The general state, physical inspection and laboratory examination of the patients were evaluated on the first day; 250 ml 0.9% sodium chloride injection was intravenous infused as control on the second and third day; 5% glucose solution added with 4u RI(product of Wanbang biochemistry medicine limited company of Jiangsu province) was administered on the forth and fifth day; 5% glucose solution added with 6u RI was administered as experimental group on the sixth and seventh day, all solutions were added with Shuxuetong(main component: leech and pheretima asiatica). The intravenous drip began at two hours after breakfast, at the speed of forty to fifty dr/min, and the time of three meals, main appetite and normal amount of exercise were fixed. The blood glucose of finger tip at empty stomach, two hours after breakfast, the end of intravenous drip and two hours after the end was measured by special investigator with fast blood glucose instrument, the blood glucose of free limb should be measured at the time of intravenous infusion and the datas should be recorded. Other glucose and salts liquid were forbidden at the experimental stage.The datas were analyzed with SPSS 13.0 statistical software. Quantitative data which signifies as, should be treated with normality test and homogeneity test of variances; the difference of blood glucose in the same solution at the different time point can be treated with repeatable measure design ANOVA; the difference of blood glucose in the same solution at two time points can be treated with Friedman tests for several related sample; the different solution at the same time point should be treated with paired t test; the quantitative data should be treated with chi-square test; the correlation between the difference of the blood glucose and the research index should be analyzed by the spearman correlation, partial correlation and Logistic regression analysis, the size of test was using double tailed test hypothesis, the difference had statistical significance when p<0.05.Results: 1. The difference of the comparison of blood glucose at the instant, the end and two hours after the end in control group had statistical significance(F=6.600,P=0.011;F=6.129,P=0.014); The difference of the comparison of blood glucose at the end and two hours after the end in two solutions had statistical significance(t=-4.748,P=0.000; t=-7.120,P=0.000); The blood glucose at the end was higher than the instant for 70 inpatients in glucose group, so was 9 inpatients in 0.9% sodium chloride, and the comparison had statistical significance(Х2=61.143,P=0.000); the level of blood glucose was descending in the process of infusion, the extent of this decline in glucose solution was relatively small, the blood glucose at the end is 10.91±3.68 mmol/L,two hours after the end is 10.16±3.60 mmol/L, they were both higher than 10mmol/l and exceeded the blood glucose control standards of WHO. The extent of this decline in sodium chloride solution was relatively big, the blood glucose at the end is 9.56±3.76 mmol/L, two hours after the end is 8.29±3.18 mmol/L, retrieving basically to 8 mmol/L.2. The difference of the blood glucose at the instance, the end and two hours after the end had statistical signifi cance(F=25.213,P=0.000;F=3.719,P=0.045), the blood glucose of two solutions at the end and two hours after the end had statistical significance (t=2.168,P=0.032; t=4.456,P=0.000); the blood glucose of seventy inpatients at the end was higher than the instance in 4u RI, that of 12 inpatients at the end was higher than the instance in 6u RI, this comparison had statistical significance(Х2=14.83,P=0.012); the level of the blood glucose was declining in the process of the infusion, the extent of the decline for 6u RI in glucose was bigger than 4u RI, the blood glucose at the end was 8.06±2.55 mmol/L, retrieving to acceptable blood glucose control standard, the blood glucose at the two hours after the end was 6.92±1.75 mmol/L, retrieving to two hours PBG ideal control state.3. Single factor Pearson correlation analysis, the influencing factor on the blood glucose at the end and the instance was age(r=0.189*,p=0.013), nation(r=-0.290**,p=0.000), course of disease(r=0.192*,p=0.012), saccharifying serum protein(r=0.263**,p=0.000), abdomen circumference(r=0.175*,p=0.022), complication(r=0.364**,p=0.000), therapeutic mode(r=0.222**,p=0.003), the main influencing factor on the blood glucose at the end was nation, saccharifying serum protein, complication and therapeutic mode.4. Logistic gradual regressive analysis, recognize the blood glucose at the end of infusion as adaptable variable, age, course of disease, nation, saccharifying serum protein, abdomen circumference, BMI, therapeutic mode, complication as independent variable, and investigate further the main factors influencing the level of blood glucose, chosing Forward: Conditional. saccharifying serum protein, nation, BMI were finally selected, age and complication were selected as interaction(b=0.048,p=0.024). The efficacy of equations was tested by chi-square criterion, x2=52.529,p=0.000.Conclusions: 1. The diabetic patients were administered with 5% glucose 250ml+4u RI by intravenous infusion, the level of the blood glucose at the end and two hours after the end can’t retrieve to the acceptable blood glucose control standard. The blood glucose at the end for 40.70% diabetics was higher than the instance in the process of the infusion.2. The liquid therapy for the type 2 diabetic patients except those incorporating hypertension, renal hypofunction and cardiac insufficiency had better choose 0.9% sodium chloride as the vehiculum for drugs, which can avoid the hyperglucose state resulting by infusion. The infusion speed which was controlled to 50-60 gtt/min was suggested to reduce volume load.3. The diabetic patients who were administered with 5% glucose 250ml+6u RI, the level of blood glucose at the end of infusion can retrieve to acceptable control standard. The blood glucose at the end for 7.0% diabetic patients was higher than the instance in the process of infusion.4. The main influencing factors on the blood glucose in the process of infusion were: nation, saccharifying serum protein, BMI, age and complication.5. Nursing intervention: enhance blood glucose monitoring, infusion process should be one of the monitoring time stages, and prevent iatrogenic hyperglycaemia; the breakfast should control quality and quantity. The diabetic patients should be told to out-of-bed activity at the time of one hour after breakfast and the end of infusion, increase musculi skeleti to utilize glucose, and reduce hyperglycaemia as soon as possible; in the middle of infusion ingestion was not admitted; insulin proposal should be individualizational.更多还原