上腹部择期手术患者围手术期院内高血糖的临床研究

发布时间：2018-03-08 07:09

本文选题：院内高血糖　切入点：QHS评分　出处：《山西医科大学》2015年硕士论文　论文类型：学位论文

【摘要】：目的:调查长治医学院附属和济医院普外科院内高血糖的发生率,对其控制现状予以评估。观察上腹部择期手术患者围手术期血糖的变化,探讨术前糖负荷对手术导致术后应激性高血糖的血糖及HOMA指数的影响。方法:对2014年5月20日0时---2014年5月21日0时长治医学院附属和济医院住院患者(除外儿科)进行调查,采集既往病史、目前的用药情况,询问患者吸烟饮酒病史,同时记录性别、年龄、身高、体重、血压一般资料,收集空腹血糖(FPG)、住院期间所有检测血糖值、总胆固醇(TC)、甘油三酯(TG)、高密度脂蛋白胆固醇(HDLC)、低密度脂蛋白胆固醇(LDL-C)、血尿酸、肝功(ALT、AST)、r-GT肾功(BUN、Cr)等生化指标,计算体重指数(BMI)、计算院内高血糖的患病率,应用耶鲁大学院内高血糖管理工具,即质量高血糖评分((The Quality Hyperglycemia Score,QHS)),评价和济医院院内高血糖的管理现况。选择上腹部择期手术患者40例,根据患者自愿原则,排除以下患者:①行急诊手术或者开腹手术的上腹部手术患者,②既往有糖尿病病史、甲状腺功能亢进症等内分泌疾病的患者,③既往有胃排空障碍,胃肠道梗阻性病史患者,④妊娠期妇女,⑤血常规、肝肾功能异常者,⑥体重指数19 kg/m2,体重指数25kg/m2。记录入选患者进行性别、年龄、身高、体重、血压、肝肾功、既往史等一般资料,随机分成两组:对照组、糖负荷组。对照组术前常规禁食8-12小时,糖负荷组术前3小时给予糖负荷,即12.5%的葡萄糖液400ml,术前2小时服用完,测定术前、术后1天、术后3天的空腹血糖和胰岛素,计算胰岛素分泌指数(HOMA-IS),胰岛素敏感指数(HOMA-ISI)和胰岛素抵抗指数(HOMA-IR)。公式:胰岛素抵抗指数=(空腹血糖的浓度×空腹胰岛素浓度)/22.5;胰岛素敏感指数=1/(空腹血糖浓度的常用对数+空腹胰岛素浓度的常用对数);胰岛素分泌指数=(空腹胰岛素浓度×20)/(空腹血糖浓度-3.5)。结果:长治医学院附属和济医院普外科院内高血糖的发生率,及QHS评分分析:1)共调查462名住院患者,院内高血糖发生率19.2%(89名),其中已诊断糖尿病患者40名(8.7%),其中外科系统院内高血糖平均发生率11.1%,普外科为外科系统中院内高血糖发生率最高的科室,其发生率为15%。2)所有住院患者的血糖应用QHS评分系统分析,正常血糖范围(3.9-10.0mmol/L)水平占64%,严重高血糖(㧐16.7mmol/L)占11.7%,低血糖(2.8-3.9mmol/L)占1.5%,QHS评分为72分,其中普外科的正常血糖水平占60%,严重高血糖占12.5%,高血糖占27.5%,无低血糖及严重低血糖,QHS评分为70分,院内高血糖控制情况不容乐观,普外科院内高血糖控制水平居整体中等水平。上腹部择期手术患者围手术期血糖的变化,术前糖负荷对手术导致术后应激性高血糖的血糖及HOMA指数的影响。与术前相比,术后两组患者的血糖、血清胰岛素浓度和HOMA-IR、HOMA-ISI均较术前显著增高(P0.05),而HOMA-IS降低(P0.05);对照组和糖负荷组患者术后应激性高血糖发生率为35%5%(P0.05);与对照组比较,糖负荷组术后血糖和HOMA-IR均明显低于对照组(P0.05),HOMA-IS、HOMA-ISI明显高于对照组(P0.05)。结论:院内高血糖整体发病率19.2%,其中普外科院内高血糖发病率15%,在外科科室发生率最高,推测可能原因与普外科急症病人多、围手术期发生应激性高血糖有关,其应激包括内源性激素(肾上腺素、糖皮质激素、高血糖素等)产生增加、细胞因子(肿瘤坏死因子、白细胞介素等)释放以及神经系统信号的调节等。应用QHS评分系统分析院内高血糖控制情况不容乐观。在上腹部择期手术患者中,术后应激性高血糖发生率35%,手术可导致病人出现应激性高血糖,术前糖负荷可减少术后高血糖的发生率(35%5%,P0.05).术前糖负荷的应用降低了围手术期应激高血糖的发生率,可能与其提高胰岛素分泌量和胰岛素敏感性,降低患者胰岛素抵抗程度有关。
[Abstract]:Objective: To investigate the prevalence of Heji Hospital Affiliated to Changzhi Medical College Hospital Department of general surgery, high blood sugar, control of the situation to be evaluated. Observation of elective abdominal surgery patients perioperative blood glucose changes on preoperative glucose load in operation due to the stress hyperglycemia and glucose HOMA index after operation. Methods: on May 20, 2014 0 ---2014 in May 21st 0 Heji Hospital Affiliated to Changzhi Medical College hospital patients (except Pediatrics) investigation, collection of past medical history, medication at present, patients were asked about smoking and drinking history, record the same gender, age, height, weight, blood pressure data collected fasting blood glucose (FPG), all values of blood glucose during hospitalization, total cholesterol (TC), triglyceride (TG), high density lipoprotein cholesterol (HDLC), low density lipoprotein cholesterol (LDL-C), blood uric acid, liver function (ALT, AST), r-GT (BUN, Cr) of renal function and other biochemical indicators, meter Body mass index (BMI), the prevalence rate of high blood sugar, high blood sugar management tools, application of Yale, namely quality score (high blood glucose (The Quality Hyperglycemia Score, QHS)), evaluation of the management of hyperglycemia in hospitals. The choice and selection of patients with abdominal surgery in 40 cases, according to the with the principle of voluntariness, exclude the following: 1. Patients with upper abdominal surgery patients underwent emergency surgery or open surgery, the patient with diabetes, endocrine diseases such as hyperthyroidism patients, the patients with gastric emptying in patients with gastrointestinal obstruction history, the pregnant women, the blood routine, liver and kidney dysfunction. The body mass index of 19 kg/m2 body mass index 25kg/m2. records the patient gender, age, height, weight, blood pressure, liver and kidney function, the general data of medical history, were randomly divided into two groups: control group, glucose load group. The control group before surgery often Rule 8-12 hours of fasting, glucose load group were given 3 h before glucose loading, i.e. glucose 400ml, 12.5%, 2 hours before the operation of taking over, were measured before operation, after 1 days of fasting blood glucose and insulin for 3 days after operation, calculated the insulin secretion index (HOMA-IS), insulin sensitivity index (HOMA-ISI) and the insulin resistance index (HOMA-IR). Formula: insulin resistance index (x = concentration of fasting blood glucose and fasting insulin concentration /22.5); insulin sensitivity index =1/ (fasting insulin concentration logarithm logarithm + fasting blood glucose levels of the insulin secretion index (=); fasting insulin concentration (x 20) / fasting blood glucose concentration -3.5). Results: the incidence of Heji Hospital Affiliated to Changzhi Medical College Hospital Department of general surgery analysis of high blood sugar, and QHS score: 1) a total of 462 patients in hospital, the incidence of hyperglycemia in 19.2% (89), which has been diagnosed 40 patients with diabetes (8.7%), including surgery The hospital system of high blood sugar the average incidence of 11.1%, the Department of general surgery for surgical system in hospital the incidence of hyperglycemia in the highest department, the incidence rate of 15%.2) to analyze all hospitalized patients with blood glucose using QHS scoring system, the normal range of blood glucose (3.9-10.0mmol/L) levels accounted for 64%, severe hyperglycemia (? 16.7mmol/L) accounted for 11.7%, hypoglycemia (2.8-3.9mmol/L) accounted for 1.5%, QHS score was 72, which accounted for 60% of the normal level of blood glucose in Department of general surgery, severe hyperglycemia accounted for 12.5%, accounted for 27.5% of high blood sugar, no hypoglycemia and severe hypoglycemia, QHS score was 70 points, hospital high glycemic control is not optimistic, the Department of general surgery hospital high level of blood glucose control in the middle level on the whole. The perioperative blood glucose change elective abdominal surgery patients, preoperative glucose loading in operation due to the stress hyperglycemia and glucose HOMA index after operation. Compared with the preoperative blood glucose of the two groups of patients after operation, serum insulin The concentration of HOMA-IR and HOMA-ISI were significantly higher than preoperative (P0.05), and HOMA-IS decreased (P0.05); the control group and the glucose load in groups of patients with stress hyperglycemia and the incidence rate was 35%5% (P0.05); compared with the control group, postoperative blood glucose and glucose load in group HOMA-IR were significantly lower than the control group (P0.05), HOMA-IS, HOMA-ISI were significantly higher than control group (P0.05). Conclusion: 19.2% the overall incidence rate of high blood sugar in the hospital, the Department of general surgery hospital hyperglycemia incidence rate of 15%, the highest incidence rate in surgical departments, may cause the Department of general surgery and emergency patients, perioperative period of stress hyperglycemia, including the stress endogenous hormones (epinephrine, glucocorticoid, glucagon etc.) increased production of cytokines (tumor necrosis factor, interleukin) release and regulation of signal of the nervous system. Analysis of nosocomial high blood glucose control situation is not optimistic about the application of QHS scoring system. In patients undergoing elective abdominal surgery, postoperative stress hyperglycemia occurred in 35% patients, surgery may lead to stress hyperglycemia, preoperative glycemic load can reduce the incidence of postoperative hyperglycemia (35%5%, P0.05). Preoperative glucose load reduces perioperative stress hyperglycemia incidence that may be related to the increase of insulin secretion and insulin sensitivity, reduce the degree of insulin resistance in patients with.

【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2015
【分类号】：R587.1

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