摘要目的 探讨血糖及血糖变异性对急性大面积脑梗死患者预后的影响.方法 回顾性分析浙江省台州恩泽医疗中心路桥医院2012年1月至2013年6月收住入院的72例非糖尿病急性大面积脑梗死患者的临床资料,记录72 h内平均血糖(GluAve)、血糖标准差(GluSD)、血糖变异率(GluCV)以及并发症发生情况(包括脑心综合征、肺部感染、应激性溃疡出血、泌尿系统感染、压力性溃疡、电解质紊乱、癫痫等).根据28 d预后将患者分为存活组(60例)及死亡组(12例),比较两组间GluAve、GluSD、GluCV的差异;根据GluAve水平将患者分为＜7.8、7.8～11.1、＞11.1 mmol/L 3组,根据GluCV将患者分为＜15％、15％～ 30％、30％～ 50％、＞50％4组,比较组间入院时急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分、病死率及并发症发生率.结果 死亡组GluAve、GluSD、GluCV均明显高于存活组[GluAve(mmol/L):15.91±5.33比12.41±3.12,t=3.145,P=0.002;GluSD(mmol/L):2.87±1.96比1.83±1.08,t=2.611,P=0.017;GluCV:(27.56±14.73)％比(20.12±10.97)％,t=2.020,P=0.043].随着GluAve逐渐增高,患者28 d病死率、总并发症发生率明显增高[28 d病死率:5.00％(1/20)、13.89％(5/36)、37.50％(6/16),x2=7.16,P=0.028;总并发症发生率:35.00％ (7/20)、55.56％(20/36)、93.75％(15/16),x2=12.85,P=0.002],入院时APACHEⅡ评分(分:9.80±4.17、12.11±5.81、13.69±6.57,F=2.241,P=0.114)、应激性溃疡出血发生率[5.00％(1/20)、11.11％(4/36)、31.25％(5/16),x2=5.59,P=0.061]虽逐渐升高,但差异无统计学意义.随着GluCV逐渐增高,患者入院时APACHEⅡ评分、28 d病死率、各种并发症及总并发症发生率显著增高[APACHEⅡ评分(分):7.00±1.56、10.08±1.88、13.14±5.76、16.76±7.17,F=12.486,P＜0.000;28 d病死率:0(0/15)、8.70％ (2/23)、23.81％(5/21)、38.46％(5/13),x2=9.27,P=0.026;总并发症发生率:40.00％(6/15)、47.83％(11/23)、57.14％(12/21)、100.00％(13/13),x2=12.42,P=0.006].结论 高血糖、血糖波动范围大均提示大面积脑梗死患者预后不良,且血糖变异性较平均血糖水平能更好地预测患者的预后,对患者住院期间不良反应事件发生可能更敏感.

abstractsObjective To investigate the relationship between the levels and variability of blood glucose and the prognosis of massive cerebral infarction.Methods A retrospective study involving 72 massive cerebral infarction patients without diabetes mellitus admitted to Taizhou Enze Medical Centre Luqiao Hospital from January 2012 to June 2013 was conducted.The mean blood glucose level (GluAve),standard deviation of blood glucose level (GluSD),and coefficient of variation of blood glucose level (GluCV) during the first 72 hours were monitored.Complications such as cerebrocardiac syndrome,pulmonary infection,stress ulcer bleeding,urinary system infection,decubitus sore,electrolyte disturbances,and epileptic seizures were also recorded.According to the 28-day outcome after admission,patients were divided into survivor group (n=60) and non-survivor group (n=12).The values of GluAve,GluSD and GluCV were compared between the two groups.The patients were again divided into three groups based on the level of GluAve (＜ 7.8,7.8-11.1,＞ 11.1 mmol/L).Finally,patients were divided into four groups based on the level of GluCV (＜ 15％,15％-30％,30％-50％,＞50％).Acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) score,mortality,and complications were compared among groups.Results The levels of GluAve,GluSD and GluCV in non-survivor group were significantly higher than those in survivor group [GluAve (mmol/L):17.91 ± 5.33 vs.12.41 ± 3.12,t=3.145,P=0.002; GluSD (mmol/L):2.87 ± 1.96 vs.1.83 ± 1.08,t=2.611,P=0.017; GluCV:(27.56± 14.73)％ vs.(20.12 ± 10.97)％,t=2.020,P=0.043].With the gradual increase of GluAve level,the mortality and total complication rate were elevated significandy [28-day mortality:5.00％ (1/20),13.89％ (5/36),37.50％ (6/16),x2=7.16,P=0.028; total complication rate:35.00％ (7/20),55.56％ (20/36),93.75％ (15/16),x2=12.85,P=0.002].But there was no significant difference in APACHE Ⅱ score (9.80 ± 4.17,12.11 ± 5.81,13.69 ± 6.57,F=2.241,P=0.114) and stress ulcer incidence rate [5.00％ (1/20),11.11％ (4/36),31.25％ (5/16),x2=5.59,P=0.061].With the gradual increase of GluCV level,APACHE Ⅱ score,28-day mortality,the incidence of various complications,and total complication rate were all raised significantly [APACHE Ⅱ score:7.00 ± 1.56,10.08 ± 1.88,13.14 ±5.76,16.76 ± 7.17,F=12.486,P=0.000; mortality:0 (0/15),8.70％ (2/23),23.81％ (5/21),38.46％ (5/13),x2 =9.27,P=0.026; total complication rate:40.00％ (6/15),47.83％ (11/23),57.14％ (12/21),100.00％ (13/13),x2=12.42,P=0.006].Conclusions Both the GluAve level and GluCV level are significantly correlated with the outcome of patients suffering from massive cerebral infarction.The change in GluCV level seems to be more sensitive in predicting the prognosis of massive cerebral infarction than GluAve.