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目的观察连续性肾替代治疗(CRRT)对危重患者血糖滤过和血胰岛素浓度的影响,探讨危重患者在CRRT时应采取的血糖控制策略。方法对2008年1月～5月我院外科重症加强医疗中心20例需要进行CRRT的危重患者,采用标准含糖5.2mmol/L的透析液进行CRRT,动态监测从CRRT开始至结束期间滤器前(动脉端)、滤器后(静脉端)血糖及血胰岛素浓度的改变,同时监测CRRT开始、期间及结束后患者血糖浓度和对外源性胰岛素需求的动态变化。结果重症患者在CRRT开始时血糖值处于相对较高水平,CRRT开始后血糖不断滤过,滤器静脉端血糖浓度明显低于动脉端[(8.27±0.35)mmol/Lvs.(9.80±1.08)mmol/L,P<0.05];约6小时后,动脉端与静脉端血糖浓度接近。重症患者血胰岛素水平增高,CRRT开始前血胰岛素为(17.82±12.90)mmol/L,1小时后动脉端血胰岛素下降至(14.20±2.67)mmol/L,静脉端下降至(11.10±7.21)mmol/L。上机3～4小时后动、静脉端血胰岛素水平接近[(5.07±0.35)mmol/Lvs.(4.68±0.56)mmol/L,P>0.05)。CRRT期间患者血糖渐接近正常,外源性胰岛素需要量减少;而CRRT结束后血糖迅速回升,外源性胰岛素用量需要迅速调整以维持血糖稳定。结论CRRT使血糖及血胰岛素同时减少,在CRRT约6小时后血糖逐渐趋于稳定,此时外源性胰岛素应逐渐减量;而CRRT停机时血胰岛素仍处于相对较低水平,此时需密切注意高血糖的发生和及时调整外源性胰岛素用量。
Objective To observe the effects of continuous renal replacement therapy (CRRT) on blood glucose and insulin in critically ill patients, and to explore the glycemic control strategy in critically ill patients during CRRT. Methods From January to May 2008, 20 CRRT critically ill patients in intensive care center of surgical intensive care center of our hospital were treated with standard 5.2mmol / L dialysate containing sugars. CRRT was dynamically monitored from the beginning of CRRT to the end of filter Arterial end), post-filter (venous end) blood glucose and insulin concentrations, and monitor the patient’s blood glucose levels and the dynamic changes in exogenous insulin requirements during the beginning, during, and after CRRT. Results The critically ill patients had a relatively high blood glucose level at the beginning of CRRT. The blood glucose level was continuously filtered after the start of CRRT, and the blood glucose level in the venous end of the filter was significantly lower than that in the arterial end [(8.27 ± 0.35) mmol / L vs (9.80 ± 1.08) mmol / L, P <0.05]. After about 6 hours, the arterial and venous blood glucose concentrations were close. Serum insulin levels were increased in critically ill patients with insulin (17.82 ± 12.90) mmol / L before CRRT, and decreased to (14.20 ± 2.67) mmol / L and (11.10 ± 7.21) mmol / / L. After 3 to 4 hours on the machine, the venous blood insulin level was close to [(5.07 ± 0.35) mmol / L vs (4.68 ± 0.56) mmol / L, P> 0.05). During CRRT, blood glucose gradually approached normal, exogenous insulin requirements decreased; and blood glucose rose rapidly after the end of CRRT, exogenous insulin dosage need to be rapidly adjusted to maintain stable blood glucose. Conclusions CRRT reduces both blood glucose and insulin at the same time. Blood glucose gradually stabilizes after about 6 hours CRRT, and exogenous insulin should be gradually reduced at this time. However, when CRRT is stopped, blood insulin is still at a relatively low level, Note the occurrence of hyperglycemia and timely adjustment of exogenous insulin dosage.