本文選題：院內(nèi)高血糖　切入點(diǎn)：QHS評(píng)分　出處：《山西醫(yī)科大學(xué)》2015年碩士論文　論文類型：學(xué)位論文

【摘要】：目的:調(diào)查長治醫(yī)學(xué)院附屬和濟(jì)醫(yī)院普外科院內(nèi)高血糖的發(fā)生率,對(duì)其控制現(xiàn)狀予以評(píng)估。觀察上腹部擇期手術(shù)患者圍手術(shù)期血糖的變化,探討術(shù)前糖負(fù)荷對(duì)手術(shù)導(dǎo)致術(shù)后應(yīng)激性高血糖的血糖及HOMA指數(shù)的影響。方法:對(duì)2014年5月20日0時(shí)---2014年5月21日0時(shí)長治醫(yī)學(xué)院附屬和濟(jì)醫(yī)院住院患者(除外兒科)進(jìn)行調(diào)查,采集既往病史、目前的用藥情況,詢問患者吸煙飲酒病史,同時(shí)記錄性別、年齡、身高、體重、血壓一般資料,收集空腹血糖(FPG)、住院期間所有檢測(cè)血糖值、總膽固醇(TC)、甘油三酯(TG)、高密度脂蛋白膽固醇(HDLC)、低密度脂蛋白膽固醇(LDL-C)、血尿酸、肝功(ALT、AST)、r-GT腎功(BUN、Cr)等生化指標(biāo),計(jì)算體重指數(shù)(BMI)、計(jì)算院內(nèi)高血糖的患病率,應(yīng)用耶魯大學(xué)院內(nèi)高血糖管理工具,即質(zhì)量高血糖評(píng)分((The Quality Hyperglycemia Score,QHS)),評(píng)價(jià)和濟(jì)醫(yī)院院內(nèi)高血糖的管理現(xiàn)況。選擇上腹部擇期手術(shù)患者40例,根據(jù)患者自愿原則,排除以下患者:①行急診手術(shù)或者開腹手術(shù)的上腹部手術(shù)患者,②既往有糖尿病病史、甲狀腺功能亢進(jìn)癥等內(nèi)分泌疾病的患者,③既往有胃排空障礙,胃腸道梗阻性病史患者,④妊娠期婦女,⑤血常規(guī)、肝腎功能異常者,⑥體重指數(shù)19 kg/m2,體重指數(shù)25kg/m2。記錄入選患者進(jìn)行性別、年齡、身高、體重、血壓、肝腎功、既往史等一般資料,隨機(jī)分成兩組:對(duì)照組、糖負(fù)荷組。對(duì)照組術(shù)前常規(guī)禁食8-12小時(shí),糖負(fù)荷組術(shù)前3小時(shí)給予糖負(fù)荷,即12.5%的葡萄糖液400ml,術(shù)前2小時(shí)服用完,測(cè)定術(shù)前、術(shù)后1天、術(shù)后3天的空腹血糖和胰島素,計(jì)算胰島素分泌指數(shù)(HOMA-IS),胰島素敏感指數(shù)(HOMA-ISI)和胰島素抵抗指數(shù)(HOMA-IR)。公式:胰島素抵抗指數(shù)=(空腹血糖的濃度×空腹胰島素濃度)/22.5;胰島素敏感指數(shù)=1/(空腹血糖濃度的常用對(duì)數(shù)+空腹胰島素濃度的常用對(duì)數(shù));胰島素分泌指數(shù)=(空腹胰島素濃度×20)/(空腹血糖濃度-3.5)。結(jié)果:長治醫(yī)學(xué)院附屬和濟(jì)醫(yī)院普外科院內(nèi)高血糖的發(fā)生率,及QHS評(píng)分分析:1)共調(diào)查462名住院患者,院內(nèi)高血糖發(fā)生率19.2%(89名),其中已診斷糖尿病患者40名(8.7%),其中外科系統(tǒng)院內(nèi)高血糖平均發(fā)生率11.1%,普外科為外科系統(tǒng)中院內(nèi)高血糖發(fā)生率最高的科室,其發(fā)生率為15%。2)所有住院患者的血糖應(yīng)用QHS評(píng)分系統(tǒng)分析,正常血糖范圍(3.9-10.0mmol/L)水平占64%,嚴(yán)重高血糖(㧐16.7mmol/L)占11.7%,低血糖(2.8-3.9mmol/L)占1.5%,QHS評(píng)分為72分,其中普外科的正常血糖水平占60%,嚴(yán)重高血糖占12.5%,高血糖占27.5%,無低血糖及嚴(yán)重低血糖,QHS評(píng)分為70分,院內(nèi)高血糖控制情況不容樂觀,普外科院內(nèi)高血糖控制水平居整體中等水平。上腹部擇期手術(shù)患者圍手術(shù)期血糖的變化,術(shù)前糖負(fù)荷對(duì)手術(shù)導(dǎo)致術(shù)后應(yīng)激性高血糖的血糖及HOMA指數(shù)的影響。與術(shù)前相比,術(shù)后兩組患者的血糖、血清胰島素濃度和HOMA-IR、HOMA-ISI均較術(shù)前顯著增高(P0.05),而HOMA-IS降低(P0.05);對(duì)照組和糖負(fù)荷組患者術(shù)后應(yīng)激性高血糖發(fā)生率為35%5%(P0.05);與對(duì)照組比較,糖負(fù)荷組術(shù)后血糖和HOMA-IR均明顯低于對(duì)照組(P0.05),HOMA-IS、HOMA-ISI明顯高于對(duì)照組(P0.05)。結(jié)論:院內(nèi)高血糖整體發(fā)病率19.2%,其中普外科院內(nèi)高血糖發(fā)病率15%,在外科科室發(fā)生率最高,推測(cè)可能原因與普外科急癥病人多、圍手術(shù)期發(fā)生應(yīng)激性高血糖有關(guān),其應(yīng)激包括內(nèi)源性激素(腎上腺素、糖皮質(zhì)激素、高血糖素等)產(chǎn)生增加、細(xì)胞因子(腫瘤壞死因子、白細(xì)胞介素等)釋放以及神經(jīng)系統(tǒng)信號(hào)的調(diào)節(jié)等。應(yīng)用QHS評(píng)分系統(tǒng)分析院內(nèi)高血糖控制情況不容樂觀。在上腹部擇期手術(shù)患者中,術(shù)后應(yīng)激性高血糖發(fā)生率35%,手術(shù)可導(dǎo)致病人出現(xiàn)應(yīng)激性高血糖,術(shù)前糖負(fù)荷可減少術(shù)后高血糖的發(fā)生率(35%5%,P0.05).術(shù)前糖負(fù)荷的應(yīng)用降低了圍手術(shù)期應(yīng)激高血糖的發(fā)生率,可能與其提高胰島素分泌量和胰島素敏感性,降低患者胰島素抵抗程度有關(guān)。
[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.

【學(xué)位授予單位】：山西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2015
【分類號(hào)】：R587.1

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