Robinson Lindsay E, van Soeren Mary H
Department of Human Biology and Nutrition Sciences, University of Guelph, Guelph, ON, Canada.
AACN Clin Issues. 2004 Jan-Mar;15(1):45-62. doi: 10.1097/00044067-200401000-00004.
Alterations in glucose metabolism, including hyperglycemia associated with insulin resistance, occur in critical illness. Acutely, such alterations result from normal, adaptive activation of endocrine responses, including increased release of catecholamines, cortisol, and glucagon and a reduced glucose uptake capacity. In prolonged critical illness, neuroendocrine changes lead to more extensive metabolic changes that may be associated with development of complications and poor prognosis. Until recently, hyperglycemia was not routinely controlled in intensive care units, except among patients with known diabetes mellitus. Studies have demonstrated that glycemic management in postmyocardial infarction in patients with diabetes is an effective practice. Recent investigation has extended this to demonstrate reduced morbidity and mortality in a surgical critically ill population with and without diabetes mellitus in later phases of critical illness. Although the mechanisms for improved patient outcomes need to be established, this novel approach to management of hyperglycemia in critical illness is a new and important concept for those working in critical care. This article reviews alterations in glucose metabolism which occur in critically ill patients and discusses potential mechanisms and mediators (e.g., hormones, cytokines) that may play a key role in hyperglycemia and insulin resistance during acute and prolonged phases of severe illness. The article addresses the application of insulin protocols and exogenous regulation of glucose concentration in critical illness based on a review of recent intervention studies.
危重病期间会出现葡萄糖代谢改变，包括与胰岛素抵抗相关的高血糖。急性情况下，这种改变源于内分泌反应的正常适应性激活，包括儿茶酚胺、皮质醇和胰高血糖素释放增加以及葡萄糖摄取能力降低。在危重病持续时间较长时，神经内分泌变化会导致更广泛的代谢改变，这可能与并发症的发生和预后不良有关。直到最近，除了已知患有糖尿病的患者外，重症监护病房中高血糖通常未得到常规控制。研究表明，对糖尿病患者心肌梗死后进行血糖管理是一种有效的做法。最近的调查进一步表明，在危重病后期，无论有无糖尿病，外科危重病患者的发病率和死亡率均有所降低。尽管改善患者预后的机制尚待确定，但这种危重病高血糖管理的新方法对于从事重症监护工作的人员来说是一个新的重要概念。本文综述了危重病患者发生的葡萄糖代谢改变，并讨论了在严重疾病的急性和持续阶段可能在高血糖和胰岛素抵抗中起关键作用的潜在机制和介质（如激素、细胞因子）。基于对近期干预研究的综述，本文探讨了胰岛素方案在危重病中的应用以及葡萄糖浓度的外源性调节。
