Coursin Douglas B, Connery Lisa E, Ketzler Jonathan T
Anesthesiology and Medicine, University of Wisconsin-Madison, USA.
Crit Care Med. 2004 Apr;32(4 Suppl):S116-25. doi: 10.1097/01.ccm.0000115623.52021.c0.
To review and discuss selected literature, expert opinion, and conventional care of the hyperglycemic perioperative or critically ill patient.
Diabetes mellitus, the most commonly encountered perioperative endocrinopathy, continues to increase dramatically in prevalence. Diabetes is the sixth most common cause of death in the United States and significantly affects other more common causes of death such as cardiac disease and stroke. Diabetic patients commonly have microvascular and macrovascular pathology that influences their perioperative course and critical illness and increases morbidity and mortality rates during hospitalization. Since diabetics require more surgeries and receive critical care more frequently than their nondiabetic counterparts, preemptive identification and anticipation of diabetic complications and comorbidities, along with an optimized treatment plan, are the foundation for the proper intensive care of this growing patient population. Hyperglycemia occurs commonly in critically ill diabetic patients but also is frequent in those who have a history of normal glucose homeostasis. The new onset of hyperglycemia in critically ill patients is driven by excessive counterregulatory stress hormone release and high tissue and circulating concentrations of inflammatory cytokines. Aggressive glycemic management improves short- and long-term outcomes in diabetic patients with acute myocardial infarction and cardiac surgical patients. Most recently, "tight" glycemic control in both diabetic and nondiabetic hyperglycemic intensive care unit patients resulted in improved survival in selected surgical patients without excessive consequences related to hypoglycemia. The mechanisms of benefit of euglycemia appear to be multifactorial.
Up to 25% of patients admitted to the intensive care unit have previously diagnosed diabetes. Diabetics are most commonly admitted for treatment of complications of comorbid diseases. New-onset hyperglycemia also is common in critically ill patients, and it affects patient morbidity and mortality rates. A growing body of literature supports the benefits of tight glycemic control in certain patient populations. However, further data are needed about the optimal concentration of blood glucose, the role of maintaining euglycemia in a broader group of patients (including the medically critically ill), and the mechanisms of benefit of infused glucose and insulin.
回顾并讨论有关围手术期或危重症高血糖患者的部分文献、专家意见及传统护理方法。
糖尿病是围手术期最常见的内分泌疾病，其患病率仍在急剧上升。糖尿病是美国第六大常见死因，并且显著影响其他更常见的死因，如心脏病和中风。糖尿病患者通常存在微血管和大血管病变，这会影响他们的围手术期过程和危重症情况，并增加住院期间的发病率和死亡率。由于糖尿病患者比非糖尿病患者需要更多的手术且更频繁地接受重症监护，因此对糖尿病并发症和合并症进行前瞻性识别和预判，以及制定优化的治疗方案，是对这一不断增长的患者群体进行恰当重症护理的基础。高血糖在危重症糖尿病患者中很常见，但在既往血糖稳态正常的患者中也很常见。危重症患者新发高血糖是由过量的反调节应激激素释放以及高组织浓度和循环浓度的炎性细胞因子驱动的。积极的血糖管理可改善急性心肌梗死糖尿病患者和心脏手术患者的短期和长期预后。最近，在糖尿病和非糖尿病高血糖重症监护病房患者中进行“严格”血糖控制，使部分手术患者的生存率提高，且未出现与低血糖相关的过度后果。血糖正常带来益处的机制似乎是多因素的。
高达25%入住重症监护病房的患者此前已被诊断患有糖尿病。糖尿病患者最常因合并症并发症入院治疗。新发高血糖在危重症患者中也很常见，并且会影响患者的发病率和死亡率。越来越多的文献支持在某些患者群体中进行严格血糖控制的益处。然而，关于血糖的最佳浓度、在更广泛的患者群体（包括内科危重症患者）中维持血糖正常的作用以及输注葡萄糖和胰岛素带来益处的机制，还需要进一步的数据。
