Chant Clarence, Wilson Gail, Friedrich Jan O
Perioperative and Critical Care Services, Department of Pharmacy, St. Michael's Hospital, Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Ontario, Canada.
Pharmacotherapy. 2005 Mar;25(3):352-9. doi: 10.1592/phco.25.3.352.61594.
To evaluate the effectiveness, safety, and associated patient outcomes of a simplified, nurse-directed insulin nomogram designed to achieve intensive blood glucose level control (target range 90-144 mg/dl).
Prospective study with a retrospective control group.
A medical-surgical intensive care unit (ICU) in a quaternary care, university-affiliated hospital in an urban center.
Eighty-six critically ill adult patients (aged>or=18 yrs) requiring blood glucose control, with 42 in the retrospective control group and 44 in the prospective nomogram group.
Control patients received insulin subcutaneously or intravenously based on ad hoc insulin sliding scales; nomogram patients received intravenous insulin at a rate specified by the nomogram, based on capillary blood glucose levels measured at the bedside.
Insulin infusion in the prospective patient group was titrated by the bedside nurse based on a predefined nomogram to attain the target blood glucose level. The retrospective control group was used as a comparison to assess the safety and effectiveness of the nomogram. Fewer patients in the nomogram (32%) than control (67%) group had a diagnosis of diabetes mellitus on admission. Overall, blood glucose levels in the nomogram group were within the target range 52% of the time versus 20% in the control group (p<0.001). Morning blood glucose levels were significantly lower compared with the control group (mean+/-SD 128+/-32 vs 176+/-50 mg/dl, p<0.001). Nomogram patients achieved target blood glucose levels faster than control patients (median 15 vs 66 hrs, p<0.0001). This improved blood glucose control remained statistically significant after adjusting for baseline differences in diabetes status. Hyperglycemia occurred less often in the nomogram than the control group (14% vs 53%, p<0.0001), and hypoglycemia occurred more often (3.8% vs 2.2%, p=0.004). The frequency of severe hypoglycemia was similar in both groups (0.2% vs 0.4%, p=NS). Such control required slightly more blood glucose checks/day in the nomogram group (7.1+/-1.5 vs 5.8+/-1.1, p<0.001). No significant reduction was observed in duration of vasopressor or antibiotic therapy or in length of stay in the ICU.
This study demonstrated that intensive blood glucose control is achievable using a nurse-directed nomogram. This improved control was achieved, regardless of diabetes status of the patient, without substantially compromising safety or increasing resource use.
评估一种简化的、由护士指导的胰岛素剂量图表在实现强化血糖水平控制（目标范围90 - 144mg/dl）方面的有效性、安全性及相关患者预后。
带有回顾性对照组的前瞻性研究。
市中心一家与大学相关的四级医疗医院的内科 - 外科重症监护病房（ICU）。
86例需要控制血糖的成年重症患者（年龄≥18岁），回顾性对照组42例，前瞻性剂量图表组44例。
对照组患者根据临时胰岛素剂量表皮下或静脉注射胰岛素；剂量图表组患者根据床旁测量的毛细血管血糖水平，按照剂量图表规定的速率静脉注射胰岛素。
前瞻性患者组的胰岛素输注由床旁护士根据预定义剂量图表进行滴定，以达到目标血糖水平。回顾性对照组用作评估剂量图表安全性和有效性的对照。剂量图表组入院时被诊断为糖尿病的患者（32%）少于对照组（67%）。总体而言，剂量图表组血糖水平在目标范围内的时间为52%，而对照组为20%（p<0.001）。与对照组相比，剂量图表组早晨血糖水平显著更低（均值±标准差128±32 vs 176±50mg/dl，p<0.001）。剂量图表组患者达到目标血糖水平的速度比对照组快（中位数15小时对66小时，p<0.0001）。在调整糖尿病状态的基线差异后，这种改善后的血糖控制在统计学上仍具有显著意义。剂量图表组高血糖的发生率低于对照组（14%对53%，p<0.0001），而低血糖的发生率更高（3.8%对2.2%，p = 0.004）。两组严重低血糖的发生率相似（0.2%对0.4%，p = 无统计学差异）。这种控制方式在剂量图表组每天需要进行的血糖检查略多（7.1±1.5次对5.8±1.1次，p<0.001）。在血管升压药或抗生素治疗持续时间或ICU住院时间方面未观察到显著减少。
本研究表明，使用由护士指导的剂量图表可实现强化血糖控制。无论患者的糖尿病状态如何，这种改善后的控制得以实现，且未对安全性造成实质性损害或增加资源使用。
