Van den Berghe Greet, Wilmer Alexander, Milants Ilse, Wouters Pieter J, Bouckaert Bernard, Bruyninckx Frans, Bouillon Roger, Schetz Miet
Department of Intensive Care Medicine, University Hospital Gasthuisberg, University of Leuven, B-3000 Leuven, Belgium.
Diabetes. 2006 Nov;55(11):3151-9. doi: 10.2337/db06-0855.
Intensive insulin therapy (IIT) improves the outcome of prolonged critically ill patients, but concerns remain regarding potential harm and the optimal blood glucose level. These questions were addressed using the pooled dataset of two randomized controlled trials. Independent of parenteral glucose load, IIT reduced mortality from 23.6 to 20.4% in the intention-to-treat group (n = 2,748; P = 0.04) and from 37.9 to 30.1% among long stayers (n = 1,389; P = 0.002), with no difference among short stayers (8.9 vs. 10.4%; n = 1,359; P = 0.4). Compared with blood glucose of 110-150 mg/dl, mortality was higher with blood glucose >150 mg/dl (odds ratio 1.38 [95% CI 1.10-1.75]; P = 0.007) and lower with <110 mg/dl (0.77 [0.61-0.96]; P = 0.02). Only patients with diabetes (n = 407) showed no survival benefit of IIT. Prevention of kidney injury and critical illness polyneuropathy required blood glucose strictly <110 mg/day, but this level carried the highest risk of hypoglycemia. Within 24 h of hypoglycemia, three patients in the conventional and one in the IIT group died (P = 0.0004) without difference in hospital mortality. No new neurological problems occurred in survivors who experienced hypoglycemia in intensive care units (ICUs). We conclude that IIT reduces mortality of all medical/surgical ICU patients, except those with a prior history of diabetes, and does not cause harm. A blood glucose target <110 mg/day was most effective but also carried the highest risk of hypoglycemia.
强化胰岛素治疗（IIT）可改善长期危重症患者的预后，但对于潜在危害和最佳血糖水平仍存在担忧。利用两项随机对照试验的汇总数据集对这些问题进行了探讨。在不考虑肠外葡萄糖负荷的情况下，IIT使意向性治疗组（n = 2748；P = 0.04）的死亡率从23.6%降至20.4%，使长期住院患者（n = 1389；P = 0.002）的死亡率从37.9%降至30.1%，短期住院患者之间无差异（8.9%对10.4%；n = 1359；P = 0.4）。与血糖110 - 150 mg/dl相比，血糖>150 mg/dl时死亡率更高（优势比1.38 [95%可信区间1.10 - 1.75]；P = 0.007），血糖<110 mg/dl时死亡率更低（0.77 [0.61 - 0.96]；P = 0.02）。仅糖尿病患者（n = 407）未显示IIT有生存获益。预防肾损伤和危重症多发性神经病需要严格将血糖控制在<110 mg/天，但该水平低血糖风险最高。在低血糖发生后的24小时内，常规治疗组有3例患者死亡，IIT组有1例患者死亡（P = 0.0004），住院死亡率无差异。在重症监护病房（ICU）发生低血糖的幸存者中未出现新的神经问题。我们得出结论，IIT可降低所有内科/外科ICU患者的死亡率，但有糖尿病既往史的患者除外，且不会造成伤害。血糖目标<110 mg/天最为有效，但低血糖风险也最高。
