Gale Stephen C, Sicoutris Corinna, Reilly Patrick M, Schwab C William, Gracias Vicente H
Tulane University School of Medicine, New Orleans, Louisiana, USA.
Am Surg. 2007 May;73(5):454-60. doi: 10.1177/000313480707300507.
Glycemic control improves outcome in cardiac surgical patients and after myocardial infarction or stroke. Hyperglycemic predicts poor outcome in trauma, but currently no data exist on the effect of glycemic control in critically ill trauma patients. In our intensive care unit (ICU), we use a subcutaneous sliding scale insulin protocol to achieve glucose levels <140 mg/dL. We hypothesized that aggressive glycemic control would be associated with improved outcome in critically ill trauma patients. At our urban Level 1 trauma center, a retrospective study was conducted of all injured patients admitted to the surgical ICU >48 hours during a 6-month period. Data were collected for mechanism of injury, age, diabetic history, Injury Severity Score (ISS), and APACHE II score. All blood glucose levels, by laboratory serum measurement or by point-of-care finger stick, were collected for the entire ICU stay. Outcome data (mortality, ICU and hospital length of stay, ventilator days, and complications) were collected and analyzed. Patients were stratified by their preinjury diabetic history and their level of glucose control (controlled <140 mg/dL vs non-controlled > or =141 mg/dL) and these groups were compared. During the study period, 103 trauma patients were admitted to the surgical ICU >48 hours. Ninety (87.4%) were nondiabetic. Most (83.5%) sustained blunt trauma. The average age was 50 +/- 21 years, the average ISS was 22 +/- 12, and the average APACHE II was 16 +/- 9. The average glucose for the population was 128 +/-25 mg/dL. Glycemic control was not attained in 27 (26.2%) patients; 19 (70.4%) of these were nondiabetic. There were no differences in ISS or APACHE II for controlled versus non-controlled patients. However, non-controlled patients were older. Mortality was 9.09 per cent for the controlled group and was 22.22 per cent for the non-controlled group. Diabetic patients were older and less severely injured than nondiabetics. For nondiabetic patients, mortality was 9.86 per cent in controlled patients and 31.58 per cent in non-controlled patients (P < 0.05). Also, urinary tract infections were more prevalent and complication rates overall were higher in nondiabetic patients with noncontrolled glucose levels. Nonsurvivors had higher average glucose than survivors (P < 0.03). Poor glycemic control is associated with increased morbidity and mortality in critically ill trauma patients; this is more pronounced in nondiabetic patients. Age may be a factor in these findings. Subcutaneous sliding scale insulin alone may be inadequate to maintain glycemic control in older critically ill injured patients and in patients with greater physiologic insult. Prospective assessment is needed to further clarify the benefits of aggressive glycemic control, to assess the optimal mode of insulin delivery, and to better define therapeutic goals in critically ill, injured patients.
血糖控制可改善心脏手术患者以及心肌梗死或中风后的预后。高血糖预示创伤患者预后不良，但目前尚无关于血糖控制对重症创伤患者影响的数据。在我们的重症监护病房（ICU），我们采用皮下胰岛素滑动剂量方案以使血糖水平低于140mg/dL。我们假设积极的血糖控制与重症创伤患者预后改善相关。在我们的城市一级创伤中心，对6个月期间入住外科ICU超过48小时的所有受伤患者进行了一项回顾性研究。收集了损伤机制、年龄、糖尿病史、损伤严重程度评分（ISS）和急性生理与慢性健康状况评分系统II（APACHE II）评分的数据。收集了整个ICU住院期间通过实验室血清测量或即时指尖血糖检测得到的所有血糖水平。收集并分析了预后数据（死亡率、ICU和住院时间、呼吸机使用天数及并发症）。根据患者伤前糖尿病史及其血糖控制水平（血糖控制在<140mg/dL vs未控制在>或 =141mg/dL）进行分层，并对这些组进行比较。在研究期间，103例创伤患者入住外科ICU超过48小时。90例（87.4%）为非糖尿病患者。大多数（83.5%）遭受钝性创伤。平均年龄为50±21岁，平均ISS为22±12，平均APACHE II为16±9。总体人群的平均血糖为128±25mg/dL。27例（26.2%）患者未实现血糖控制；其中19例（70.4%）为非糖尿病患者。血糖控制组与未控制组在ISS或APACHE II方面无差异。然而，未控制组患者年龄较大。控制组死亡率为9.09%，未控制组为22.22%。糖尿病患者比非糖尿病患者年龄更大且受伤程度较轻。对于非糖尿病患者，血糖控制组死亡率为9.86%，未控制组为31.58%（P<0.05）。此外，血糖未控制的非糖尿病患者尿路感染更普遍，总体并发症发生率更高。非幸存者的平均血糖高于幸存者（P<0.03）。血糖控制不佳与重症创伤患者发病率和死亡率增加相关；这在非糖尿病患者中更为明显。年龄可能是这些结果的一个因素。单独使用皮下胰岛素滑动剂量方案可能不足以维持老年重症受伤患者和生理损伤较重患者的血糖控制。需要进行前瞻性评估以进一步阐明积极血糖控制的益处，评估胰岛素给药的最佳方式，并更好地确定重症受伤患者的治疗目标。
