Bilotta Federico, Spinelli Allison, Giovannini Federico, Doronzio Andrea, Delfini Roberto, Rosa Giovanni
Department of Anesthesiology and Neurosurgery, University of Rome La Sapienza, Rome, Italy.
J Neurosurg Anesthesiol. 2007 Jul;19(3):156-60. doi: 10.1097/ANA.0b013e3180338e69.
It is unclear if avoiding hyperglycemia during intensive care after acute brain injury improves morbidity, mortality, and neurologic outcome. This prospective randomized trial tested whether intensive insulin therapy affected infection rates, vasospasm, mortality, or long-term neurologic outcome in subarachnoid hemorrhage patients during their intensive care unit (ICU) stay. Comparison was made against conventional insulin therapy using a randomized trial design. The primary outcome measure was infection rate until the fourteenth postoperative day in the ICU or until patient discharge. Secondary end points were the incidence of vasospasm until the fourteenth postoperative day in the ICU or until patient discharge, and neurologic outcome and mortality at 6 months follow-up. A total of 78 patients were prospectively enrolled and randomly assigned either to conventional insulin therapy or to intensive insulin therapy (38 and 40 patients, respectively). The infection rate during the study was significantly higher in patients who received conventional insulin therapy than in patients who received intensive insulin therapy (42% vs. 27%; P<0.001). The incidence of vasospasm during the study was also similar in conventional and intensive therapy groups (31.5% vs. 27.6% in the conventional and intensive insulin therapy groups; P=0.9). Overall mortality rates at 6 months were similar in the 2 groups (18% vs.15%; P=0.9), as was the neurologic outcome at 6 months [modified Rankin score >3 in 22/38 patients (57.8%) in the conventional therapy group vs. 21/40 patients (52.5%) in the intensive insulin therapy group; P=0.7]. Intensive insulin therapy in patients with acute subarachnoid hemorrhage admitted to a postoperative neurosurgical ICU after surgical clipping of intracranial aneurysms decreases infection rates. The benefit of strict glycemic control on postoperative vasospasm, neurologic outcome, and mortality rates does not seem to be affected by intensive insulin therapy.
急性脑损伤后在重症监护期间避免高血糖是否能改善发病率、死亡率和神经功能结局尚不清楚。这项前瞻性随机试验检验了强化胰岛素治疗是否会影响蛛网膜下腔出血患者在重症监护病房（ICU）住院期间的感染率、血管痉挛、死亡率或长期神经功能结局。采用随机试验设计与传统胰岛素治疗进行比较。主要结局指标是术后第14天在ICU期间或直至患者出院的感染率。次要终点是术后第14天在ICU期间或直至患者出院的血管痉挛发生率，以及6个月随访时的神经功能结局和死亡率。共有78例患者前瞻性入组并随机分为传统胰岛素治疗组或强化胰岛素治疗组（分别为38例和40例患者）。研究期间，接受传统胰岛素治疗的患者感染率显著高于接受强化胰岛素治疗的患者（42%对27%；P<0.001）。传统治疗组和强化治疗组研究期间血管痉挛的发生率也相似（传统胰岛素治疗组和强化胰岛素治疗组分别为31.5%对27.6%；P=0.9）。两组6个月时的总体死亡率相似（18%对15%；P=0.9），6个月时的神经功能结局也相似[传统治疗组38例患者中有22例（57.8%）改良Rankin评分>3，强化胰岛素治疗组40例患者中有21例（52.5%）；P=0.7]。颅内动脉瘤手术夹闭术后入住神经外科术后ICU的急性蛛网膜下腔出血患者，强化胰岛素治疗可降低感染率。严格血糖控制对术后血管痉挛、神经功能结局和死亡率的益处似乎不受强化胰岛素治疗的影响。
