Scalea Thomas M, Bochicchio Grant V, Bochicchio Kelly M, Johnson Steven B, Joshi Manjari, Pyle Anne
R Adams Cowley Shock Trauma Center, Division of Clinical and Outcomes Research, Department of Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Ann Surg. 2007 Oct;246(4):605-10; discussion 610-2. doi: 10.1097/SLA.0b013e318155a789.
Evaluate the impact of a tight glucose control (TGC) protocol during the first week of admission in critically injured trauma patients.
A prospective quasi-experimental interrupted time-series design was used to evaluate the impact of TGC [24-month preintervention phase (no TGC) vs. 24-month postintervention phase]. Patients were stratified by serum glucose level on day 1 to 7 (low, 0-150 mg/dL; medium-high, 151-219 mg/dL; and high, >/=220 mg/dL), age, gender, and injury severity. Patients were further stratified by pattern of glucose control (all low, all medium high, all high, improving, worsening, highly variable). Outcome was measured by ventilator days, infection, hospital (HLOS) and ICU (ILOS) length of stay, and mortality.
One thousand twenty-one patients were evaluated in the preintervention phase as compared with 1108 patients in the postintervention phase. There was no significant difference in mechanism of injury (83% vs. 84% blunt), gender (74% vs. 73% male), age (44 vs. 43 years), and Injury Severity Score (ISS) (26 vs. 25). The TGC group was more likely to be in the all low and improving pattern of glucose control (P<0.001). The incidence of infection significantly decreased (over the first 2 weeks) from 29% to 21% in the TGC group (P<0.001). Ventilator days (OR=3.9, 1.8, 8.1), ILOS (OR=4.3, 2.1, 7.5), and HLOS (OR=5.5, 2.2, 11) and mortality (OR=1.4, 1.1, 10) were significantly higher in the non-TGC group when controlled for age, ISS, obesity, and diabetes (P<0.01).
The positive outcomes associated with the implementation of a TGC protocol necessitates further evaluation in a randomized prospective trial.
评估在重症创伤患者入院第一周实施严格血糖控制（TGC）方案的影响。
采用前瞻性准实验性中断时间序列设计来评估TGC的影响（干预前24个月阶段（无TGC）与干预后24个月阶段）。患者根据第1至7天的血糖水平（低，0 - 150mg/dL；中高，151 - 219mg/dL；高，≥220mg/dL）、年龄、性别和损伤严重程度进行分层。患者进一步根据血糖控制模式分层（全低、全中高、全高、改善、恶化、高度可变）。通过呼吸机使用天数、感染情况、住院（HLOS）和重症监护病房（ILOS）住院时间以及死亡率来衡量结果。
干预前阶段评估了1021例患者，干预后阶段评估了1108例患者。损伤机制（钝性伤分别为83%和84%）、性别（男性分别为74%和73%）、年龄（分别为44岁和43岁）以及损伤严重程度评分（ISS）（分别为26和25）方面无显著差异。TGC组更有可能处于血糖控制全低和改善模式（P<0.001）。TGC组感染发生率（在最初2周内）从29%显著降至21%（P<0.001）。在控制年龄、ISS、肥胖和糖尿病因素后，非TGC组的呼吸机使用天数（OR = 3.9、1.8、8.1）、ILOS（OR = 4.3、2.1、7.5）、HLOS（OR = 5.5、2.2、11）和死亡率（OR = 1.4、1.1、10）显著更高（P<0.01）。
与实施TGC方案相关的积极结果需要在随机前瞻性试验中进一步评估。
