采用两种“实用”方案对内科重症监护病房患者的糖尿病及医院相关高血糖进行管理：一项可行性研究

Hensen J, Thomas T, Mueller-Ziehm J, Worthmann W, Kleine E, Behrens E-M

Klinikum Hannover Nordstadt, Medizinische Klinik, Department of Medicine, Krankenhaus Nordstadt, Klinikum Region Hannover, Hannover, Germany.

Exp Clin Endocrinol Diabetes. 2007 Oct;115(9):577-83. doi: 10.1055/s-2007-980177.

OBJECTIVE

Optimal control of blood glucose in the ICU has been shown to significantly decrease mortality and morbidity of severely ill patients. The purpose of the present project was to develop and implement undemanding, "down-to-earth" protocols, enabling tight glucose control in critically ill patients, in the setting of a city hospital ICU with limited personnel and facilities.

RESEARCH DESIGN AND METHODS

From January 2003 to January 2006, a total of 745 patients (3197 patient-days) were treated for hyperglycemia in our medical ICU. On July 2003 two different intensive insulin therapy protocols were implemented: A protocol of continuous intravenous insulin, including specific algorithms for calculation of initial insulin bolus, initial infusion rate and further adjustment plan, was used for patients with compromised peripheral tissue perfusion. For patients with stable circulation, a protocol of subcutaneous intensive insulin therapy, including a formula for calculation of daily insulin dosage in previously non-insulin-treated diabetics, was adopted. 134 patients were treated during the run-in phase of the project and 539 patients were treated during the main treatment phase. 72 patients treated for hyperglycemia in our ICU prior to the implementation of the two protocols (from January 2003 to July 2003) served as controls.

RESULTS

After the implementation of the two protocols, a marked overall increase of normoglycemic blood glucose values (64.7% vs. 48.5%, P<0.001), a decrease of manifest hyperglycemias (6.4% vs. 17.4%, P<0.001) and an increase in hypoglycemic events (1.8% vs. 0.7%, P<0.001) was observed. Seven cases of severe hypoglycemia requiring glucose infusion were observed during the main treatment phase (0.3%). No hypoglycemia-associated deaths occurred.

CONCLUSIONS

The combined implementation of the two protocols presents a simple, safe and effective way of pursuing normoglycemia in critically ill patients.

目的

在重症监护病房（ICU）中对血糖进行优化控制已被证明可显著降低重症患者的死亡率和发病率。本项目的目的是在一家人员和设施有限的城市医院ICU环境中，制定并实施要求不高、“切实可行”的方案，以实现对重症患者的严格血糖控制。

研究设计与方法

2003年1月至2006年1月，我们的内科ICU共有745例患者（3197个患者日）接受了高血糖治疗。2003年7月实施了两种不同的强化胰岛素治疗方案：对于外周组织灌注受损的患者，采用持续静脉胰岛素输注方案，该方案包括用于计算初始胰岛素推注量、初始输注速率和进一步调整计划的特定算法。对于循环稳定的患者，采用皮下强化胰岛素治疗方案，该方案包括一个用于计算既往未接受胰岛素治疗的糖尿病患者每日胰岛素剂量的公式。134例患者在项目的导入期接受治疗，539例患者在主要治疗期接受治疗。在实施这两种方案之前（2003年1月至2003年7月），在我们ICU接受高血糖治疗的72例患者作为对照。

结果

实施这两种方案后，观察到血糖正常的血糖值显著总体增加（64.7%对48.5%，P<0.001），明显高血糖症减少（6.4%对17.4%，P<0.001），低血糖事件增加（1.8%对0.7%，P<0.001）。在主要治疗期观察到7例需要输注葡萄糖的严重低血糖事件（0.3%）。未发生与低血糖相关的死亡。