危重外科患者强化血糖控制的实施：流程改进分析。

Department of Surgery, Weill Cornell Medical College, New York, New York, USA.

Surg Infect (Larchmt). 2009 Dec;10(6):523-31. doi: 10.1089/sur.2009.003.

BACKGROUND

Tight glucose control has been advocated as a method to improve outcomes of surgical critical care. However, continuous infusion of insulin has potential morbidity (e.g., neurologic consequences of hypoglycemia), and it remains unclear to what degree the glucose concentration must be controlled. We examined our performance in instituting a protocol for tight glucose control in our surgical intensive care unit (ICU).

METHODS

Prospective study of 220 consecutive patients (February, 2003-March, 2006) who received an infusion of insulin for glucose control for >24 h by protocol. Data collected included age, acuity (Acute Physiology and Chronic Health Evaluation [APACHE] III) score, sex, history of diabetes mellitus, organ dysfunction (Marshall), and death or survival. Infusion-related data included initial glucose concentration, time to glucose <120 mg/dL, h/day of glucose <110 mg/dL and <140 mg/dL, duration of infusion (days), insulin units/day, year of therapy, and complications. Analysis was performed by chi(2), analysis of variance, and logistic regression, with p < 0.05 considered significant.

RESULTS

Insulin drips were required by 10.2% of patients (287/2,804); 29 of these (10.1%) had diabetes mellitus. The mean APACHE III score for the treated patients was 77 +/- 2 (standard deviation), and the mortality rate was 24%. Hypoglycemia (<60 mg/dL) occurred in 4.2% of patients. The trigger insulin concentration decreased over time (2003 vs. 2005) from 249 +/- 14 to 160 +/- 5 mg/dL, and the h/day of glucose <140 increased from 11 +/- 1 to 16 +/- 1. However, age, acuity, APACHE III, days of insulin, time to achieve glucose <120, h/day of glucose <110, and mortality rate were unchanged. By logistic regression, only the year of treatment (odds ratio [OR] 1.871; 95% confidence interval [CI] 1.177, 2.972; p = 0.008] predicted success in controlling the blood glucose concentration to <140 mg/dL; age, illness severity, diabetes history, and trigger glucose concentration [OR 0.996; 95% CI 0.992, 1.001; p = 0.11] did not.

CONCLUSIONS

Success in implementing tight glucose control was modest, albeit improving, despite a specific protocol for administration. No medical reason could be identified for inability to achieve tight glucose control; therefore, successful implementation must be volitional. Education, particularly regarding hypoglycemia, and possible refinement of our protocol may improve our ability to control blood glucose in our ICU.

背景

强化血糖控制被认为是改善外科重症监护治疗结果的一种方法。然而，胰岛素持续输注可能会产生一定的发病率（例如，低血糖导致的神经系统后果），并且仍不清楚血糖浓度需要控制到什么程度。我们检查了我们在外科重症监护病房（ICU）实施严格血糖控制方案的表现。

方法

对 220 例连续患者（2003 年 2 月至 2006 年 3 月）进行前瞻性研究，这些患者根据方案接受>24 小时的胰岛素输注以控制血糖。收集的数据包括年龄、严重程度（急性生理学和慢性健康评估 [APACHE] III 评分）、性别、糖尿病史、器官功能障碍（Marshall）、死亡或存活。输注相关数据包括初始血糖浓度、血糖<120mg/dL 的时间、血糖<110mg/dL 和<140mg/dL 的小时/天、输注持续时间（天）、胰岛素单位/天、治疗年份和并发症。通过卡方检验、方差分析和逻辑回归进行分析，p<0.05 被认为具有统计学意义。

结果

10.2%（287/2804）的患者需要胰岛素滴注；其中 29 例（10.1%）患有糖尿病。接受治疗的患者的平均 APACHE III 评分为 77±2（标准差），死亡率为 24%。<60mg/dL 的低血糖发生在 4.2%的患者中。触发胰岛素浓度随时间降低（2003 年与 2005 年），从 249±14 降至 160±5mg/dL，血糖<140mg/dL 的小时/天从 11±1 增加到 16±1。然而，年龄、严重程度、APACHE III、胰岛素使用天数、血糖<120mg/dL 的时间、血糖<110mg/dL 的小时/天以及死亡率均无变化。通过逻辑回归，只有治疗年份（优势比 [OR] 1.871；95%置信区间 [CI] 1.177，2.972；p=0.008）可以预测控制血糖浓度至<140mg/dL 的成功；年龄、疾病严重程度、糖尿病史和触发血糖浓度（OR 0.996；95%CI 0.992，1.001；p=0.11）则不能。