Mowery Nathan T, Guillamondegui Oscar D, Gunter Oliver L, Diaz Jose J, Collier Bryan R, Dossett Lesly A, Dortch Marcus J, May Addison K
Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA.
J Trauma. 2010 Feb;68(2):342-7. doi: 10.1097/TA.0b013e3181c825f2.
Fear of the adverse effects of hypoglycemia has limited the widespread application of intensive insulin therapy (goal, 80-110 mg/dL) in the trauma population. We hypothesized that severe hypoglycemia (SH; <or=40 mg/dL) was not an independent predictor of mortality in the trauma population.
An analysis of critically ill trauma patients treated with intensive insulin therapy from November 2005 to May 2008 was performed. The primary outcomes of interest were any episode of SH (<40 mg/dL) and all-cause inhospital mortality. Multivariate logistic regression was used to estimate the independent relationship between hypoglycemia and death.
: Fifty-seven thousand two hundred eighty-four data entries (1,824 patients) from the euglycemia protocol were analyzed (mortality = 16.0%). Median glucose was 119 mg/dL, with 43% of values between 80 mg/dL and 110 mg/dL, 81% between 80 mg/dL and 150 mg/dL, and 0.3% <40 mg/dL. There were 126 severe hypoglycemic episodes in 111 patients (6.1% of the patients). Multivariate logistic regression revealed that SH was not independently associated with death after adjusting for other known risk factors (odds ratio, 1.244; 95% confidence interval, 0.853-1.816; p = 0.257).
Hypoglycemia may be an unavoidable byproduct of tight glucose control with 6.1% of the patients experiencing a severe hypoglycemic event (<40 mg/dL). Hypoglycemia is not an independent predictor of death. Hypoglycemia is a statistical probability of time spent on protocol rather than an event leading to death. These data suggest that lower glucose ranges should be targeted in the trauma population without fear of hypoglycemia's adverse effect on mortality.
对低血糖不良反应的担忧限制了强化胰岛素治疗（目标值为80 - 110mg/dL）在创伤人群中的广泛应用。我们假设严重低血糖（SH；≤40mg/dL）并非创伤人群死亡率的独立预测因素。
对2005年11月至2008年5月接受强化胰岛素治疗的重症创伤患者进行分析。主要关注的结果是任何严重低血糖发作（<40mg/dL）和全因住院死亡率。采用多因素逻辑回归来估计低血糖与死亡之间的独立关系。
对来自血糖正常方案的57284条数据记录（1824例患者）进行了分析（死亡率 = 16.0%）。血糖中位数为119mg/dL，43%的值在80mg/dL至110mg/dL之间，81%在80mg/dL至150mg/dL之间，0.3%<40mg/dL。111例患者发生了126次严重低血糖发作（占患者的6.1%）。多因素逻辑回归显示，在调整其他已知风险因素后，严重低血糖与死亡无独立相关性（比值比，1.244；95%置信区间，0.853 - 1.816；p = 0.257）。
低血糖可能是严格血糖控制不可避免的副产品，6.1%的患者经历了严重低血糖事件（<40mg/dL）。低血糖并非死亡的独立预测因素。低血糖是在方案规定时间内出现的统计学概率事件，而非导致死亡的事件。这些数据表明，在创伤人群中应设定更低的血糖范围，而无需担心低血糖对死亡率产生不利影响。
