Klonoff David C
Diabetes Research Institute, Mills-Peninsula Health Services, San Mateo, California, USA.
J Diabetes Sci Technol. 2011 May 1;5(3):755-67. doi: 10.1177/193229681100500330.
Intensive insulin therapy (IIT) for hyperglycemia in critically ill patients has become a standard practice. Target levels for glycemia have fluctuated since 2000, as evidence initially indicated that tight glycemic control to so-called normoglycemia (80-110 mg/dl) leads to the lowest morbidity and mortality without hypoglycemic complications. Subsequent studies have demonstrated minimal clinical benefit combined with greater hypoglycemic morbidity and mortality with tight glycemic control in this population. The consensus glycemic targets were then liberalized to the mid 100s (mg/dl). Handheld POC blood glucose (BG) monitors have migrated from the outpatient setting to the hospital environment because they save time and money for managing critically ill patients who require IIT. These devices are less accurate than hospital-grade POC blood analyzers or central laboratory analyzers. Three questions must be answered to understand the role of IIT for defined populations of critically ill patients: (1) How safe is IIT, with various glycemic targets, from the risk of hypoglycemia? (2) How tightly must BG be controlled for this approach to be effective? (3) What role does the accuracy of BG measurements play in affecting the safety of this method? For each state of impaired glucose regulation seen in the hospital, such as hyperglycemia, hypoglycemia, or glucose variability, the benefits, risks, and goals of treatment, including IIT, might differ. With improved accuracy of BG monitors, IIT might be rendered even more intensive than at present, because patients will be less likely to receive inadvertent overdosages of insulin. Greater doses of insulin, but with dosing based on more accurate glucose levels, might result in less hypoglycemia, less hyperglycemia, and less glycemic variability.
对重症患者的高血糖进行强化胰岛素治疗（IIT）已成为一种标准做法。自2000年以来，血糖目标水平一直在波动，因为最初有证据表明，将血糖严格控制在所谓的正常血糖范围（80 - 110毫克/分升）可使发病率和死亡率最低，且无低血糖并发症。随后的研究表明，在这一人群中进行严格血糖控制，临床益处极小，同时低血糖发病率和死亡率更高。随后，血糖目标共识放宽至100多毫克/分升（毫克/分升）。手持式即时检测（POC）血糖仪已从门诊环境进入医院环境，因为它们为管理需要IIT的重症患者节省了时间和金钱。这些设备的准确性低于医院级POC血液分析仪或中心实验室分析仪。为了理解IIT对特定重症患者群体的作用，必须回答三个问题：（1）对于不同血糖目标的IIT，低血糖风险有多安全？（2）为使这种方法有效，血糖必须控制得多严格？（3）血糖测量的准确性在影响该方法的安全性方面起什么作用？对于医院中出现的每种葡萄糖调节受损状态，如高血糖、低血糖或血糖变异性，包括IIT在内的治疗益处、风险和目标可能会有所不同。随着血糖仪准确性的提高，IIT可能会比目前更加强化，因为患者不太可能接受意外过量的胰岛素。更大剂量的胰岛素，但基于更准确的血糖水平给药，可能会导致低血糖、高血糖和血糖变异性减少。
