Eriksson Evert A, Christianson David A, Vanderkolk Wayne E, Bonnell Bruce W, Hoogeboom James E, Ott Mickey M
Departments of Trauma, Surgical Critical Care and Acute Care Surgery, Medical University of South Carolina, Charleston, SC, USA.
J Emerg Trauma Shock. 2011 Jul;4(3):359-64. doi: 10.4103/0974-2700.83864.
This study was designed to evaluate the effect of intensive insulin control (IIT) on outcomes for traumatically injured patients as a function of injury severity score (ISS) and age.
A retrospective review of 2028 adult trauma patients admitted to the surgical intensive care unit (SICU) in a Level I trauma center was performed. Data were collected from a 48-month period before (Pre-IIT) (goal blood glucose 80-200 mg/dL) and after (Post-IIT) (goal blood glucose level 80-110 mg/dL), an IIT protocol was initiated. Patients were stratified by age and ISS. The primary endpoint was mortality.
There were 784 Pre-IIT and 1244 Post-IIT patients admitted. There was no significant difference between Pre-IIT vs. Post-IIT for the mechanism of injury or ISS. Values for the Pre-IIT group were significantly higher for mortality (21.5% vs. 14.7%, P<0.001) and hospital, but not ICU length of stay were decreased. A significant improvement in mortality was demonstrated between Pre-IIT vs. Post-IIT stratified within the age groups of 41-50, 51-60, and 61 but not the groups 18-30 and 31-40. Mean glucose levels (mg/dL) decreased significantly after the institution of IIT (144.7±1.4 vs. 130.9±0.9; P<0.001). In addition, the occurrence per patient of blood glucose levels <40 mg/dL increased (0.77% vs. 2.86%; P=0.001) and blood glucose levels greater than 200 mg/dL was similar (39.1% vs. 38.8%; P=0.892) in the Pre-IIT and Post-IIT groups, respectively. Glycemic variability, reflected by the standard deviation of each patient's mean glucose level during ICU stay, as well as mean glucose level were lower in survivors than in nonsurvivors. Finally, multivariable logistic regression analysis identified both mean glucose level and glycemic variability as independent contributors to the risk of mortality.
The implementation of IIT has been associated with a decrease in both hospital length of stay as well as mortality. Average glucose value and glucose variability are independent predictors of survival. Trauma patients with moderate, severe, and very severe injuries benefit most from IIT. These observational data suggest that patients over 40 years of age benefited a great deal more than their younger counterparts from IIT. This study supports the need for a randomized controlled trial to investigate the role of IIT in traumatically injured patients.
本研究旨在评估强化胰岛素控制（IIT）对创伤患者预后的影响，并分析其与损伤严重程度评分（ISS）和年龄的关系。
对一家一级创伤中心外科重症监护病房（SICU）收治的2028例成年创伤患者进行回顾性研究。收集了实施IIT方案前（IIT前）（目标血糖80 - 200mg/dL）48个月期间及实施后（IIT后）（目标血糖水平80 - 110mg/dL）的数据。患者按年龄和ISS分层。主要终点为死亡率。
IIT前收治784例患者，IIT后收治1244例患者。IIT前与IIT后在损伤机制或ISS方面无显著差异。IIT前组的死亡率显著更高（21.5%对14.7%，P<0.001），住院时间缩短，但ICU住院时间未缩短。在41 - 50岁、51 - 60岁和61岁及以上年龄组中，IIT前与IIT后相比死亡率有显著改善，但在18 - 30岁和31 - 40岁组中未出现。实施IIT后平均血糖水平（mg/dL）显著下降（144.7±1.4对130.9±0.9；P<0.001）。此外，IIT前组和IIT后组患者血糖水平<40mg/dL的发生率分别增加（0.77%对2.86%；P = 0.001），血糖水平大于200mg/dL的发生率相似（39.1%对38.8%；P = 0.892）。由ICU住院期间每位患者平均血糖水平标准差反映的血糖变异性以及平均血糖水平，幸存者低于非幸存者。最后，多变量逻辑回归分析确定平均血糖水平和血糖变异性均为死亡率风险的独立影响因素。
实施IIT与住院时间和死亡率的降低相关。平均血糖值和血糖变异性是生存的独立预测因素。中度、重度和极重度创伤患者从IIT中获益最大。这些观察数据表明，40岁以上患者比年轻患者从IIT中获益更多。本研究支持开展随机对照试验以研究IIT在创伤患者中的作用。
