Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee 37212, USA.
Surg Infect (Larchmt). 2011 Oct;12(5):405-18. doi: 10.1089/sur.2011.019. Epub 2011 Oct 17.
Hyperglycemia is common in surgical patients and is associated with adverse outcomes. Conflicting data exist regarding the best method and the value of glycemic control in various patient populations. The contributions to hyperglycemia and the components of its control are complex and overlapping and likely contribute to the documented variation in outcomes. We provide an overview of the physiologic contributors to hyperglycemia and its control, review the differences in the major randomized trial results, and summarize the data regarding glycemic control in surgical patients.
Major reviews of the pathophysiology of hyperglycemia in surgical patients, large randomized trials in critically ill and peri-operative populations, and meta-analyses were reviewed. Summations are provided for the critically ill population and for the peri-operative group.
A substantial physiologic rationale exists for the control of hyperglycemia in surgical patients during critical illness and in the peri-operative period. Randomized, controlled studies are limited predominately to critically ill populations. The data support controlling hyperglycemia to a serum glucose concentration <200 mg/dL, but the absolute target range remains controversial and studied inadequately. The data indicate the benefit of tight glycemic control using insulin to achieve a target of 80-110 mg/dL (intensive insulin therapy [IIT]) vs. a liberal target of 180-200 mg/dL in critically ill surgical patients, although hypoglycemia is more common with IIT. Inadequate studies are available in the peri-operative period to draw conclusions about non-critically ill surgical patients, but the weight of the data suggests control to < 200 mg/dL likely is beneficial.
Surgical patients benefit from maintaining serum glucose concentrations <200 mg/dL. Intensive insulin therapy (80-110 mg/dL), which appears beneficial in critically ill surgical patients but requires frequent measurement of glucose to avoid hypoglycemia. Further studies are needed to determine the appropriate target range and the influence of nutritional provision and other factors on outcome.
高血糖在外科患者中很常见，并且与不良预后相关。关于最佳方法和各种患者人群血糖控制的价值，存在相互矛盾的数据。导致高血糖的因素及其控制的组成部分复杂且重叠，可能导致已记录的结果差异。我们提供了对高血糖及其控制的生理因素的概述，回顾了主要随机试验结果的差异，并总结了外科患者的血糖控制数据。
主要综述了外科患者高血糖的病理生理学、危重症和围手术期人群中的大型随机试验以及荟萃分析。为危重症患者和围手术期患者提供总结。
在危重症和围手术期期间，控制外科患者的高血糖具有重要的生理依据。随机对照研究主要局限于危重症人群。数据支持将血糖控制在血清葡萄糖浓度<200mg/dL 以下，但绝对目标范围仍存在争议且研究不足。数据表明，使用胰岛素将目标血糖浓度控制在 80-110mg/dL（强化胰岛素治疗[IIT]）比在危重症外科患者中控制在 180-200mg/dL 更宽松的目标范围更有益，尽管 IIT 更常见低血糖。在围手术期期间，没有足够的研究可以得出关于非危重症外科患者的结论，但数据的重要性表明将血糖控制在<200mg/dL 可能有益。
外科患者受益于将血清葡萄糖浓度保持在<200mg/dL。强化胰岛素治疗（80-110mg/dL）似乎对危重症外科患者有益，但需要频繁测量血糖以避免低血糖。需要进一步研究以确定适当的目标范围以及营养提供和其他因素对结果的影响。
