[重症急性胰腺炎患者的短期强化血糖控制]

Zuo Yan-yan, Kang Yan, Wang Bo, Yin Wan-hong

Sichuan University, Chengdu, Sichuan, China.

Zhongguo Wei Zhong Bing Ji Jiu Yi Xue. 2012 Jan;24(1):24-8.

OBJECTIVE

To investigate effects of intensive glucose control (IGC) on glucose variability (GV) and clinical outcomes in patients with severe acute pancreatitis (SAP), and to assess predictive values of different measures of GV on intensive care unit (ICU) death.

METHODS

A prospective, randomized, non-blinded clinical trial was conducted. All adult patients with diagnosis of SAP, who were admitted to ICU of West China Hospital between July 1st 2010 and July 1st 2011, were enrolled. Eligible patients were randomly assigned to receive either IGC to maintain glucose level between 6.1 mmol/L and 8.3 mmol/L or control group (none intervention was given). GV, ICU mortality, the incidence of infection, length of mechanical ventilation and ICU stay of the two groups were compared. The standard deviation of blood glucose level [GLU(SD)], mean amplitude of glycemic excursion [GLU(MAGE)] and glycemic lability index [GLU(GLI)] were chosen as measures of GV to analyze the multi variable correlation between them and ICU mortality, and the ability of these three parameters was assessed in predicting ICU death using area under a receiver operating characteristic curve (AUC).

RESULTS

One hundred and twenty-two patients were eligible for the study, and 30 patients with SAP were enrolled in the study, with 15 cases in each group. The basic data of the two groups were comparable. Compared with control group, IGC showed an effect to reduce GV, including GLU(SD) [mmol/L: 1.81 (0.97, 2.65) vs. 2.48 (1.29, 2.87)], GLU(MAGE) [mmol/L: 3.76 (3.67, 5.85) vs. 5.30 (4.35, 6.80)], GLU(GLI) [306.8 (220.6, 613.3) vs. 339.5 (218.4, 423.1)], and lower ICU mortality (13.3% vs. 40.0%), but the difference showed no significant difference (all P > 0.05). It could also shorten the length of ICU stay (days: 11.3 ± 9.9 vs. 15.8 ± 7.6, P < 0.01), decrease the incidence of infection of blood stream and the lung (6.7% vs. 40.0%; 33.3% vs. 73.3%, both P < 0.05). A positive correlation between GLU(GLU) and ICU mortality was found (r = 0.371, P = 0.044), but no correlation was found between GLU(SD) or GLU(MAGE) and ICU mortality (r value was -0.144 and -0.065, P value was 0.448 and 0.731). AUC for GLU(SD), GLU(MAGE) and GLU(GLI) was 0.594 [95% confidence interval (95%CI) 0.382-0.805], 0.543 (95%CI 0.287-0.798) and 0.751 (95%CI 0.548-0.954) respectively, and GLU(GLI) was the best predictor of ICU death.

CONCLUSIONS

IGC had an effect to reduce GV, decrease ICU mortality, shorten length of ICU stay, and lower the incidence of infection. Compared with GLU(SD) and GLU(MAGE), GLU(GLI) was the best predictor of ICU death.

目的

探讨强化血糖控制（IGC）对重症急性胰腺炎（SAP）患者血糖变异性（GV）及临床结局的影响，并评估不同GV指标对重症监护病房（ICU）死亡的预测价值。

方法

进行一项前瞻性、随机、非盲临床试验。纳入2010年7月1日至2011年7月1日期间入住四川大学华西医院ICU的所有成年SAP患者。符合条件的患者被随机分配接受IGC以维持血糖水平在6.1 mmol/L至8.3 mmol/L之间或对照组（不给予干预）。比较两组的GV、ICU死亡率、感染发生率、机械通气时间和ICU住院时间。选择血糖水平标准差[GLU(SD)]、血糖波动平均幅度[GLU(MAGE)]和血糖不稳定指数[GLU(GLI)]作为GV指标，分析它们与ICU死亡率之间的多变量相关性，并使用受试者工作特征曲线下面积（AUC）评估这三个参数预测ICU死亡的能力。

结果

122例患者符合研究条件，30例SAP患者纳入研究，每组15例。两组的基础数据具有可比性。与对照组相比，IGC显示出降低GV的作用，包括GLU(SD)[mmol/L：1.81(0.97, 2.65) vs. 2.48(1.29, 2.87)]、GLU(MAGE)[mmol/L：3.76(3.67, 5.85) vs. 5.30(4.35, 6.80)]、GLU(GLI)[306.8(220.6, 613.3) vs. 339.5(218.4, 423.1)]，且ICU死亡率较低(13.3% vs. 40.0%)，但差异无统计学意义（均P>0.05）。IGC还可缩短ICU住院时间（天：11.3±9.9 vs. 15.8±7.6，P<0.01），降低血流感染和肺部感染的发生率（6.7% vs. 40.0%；33.3% vs. 73.3%，均P<0.05）。发现GLU(GLI)与ICU死亡率呈正相关（r = 0.371，P = 0.044），但GLU(SD)或GLU(MAGE)与ICU死亡率无相关性（r值分别为-0.144和-0.065，P值分别为0.448和0.731）。GLU(SD)、GLU(MAGE)和GLU(GLI)的AUC分别为0.594[95%置信区间(95%CI) 0.382 - 0.805]、0.543(95%CI 0.287 - 0.798)和0.751(95%CI 0.548 - 0.954)，GLU(GLI)是ICU死亡的最佳预测指标。