危重症患者低血糖与死亡风险。

Hypoglycemia and risk of death in critically ill patients.

出版信息

N Engl J Med. 2012 Sep 20;367(12):1108-18. doi: 10.1056/NEJMoa1204942.

DOI:10.1056/NEJMoa1204942

PMID:22992074

Abstract

BACKGROUND

Whether hypoglycemia leads to death in critically ill patients is unclear.

METHODS

We examined the associations between moderate and severe hypoglycemia (blood glucose, 41 to 70 mg per deciliter [2.3 to 3.9 mmol per liter] and ≤40 mg per deciliter [2.2 mmol per liter], respectively) and death among 6026 critically ill patients in intensive care units (ICUs). Patients were randomly assigned to intensive or conventional glucose control. We used Cox regression analysis with adjustment for treatment assignment and for baseline and postrandomization covariates.

RESULTS

Follow-up data were available for 6026 patients: 2714 (45.0%) had moderate hypoglycemia, 2237 of whom (82.4%) were in the intensive-control group (i.e., 74.2% of the 3013 patients in the group), and 223 patients (3.7%) had severe hypoglycemia, 208 of whom (93.3%) were in the intensive-control group (i.e., 6.9% of the patients in this group). Of the 3089 patients who did not have hypoglycemia, 726 (23.5%) died, as compared with 774 of the 2714 with moderate hypoglycemia (28.5%) and 79 of the 223 with severe hypoglycemia (35.4%). The adjusted hazard ratios for death among patients with moderate or severe hypoglycemia, as compared with those without hypoglycemia, were 1.41 (95% confidence interval [CI], 1.21 to 1.62; P<0.001) and 2.10 (95% CI, 1.59 to 2.77; P<0.001), respectively. The association with death was increased among patients who had moderate hypoglycemia on more than 1 day (>1 day vs. 1 day, P=0.01), those who died from distributive (vasodilated) shock (P<0.001), and those who had severe hypoglycemia in the absence of insulin treatment (hazard ratio, 3.84; 95% CI, 2.37 to 6.23; P<0.001).

CONCLUSIONS

In critically ill patients, intensive glucose control leads to moderate and severe hypoglycemia, both of which are associated with an increased risk of death. The association exhibits a dose-response relationship and is strongest for death from distributive shock. However, these data cannot prove a causal relationship. (Funded by the Australian National Health and Medical Research Council and others; NICE-SUGAR ClinicalTrials.gov number, NCT00220987.).

摘要

背景

低血糖是否会导致危重症患者死亡尚不清楚。

方法

我们考察了中等程度和严重低血糖（血糖水平分别为 41 至 70 毫克/分升[2.3 至 3.9 毫摩尔/升]和≤40 毫克/分升[2.2 毫摩尔/升]）与重症监护病房（ICU）内 6026 例危重症患者死亡之间的相关性。患者被随机分配接受强化或常规血糖控制。我们使用 Cox 回归分析，同时调整治疗分组以及基线和随机分组后协变量。

结果

对 6026 例患者进行了随访数据评估：2714 例（45.0%）有中度低血糖，其中 2237 例（82.4%）在强化血糖控制组（即 3013 例患者中的 74.2%），223 例（3.7%）有严重低血糖，其中 208 例（93.3%）在强化血糖控制组（即该组患者中的 6.9%）。在 3089 例无低血糖患者中，726 例（23.5%）死亡，而 2714 例有中度低血糖的患者中有 774 例（28.5%）死亡，223 例有严重低血糖的患者中有 79 例（35.4%）死亡。与无低血糖患者相比，有中度或严重低血糖的患者死亡风险的校正比值比分别为 1.41（95%置信区间[CI]，1.21 至 1.62；P<0.001）和 2.10（95% CI，1.59 至 2.77；P<0.001）。在有中度低血糖超过 1 天（>1 天与 1 天，P=0.01）、因分布性（血管扩张性）休克而死亡（P<0.001）或无胰岛素治疗而发生严重低血糖的患者中（风险比，3.84；95% CI，2.37 至 6.23；P<0.001），与死亡的相关性增加。

结论

在危重症患者中，强化血糖控制可导致中度和严重低血糖，两者均与死亡风险增加相关。这种相关性呈现出剂量-反应关系，且与分布性休克导致的死亡关系最强。但是，这些数据并不能证明因果关系。（由澳大利亚国家健康与医学研究理事会和其他机构资助；NICE-SUGAR 临床试验。gov 编号，NCT00220987。）