Hiram C. Polk Department of Surgery, University of Louisville, Louisville, KY 40202, USA.
Diabetes Technol Ther. 2013 Mar;15(3):246-52. doi: 10.1089/dia.2012.0277. Epub 2013 Jan 4.
The management of critically ill hyperglycemic patients in the intensive care unit (ICU) has been fraught with recent controversy. Only one randomized trial has demonstrated a mortality benefit to intensive glycemic control, with all subsequent studies failing to confirm this benefit and revealing a markedly increased risk of severe hypoglycemia (SH) in intensively treated patients. In most of these trials, adherence to the protocols were neither tracked nor reported.
A retrospective analysis of all patients admitted to an ICU who were treated with an insulin infusion directed by the GlucoCare™ IGC System, an FDA-cleared insulin-dosing calculator (Yale 100-140 mg/dL protocol). Mean blood glucose (BG) levels, time to target range and incidence of SH (<40 mg/dL) and moderate hypoglycemia (MH) (40-69 mg/dL) were determined, and potential causes of hypoglycemic episodes were assessed.
Mean post-target BG was approximately 123 mg/dL. Of >55,000 readings in 1,657 patients, overall incidence of SH was 0.01% of readings and 0.3% of patients. MH occurred in 1.1% of readings and 17.6% of patients. The top potential causes of MH were: (1) Protocol-directed recommendations including continuation of insulin with BG <100 mg/dL and decreases in the frequency of BG checks (63.7%), and (2) Staff non-adherence to protocol directives (15.3%).
The results of the GlucoCare-directed Yale 100-140 mg/dL protocol experience revealed an extremely low incidence of SH and an incidence of MH of 1.1%. The incidence of SH in this study was lower than the control group of the NICE-SUGAR study and are supportive of the new Society of Critical Care guidelines to target BG levels of 100-150 mg/dL in critically ill patients. Further refinements to the original protocol and emphasis on staff adherence to protocol directives could potentially further reduce these very low hypoglycemia rates.
在重症监护病房（ICU）中，对危重病高血糖患者的管理一直存在争议。只有一项随机试验表明强化血糖控制可降低死亡率，但随后的所有研究均未能证实这一益处，并且在强化治疗的患者中明显增加了严重低血糖（SH）的风险。在这些试验中，大多数都没有跟踪或报告对方案的遵守情况。
对使用 GlucoCare™IGC 系统（FDA 批准的胰岛素剂量计算器[耶鲁 100-140mg/dL 方案]）进行胰岛素输注治疗的 ICU 住院患者进行回顾性分析。测定平均血糖（BG）水平、达到目标范围的时间以及 SH（<40mg/dL）和中度低血糖（MH）（40-69mg/dL）的发生率，并评估低血糖发作的潜在原因。
目标后平均 BG 约为 123mg/dL。在 1657 名患者的 55000 多次读数中，SH 的总发生率为读数的 0.01%，患者的 0.3%。MH 发生率为读数的 1.1%，患者的 17.6%。MH 的潜在主要原因包括：（1）方案指导建议，包括在 BG<100mg/dL 时继续使用胰岛素和减少 BG 检查频率（63.7%），以及（2）工作人员不遵守方案指令（15.3%）。
GlucoCare 指导的耶鲁 100-140mg/dL 方案的结果显示，SH 的发生率极低，MH 的发生率为 1.1%。本研究中的 SH 发生率低于 NICE-SUGAR 研究的对照组，支持新的重症监护协会指南将危重患者的 BG 水平目标设定为 100-150mg/dL。对原始方案的进一步改进和强调工作人员对方案指令的遵守，可能会进一步降低这些非常低的低血糖发生率。
