耶鲁胰岛素输注方案的计算机化及静脉用胰岛素致低血糖原因的潜在见解。
Computerization of the Yale insulin infusion protocol and potential insights into causes of hypoglycemia with intravenous insulin.
机构信息
Hiram C. Polk Department of Surgery, University of Louisville, Louisville, KY 40202, USA.
出版信息
Diabetes Technol Ther. 2013 Mar;15(3):246-52. doi: 10.1089/dia.2012.0277. Epub 2013 Jan 4.
BACKGROUND
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.
METHODS
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.
RESULTS
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%).
CONCLUSIONS
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.
背景
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。
方法
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。
结果
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%）。
结论
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。
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