Forbes Neil Christopher, Anders Nicola
Department of Anaesthesia, Royal Manchester Children's Hospital, Greater Manchester, England.
Int J Gen Med. 2013 Dec 6;7:1-11. doi: 10.2147/IJGM.S55649.
This literature review examines the current evidence regarding the potential usefulness of tight glycemic control in pediatric surgical patients. In adults, fluctuations in glucose levels and/or prolonged hyperglycemia have been shown to be associated with poor outcomes with respect to morbidity and mortality. This review begins by summarizing the findings of key papers in adult patients and continues by investigating whether or not similar results have been seen in pediatric patients by performing a comprehensive literature review using Medline (OVID). A database search using the OVID interface and including the search terms (exp glucose) AND (exp surgery) AND (exp Paediatric/pediatric) AND (exp Hypoglycaemia/hypoglycemia) AND (exp Hyperglycaemia/hyperglycemia) yielded a total of 150+ papers, of which 24 fulfilled our criteria. We isolated papers utilizing pediatric patients who were hospitalized due to illness and/or surgery. Our review highlights several difficulties encountered in addressing this potentially useful clinical intervention. An absence of scientifically robust and randomized trials and the existence of several small-powered trials yielding conflicting results mean we cannot recommend tight glycemic control in these patients. Differences in study design and disagreements concerning the crucial stage of surgery where hyperglycemia becomes important are compounded by an over-reliance on the discretion of clinicians in the absence of well described treatment protocols. Closer inspection of key papers in adult patients identified fundamental discrepancies between exact definitions of both hyperglycemia and hypoglycemia. This lack of consensus, along with a fear of inducing iatrogenic hypoglycemia in pediatric patients, has resulted in professional bodies advising against this form of intervention. In conclusion, we cannot recommend use of tight glycemic control in pediatric surgical patients due to unclear glucose definitions, unclear thresholds for treatment, and the unknown long-term effects of iatrogenic hypoglycemia on the developing body and brain.
这篇文献综述探讨了目前关于严格血糖控制在儿科手术患者中潜在效用的证据。在成人中，血糖水平波动和/或长期高血糖已被证明与发病率和死亡率方面的不良结局相关。本综述首先总结成人患者关键论文的研究结果，接着通过使用医学在线数据库（OVID）进行全面的文献综述，调查儿科患者中是否也有类似结果。使用OVID界面进行数据库搜索，搜索词包括（葡萄糖[展开]）、（手术[展开]）、（儿科/小儿科[展开]）、（低血糖症/低血糖[展开]）、（高血糖症/高血糖[展开]），共得到150多篇论文，其中24篇符合我们的标准。我们筛选出了针对因疾病和/或手术住院的儿科患者的论文。我们的综述强调了在应对这种潜在有用的临床干预措施时遇到的几个困难。缺乏科学严谨的随机试验，以及存在一些样本量小且结果相互矛盾的试验，这意味着我们不能推荐对这些患者进行严格血糖控制。研究设计的差异以及关于高血糖变得重要的关键手术阶段的分歧，因在缺乏详细治疗方案的情况下过度依赖临床医生的判断而变得更加复杂。对成人患者关键论文的仔细审查发现，高血糖和低血糖的确切定义之间存在根本差异。这种缺乏共识，以及担心在儿科患者中诱发医源性低血糖，导致专业机构不建议采用这种干预形式。总之，由于血糖定义不明确、治疗阈值不明确以及医源性低血糖对发育中的身体和大脑的长期影响未知，我们不能推荐在儿科手术患者中使用严格血糖控制。
