Gardner Andrew John
Faculty of Medicine, The University of Oxford, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, UK.
Indian J Crit Care Med. 2014 Dec;18(12):807-13. doi: 10.4103/0972-5229.146315.
Hyperglycemia has long been observed amongst critically ill patients and associated with increased mortality and morbidity. Tight glycemic control (TGC) is the clinical practice of controlling blood glucose (BG) down to the "normal" 4.4-6.1 mmol/L range of a healthy adult, aiming to avoid any potential deleterious effects of hyperglycemia. The ground-breaking Leuven trials reported a mortality benefit of approximately 10% when using this technique, which led many to endorse its benefits. In stark contrast, the multi-center normoglycemia in intensive care evaluation-survival using glucose algorithm regulation (NICE-SUGAR) trial, not only failed to replicate this outcome, but showed TGC appeared to be harmful. This review attempts to re-analyze the current literature and suggests that hope for a benefit from TGC should not be so hastily abandoned. Inconsistencies in study design make a like-for-like comparison of the Leuven and NICE-SUGAR trials challenging. Inadequate measures preventing hypoglycemic events are likely to have contributed to the increased mortality observed in the NICE-SUGAR treatment group. New technologies, including predictive models, are being developed to improve the safety of TGC, primarily by minimizing hypoglycemia. Intensive Care Units which are unequipped in trained staff and monitoring capacity would be unwise to attempt TGC, especially considering its yet undefined benefit and the deleterious nature of hypoglycemia. International recommendations now advise clinicians to ensure critically ill patients maintain a BG of <10 mmol/L. Despite encouraging evidence, currently we can only speculate and remain optimistic that the benefit of TGC in clinical practice is sweeter than assumed.
长期以来，人们一直观察到危重症患者存在高血糖现象，且这与死亡率和发病率的增加有关。严格血糖控制（TGC）是将血糖（BG）控制在健康成年人“正常”的4.4 - 6.1 mmol/L范围内的临床实践，旨在避免高血糖的任何潜在有害影响。具有开创性意义的鲁汶试验报告称，使用该技术可使死亡率降低约10%，这使得许多人认可其益处。与之形成鲜明对比的是，多中心的重症监护中使用葡萄糖算法调节的正常血糖评估 - 生存（NICE - SUGAR）试验不仅未能重现这一结果，反而显示严格血糖控制似乎是有害的。本综述试图重新分析当前的文献，并表明不应如此草率地放弃从严格血糖控制中获益的希望。研究设计的不一致使得对鲁汶试验和NICE - SUGAR试验进行同类比较具有挑战性。预防低血糖事件的措施不足可能导致了NICE - SUGAR治疗组中观察到的死亡率增加。正在开发包括预测模型在内的新技术，以提高严格血糖控制的安全性，主要是通过尽量减少低血糖的发生。对于没有配备训练有素的工作人员和监测能力的重症监护病房来说，尝试严格血糖控制是不明智的，尤其是考虑到其尚未明确的益处以及低血糖的有害性质。目前国际上的建议是，临床医生应确保危重症患者的血糖维持在<10 mmol/L。尽管有令人鼓舞的证据，但目前我们只能进行推测，并乐观地认为严格血糖控制在临床实践中的益处比预期的更可观。
