大剂量地塞米松对围手术期乳酸水平及血糖控制的影响：一项随机对照试验
Effect of high-dose dexamethasone on perioperative lactate levels and glucose control: a randomized controlled trial.
作者信息
Ottens Thomas H, Nijsten Maarten W N, Hofland Jan, Dieleman Jan M, Hoekstra Miriam, van Dijk Diederik, van der Maaten Joost Maa
机构信息
Department of Anesthesiology and Intensive Care, University Medical Center Utrecht, Mail stop Q.04.2.313, PO Box 85500, Utrecht, 3508, GA, The Netherlands.
Department of Critical Care, University Medical Center, University of Groningen, Hanzeplein 1, Groningen, RB, 9700, The Netherlands.
出版信息
Crit Care. 2015 Feb 13;19(1):41. doi: 10.1186/s13054-015-0736-9.
INTRODUCTION
Blood lactate levels are increasingly used to monitor patients. Steroids are frequently administered to critically ill patients. However, the effect of steroids on lactate levels has not been adequately investigated. We studied the effect of a single intraoperative high dose of dexamethasone on lactate and glucose levels in patients undergoing cardiac surgery.
METHODS
The Dexamethasone for Cardiac Surgery (DECS) trial was a multicenter randomized trial on the effect of dexamethasone 1 mg/kg versus placebo on clinical outcomes after cardiac surgery in adults. Here we report a pre-planned secondary analysis of data from DECS trial participants included at the University Medical Center Groningen. The use of a computer-assisted glucose regulation protocol--Glucose Regulation for Intensive care Patients (GRIP)--was part of routine postoperative care. GRIP aimed at glucose levels of 4 to 8 mmol/L. Primary outcome parameters were area under the lactate and glucose curves over the first 15 hours of ICU stay (AUC₁₅). ICU length of stay and mortality were observed as well.
RESULTS
The primary outcome could be determined in 497 patients of the 500 included patients. During the first 15 hours of ICU stay, lactate and glucose levels were significantly higher in the dexamethasone group than in the placebo group: lactate AUC₁₅ 25.8 (13.1) versus 19.9 (11.2) mmol/L × hour, P <0.001 and glucose AUC₁₅ 126.5 (13.0) versus 114.4 (13.9) mmol/L × hour, P <0.001. In this period, patients in the dexamethasone group required twice as much insulin compared with patients who had received placebo. Multivariate and cross-correlation analyses suggest that the effect of dexamethasone on lactate levels is related to preceding increased glucose levels. Patients in the placebo group were more likely to stay in the ICU for more than 24 hours (39.2%) compared with patients in the dexamethasone group (25.0%, P = 0.001), and 30-day mortality rates were 1.6% and 2.4%, respectively (P = 0.759).
CONCLUSIONS
Intraoperative high-dose dexamethasone increased postoperative lactate and glucose levels in the first 15 hours of ICU stay. Still, patients in the dexamethasone group had a shorter ICU length of stay and similar mortality compared with controls.
TRIAL REGISTRATION
ClinicalTrials.gov NCT00293592 . Registered 16 February 2006.
引言
血乳酸水平越来越多地用于监测患者。重症患者经常使用类固醇。然而，类固醇对乳酸水平的影响尚未得到充分研究。我们研究了术中单次大剂量地塞米松对心脏手术患者乳酸和葡萄糖水平的影响。
方法
心脏手术地塞米松（DECS）试验是一项多中心随机试验，研究1mg/kg地塞米松与安慰剂对成人心脏手术后临床结局的影响。在此，我们报告对格罗宁根大学医学中心纳入的DECS试验参与者数据进行的一项预先计划的二次分析。使用计算机辅助血糖调节方案——重症监护患者血糖调节（GRIP）——是术后常规护理的一部分。GRIP的目标是将血糖水平控制在4至8mmol/L。主要结局参数是重症监护病房（ICU）住院前15小时乳酸和葡萄糖曲线下面积（AUC₁₅）。还观察了ICU住院时间和死亡率。
结果
在纳入的500例患者中，497例患者的主要结局可以确定。在ICU住院的前15小时内，地塞米松组的乳酸和葡萄糖水平显著高于安慰剂组：乳酸AUC₁₅为25.8（13.1）mmol/L·小时，而安慰剂组为19.9（11.2）mmol/L·小时，P<0.001；葡萄糖AUC₁₅为126.5（13.0）mmol/L·小时，而安慰剂组为114.4（13.9）mmol/L·小时，P<0.001。在此期间，地塞米松组患者所需胰岛素量是接受安慰剂患者的两倍。多变量和交叉相关分析表明，地塞米松对乳酸水平的影响与之前血糖水平升高有关。与地塞米松组患者（25.0%）相比，安慰剂组患者更有可能在ICU停留超过24小时（39.2%），P=0.001，30天死亡率分别为1.6%和2.4%（P=0.759）。
结论
术中高剂量地塞米松在ICU住院的前15小时内增加了术后乳酸和葡萄糖水平。尽管如此，与对照组相比，地塞米松组患者的ICU住院时间更短，死亡率相似。
试验注册
ClinicalTrials.gov NCT00293592。2006年2月16日注册。
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