Bosarge Patrick L, Shoultz Thomas H, Griffin Russell L, Kerby Jeffrey D
From the Division of Trauma, Burns, and Surgical Critical Care, University of Alabama at Birmingham, Birmingham, Alabama.
J Trauma Acute Care Surg. 2015 Aug;79(2):289-94. doi: 10.1097/TA.0000000000000716.
An association between stress-induced hyperglycemia (SIH) and increased mortality has been demonstrated following trauma. Experimental animal model data regarding the association between hyperglycemia and outcomes following traumatic brain injury (TBI) are inconsistent, suggesting that hyperglycemia may be harmful, neutral, or beneficial. The purpose of this study was to examine the effects of SIH versus diabetic hyperglycemia (DH) on severe TBI.
Admission glycosylated hemoglobin (HbA1c), glucose levels, and comorbidity data were collected during a 4-year period from September 2009 to December 2013 for patients with severe TBI (i.e., admission Glasgow Coma Scale [GCS] score of 3-8 and head Abbreviated Injury Scale [AIS] score ≥ 3). Diabetes mellitus was determined by patient history or admission HbA1c of 6.5% or greater. SIH was determined by the absence of diabetes mellitus and admission glucose of 200 mg/dL or greater. A Cox proportional hazards model adjusted for age, sex, injury mechanism, and Injury Severity Score (ISS) was used to calculate hazard ratios (HRs) and associated 95% confidence intervals (CIs) for the association between SIH and the outcomes of interest.
During the study period, a total of 626 patients were included in the study group, having severe TBI defined by both GCS score of 3 to 8 and head AIS score being 3 or greater and also had available HbA1c and admission glucose levels. A total of 184 patients were admitted with hyperglycemia; 152 patients (82.6%) were diagnosed with SIH, and 32 patients (17.4%) were diagnosed with DH. When comparing patients with severe TBI adjusted for age, sex, injury mechanism, ISS, Revised Trauma Score (RTS), and lactic acid greater than 2.5 mmol/L, patients with SIH had a 50% increased mortality (HR, 1.49; 95% CI, 1.13-1.95) compared with the nondiabetic normoglycemia patients. DH patients did not have a significant increase in mortality (HR, 0.94; 95% CI, 0.56-1.58).
SIH is associated with higher mortality after severe TBI. This association was not observed among patients with DH, which suggests that hyperglycemia related to diabetes is of less importance compared with SIH in terms of mortality in the acute trauma and TBI patient. Further research is warranted to identify mechanisms causing SIH and subsequent worse outcomes after TBI.
Prognostic/epidemiologic study, leve III.
创伤后应激性高血糖（SIH）与死亡率增加之间的关联已得到证实。关于创伤性脑损伤（TBI）后高血糖与预后之间关联的实验动物模型数据并不一致，这表明高血糖可能是有害的、中性的或有益的。本研究的目的是探讨SIH与糖尿病性高血糖（DH）对重度TBI的影响。
收集2009年9月至2013年12月4年间重度TBI患者（即入院时格拉斯哥昏迷量表[GCS]评分为3 - 8分且头部简明损伤量表[AIS]评分≥3）的入院糖化血红蛋白（HbA1c）、血糖水平和合并症数据。糖尿病通过患者病史或入院时HbA1c≥6.5%来确定。SIH通过无糖尿病且入院血糖≥200mg/dL来确定。使用调整了年龄、性别、损伤机制和损伤严重程度评分（ISS）的Cox比例风险模型来计算SIH与感兴趣结局之间关联的风险比（HRs）及相关的95%置信区间（CIs）。
在研究期间，研究组共纳入626例患者，这些患者具有由GCS评分为3至8分以及头部AIS评分≥3所定义的重度TBI，并且有可用的HbA1c和入院血糖水平。共有184例患者入院时存在高血糖；152例患者（82.6%）被诊断为SIH，32例患者（17.4%）被诊断为DH。在比较调整了年龄、性别、损伤机制、ISS、修订创伤评分（RTS）和乳酸大于2.5mmol/L的重度TBI患者时，与非糖尿病正常血糖患者相比，SIH患者的死亡率增加了50%（HR，1.49；95%CI，1.13 - 1.95）。DH患者的死亡率没有显著增加（HR，0.94；95%CI，0.56 - 1.58）。
SIH与重度TBI后的较高死亡率相关。在DH患者中未观察到这种关联，这表明在急性创伤和TBI患者的死亡率方面，与糖尿病相关的高血糖与SIH相比重要性较低。有必要进一步研究以确定导致SIH及TBI后不良结局的机制。
预后/流行病学研究，III级。
