1Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA. 2Department of Surgery and Emory Critical Care Center, Emory University School of Medicine, Atlanta, GA.
Crit Care Med. 2015 Dec;43(12):e541-50. doi: 10.1097/CCM.0000000000001353.
Many patients with diabetes and their care providers are unaware of the presence of the disease. Dysglycemia encompassing hyperglycemia, hypoglycemia, and glucose variability is common in the ICU in patients with and without diabetes. The purpose of this study was to determine the impact of unknown diabetes on glycemic control in the ICU.
Prospective observational study.
Nine ICUs in an academic, tertiary hospital and a hybrid academic/community hospital.
Hemoglobin A1c levels were ordered at all ICU admissions from March 1, 2011 to September 30, 2013. Electronic medical records were examined for a history of antihyperglycemic medications or International Classification of Diseases, 9th Edition diagnosis of diabetes. Patients were categorized as having unknown diabetes (hemoglobin A1c > 6.5%, without history of diabetes), no diabetes (hemoglobin A1c < 6.5%, without history of diabetes), controlled known diabetes (hemoglobin A1c < 6.5%, with documented history of diabetes), and uncontrolled known diabetes (hemoglobin A1c > 6.5%, with documented history of diabetes).
None.
A total of 15,737 patients had an hemoglobin A1c and medical record evaluable for the history of diabetes, and 5,635 patients had diabetes diagnosed by either medical history or an elevated hemoglobin A1c in the ICU. Of these, 1,460 patients had unknown diabetes, accounting for 26.0% of all patients with diabetes. This represented 41.0% of patients with an hemoglobin A1c > 6.5% and 9.3% of all ICU patients. Compared with patients without diabetes, patients with unknown diabetes had a higher likelihood of requiring an insulin infusion (44.3% vs 29.3%; p < 0.0001), a higher average blood glucose (172 vs 126 mg/dL; p < 0.0001), an increased percentage of hyperglycemia (19.7% vs 7.0%; blood glucose > 180 mg/dL; p < 0.0001) and hypoglycemia (8.9% vs 2.5%; blood glucose < 70 mg/dL; p < 0.0001), higher glycemic variability (55.6 vs 28.8, average of patient SD of glucose; p < 0.0001), and increased mortality (13.8% vs 11.4%; p = 0.01).
Patients with unknown diabetes represent a significant percentage of ICU admissions. Measurement of hemoglobin A1c at admission can prospectively identify a population that are not known to have diabetes but have significant challenges in glycemic control in the ICU.
许多糖尿病患者及其护理人员都不知道疾病的存在。在伴有或不伴有糖尿病的 ICU 患者中，高血糖、低血糖和血糖变异性等糖代谢异常很常见。本研究旨在确定未知糖尿病对 ICU 血糖控制的影响。
前瞻性观察性研究。
一家学术性的、三级医院和一家学术/社区混合医院的 9 个 ICU。
2011 年 3 月 1 日至 2013 年 9 月 30 日期间，所有 ICU 入院患者均进行了糖化血红蛋白水平检测。查阅电子病历，了解是否使用过降糖药物或是否有糖尿病的国际疾病分类第 9 版诊断。患者分为三类：未知糖尿病（糖化血红蛋白＞6.5%，无糖尿病史）、无糖尿病（糖化血红蛋白＜6.5%，无糖尿病史）、控制良好的已知糖尿病（糖化血红蛋白＜6.5%，有糖尿病病史）和控制不佳的已知糖尿病（糖化血红蛋白＞6.5%，有糖尿病病史）。
无。
共有 15737 例患者的糖化血红蛋白和病历可用于评估糖尿病史，5635 例患者在 ICU 通过病史或糖化血红蛋白升高被诊断为糖尿病。其中 1460 例患者患有未知糖尿病，占所有糖尿病患者的 26.0%。这代表了所有糖化血红蛋白＞6.5%的患者的 41.0%和所有 ICU 患者的 9.3%。与无糖尿病的患者相比，患有未知糖尿病的患者更有可能需要接受胰岛素输注（44.3% vs 29.3%；p＜0.0001），平均血糖水平更高（172 vs 126 mg/dL；p＜0.0001），高血糖的发生率更高（19.7% vs 7.0%；血糖＞180 mg/dL；p＜0.0001）和低血糖的发生率更高（8.9% vs 2.5%；血糖＜70 mg/dL；p＜0.0001），血糖变异性更高（55.6 vs 28.8，患者血糖标准差的平均值；p＜0.0001），死亡率更高（13.8% vs 11.4%；p=0.01）。
患有未知糖尿病的患者占 ICU 入院患者的很大比例。入院时测量糖化血红蛋白可以前瞻性地识别出一类以前不知道患有糖尿病但在 ICU 血糖控制方面存在显著挑战的人群。
