Rehou Sarah, Mason Stephanie, Burnett Marjorie, Jeschke Marc G
1Ross Tilley Burn Centre, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 2Division of General Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 3Division of Plastic and Reconstructive Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, Toronto, ON, Canada. 4Department of Immunology, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
Crit Care Med. 2016 Jun;44(6):1059-66. doi: 10.1097/CCM.0000000000001605.
Metabolic alterations after burn injury have been well described in children; however, in adult patients, glucose metabolism and insulin sensitivity are essentially unknown. We sought to characterize metabolic alterations and insulin resistance after burn injury and determine their magnitude and persistence at discharge.
Prospective, cohort study.
Tertiary burn centre.
Nondiabetic adults with an acute burn involving greater than or equal to 20% total body surface area.
An oral glucose tolerance test was administered at discharge.
Glucose, insulin, and C-peptide levels were measured to derive surrogate measures of insulin resistance and β-cell function, including quantitative insulin sensitivity check index, homeostasis model assessment of β-cell function, homeostasis model assessment of insulin sensitivity, homeostasis model assessment of insulin resistance, and the composite whole-body insulin sensitivity index. Patients were grouped according to the degree of glucose tolerance: normal glucose tolerance, impaired fasting glucose/impaired glucose tolerance, or diabetes. Forty-five adults, 44 ± 15 years old and with 38% ± 14% total body surface area burned, underwent an oral glucose tolerance test at discharge. Median quantitative insulin sensitivity check index (0.348 [0.332-0.375]) and median homeostasis model assessment of insulin resistance (1.13 [0.69-1.45]) were abnormal, indicating insulin resistance and impaired insulin production at discharge. Two-thirds of patients (n = 28) met criteria for impaired fasting glucose/impaired glucose tolerance or diabetes.
We have demonstrated that burn-injured adults remain hyperglycemic, are insulin resistant, and express defects in insulin secretion at discharge. Patients with lower burn severity (total body surface area, 20-30%) express similar metabolic alterations as patients with larger burns (total body surface area, ≥ 30%). Glucose tolerance testing at discharge offers an opportunity for early identification of burn patients who may be at high risk of prediabetes and diabetes. Our findings demonstrated that two-thirds of burn patients had some degree of glucose intolerance. With this in mind, surveillance of glucose intolerance post discharge should be considered. As hyperglycemia and insulin resistance are associated with poor outcomes, studies should focus on how long these profound alterations persist.
儿童烧伤后的代谢改变已有详尽描述；然而，成年患者的葡萄糖代谢和胰岛素敏感性基本未知。我们试图明确烧伤后的代谢改变和胰岛素抵抗，并确定其在出院时的程度和持续性。
前瞻性队列研究。
三级烧伤中心。
急性烧伤累及全身表面积大于或等于20%的非糖尿病成年患者。
出院时进行口服葡萄糖耐量试验。
测量葡萄糖、胰岛素和C肽水平，以得出胰岛素抵抗和β细胞功能的替代指标，包括定量胰岛素敏感性检查指数、β细胞功能的稳态模型评估、胰岛素敏感性的稳态模型评估、胰岛素抵抗的稳态模型评估以及综合全身胰岛素敏感性指数。根据葡萄糖耐量程度将患者分组：葡萄糖耐量正常、空腹血糖受损/糖耐量受损或糖尿病。45名成年患者，年龄44±15岁，烧伤总面积为38%±14%，出院时接受了口服葡萄糖耐量试验。定量胰岛素敏感性检查指数中位数（0.348[0.332 - 0.375]）和胰岛素抵抗的稳态模型评估中位数（1.13[0.69 - 1.45]）异常，表明出院时存在胰岛素抵抗和胰岛素分泌受损。三分之二的患者（n = 28）符合空腹血糖受损/糖耐量受损或糖尿病的标准。
我们已证明烧伤成年患者出院时仍存在高血糖、胰岛素抵抗，并表现出胰岛素分泌缺陷。烧伤严重程度较低（全身表面积，20 - 30%）的患者与烧伤面积较大（全身表面积，≥30%）的患者表现出相似的代谢改变。出院时进行葡萄糖耐量试验为早期识别可能有糖尿病前期和糖尿病高风险的烧伤患者提供了机会。我们的研究结果表明，三分之二的烧伤患者有一定程度的葡萄糖不耐受。考虑到这一点，应考虑出院后对葡萄糖不耐受进行监测。由于高血糖和胰岛素抵抗与不良预后相关，研究应关注这些严重改变会持续多长时间。
