Stewart Kent W, Chase J Geoffrey, Pretty Christopher G, Shaw Geoffrey M
Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Private Bag 4800, Christchurch, 8140, New Zealand.
Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand.
Ann Intensive Care. 2018 Jan 10;8(1):4. doi: 10.1186/s13613-017-0351-9.
Hyperglycaemia is commonplace in the adult intensive care unit (ICU), associated with increased morbidity and mortality. Effective glycaemic control (GC) can reduce morbidity and mortality, but has proven difficult. STAR is a proven, effective model-based ICU GC protocol that uniquely maintains normo-glycaemia by changing both insulin and nutrition interventions to maximise nutrition in the context of GC in the 4.4-8.0 mmol/L range. Hence, the level of nutrition it provides is a time-varying estimate of the patient-specific ability to take up glucose.
First, the clinical provision of nutrition by STAR in Christchurch Hospital, New Zealand (N = 221 Patients) is evaluated versus other ICUs, based on the Cahill et al. survey of 158 ICUs. Second, the inter- and intra- patient variation of nutrition delivery with STAR is analysed. Nutrition rates are in terms of percentage of caloric goal achieved.
Mean nutrition rates clinically achieved by STAR were significantly higher than the mean and best ICU surveyed, for the first 3 days of ICU stay. There was large inter-patient variation in nutrition rates achieved per day, which reduced overtime as patient-specific metabolic state stabilised. Median intra-patient variation was 12.9%; however, the interquartile range of the mean per-patient nutrition rates achieved was 74.3-98.2%, suggesting patients do not deviate much from their mean patient-specific nutrition rate. Thus, the ability to tolerate glucose intake varies significantly between, rather than within, patients.
Overall, STAR's protocol-driven changes in nutrition rate provide higher nutrition rates to hyperglycaemic patients than those of 158 ICUs from 20 countries. There is significant inter-patient variability between patients to tolerate and uptake glucose, where intra-patient variability over stay is much lower. Thus, a best nutrition rate is likely patient specific for patients requiring GC. More importantly, these overall outcomes show high nutrition delivery and safe, effective GC are not exclusive and that restricting nutrition for GC does not limit overall nutritional intake compared to other ICUs.
高血糖在成人重症监护病房（ICU）中很常见，与发病率和死亡率增加相关。有效的血糖控制（GC）可以降低发病率和死亡率，但事实证明这很困难。STAR是一种经过验证的、有效的基于模型的ICU血糖控制方案，它通过改变胰岛素和营养干预措施，在4.4-8.0毫摩尔/升的血糖控制范围内，独特地维持正常血糖水平，从而在血糖控制的背景下最大限度地提供营养。因此，它提供的营养水平是对患者特定葡萄糖摄取能力的随时间变化的估计。
首先，根据Cahill等人对158个ICU的调查，评估新西兰克赖斯特彻奇医院（N = 221例患者）STAR临床提供的营养情况，并与其他ICU进行比较。其次，分析STAR营养输送在患者之间和患者内部的差异。营养率以达到热量目标的百分比表示。
在ICU住院的前3天，STAR临床实现的平均营养率显著高于所调查的ICU的平均水平和最佳水平。每天实现的营养率在患者之间存在很大差异，随着患者特定代谢状态的稳定，这种差异会随着时间推移而减小。患者内部差异的中位数为12.9%；然而，每位患者实现的平均营养率的四分位间距为74.3%-98.2%，这表明患者与其特定的平均营养率偏差不大。因此，患者之间耐受葡萄糖摄入的能力差异显著，而非患者内部。
总体而言，STAR方案驱动的营养率变化为高血糖患者提供的营养率高于来自20个国家的158个ICU。患者之间耐受和摄取葡萄糖的能力存在显著差异，而住院期间患者内部的差异要小得多。因此，对于需要血糖控制的患者，最佳营养率可能因患者而异。更重要的是，这些总体结果表明高营养输送与安全、有效的血糖控制并非相互排斥，与其他ICU相比，为控制血糖而限制营养并不会限制总体营养摄入。
