Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia.
Department of Anesthesia and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Largo Agostino Gemelli, Roma, Italy.
Crit Care Med. 2018 Jun;46(6):935-942. doi: 10.1097/CCM.0000000000003087.
To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes.
Prospective, open-label, sequential period study.
A 22-bed mixed ICU of a tertiary hospital in Australia.
We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control.
Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10-14 mmol/L [180-252 mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6-10 mmol/L [108-180 mg/dL]).
We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose ≤ 3.9 mmol/L [70 mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7-12.0 mmol/L]; 198 mg/dL [157-216 mg/dL]) than in the conventional control group (9.6 mmol/L [8.5-11.0 mmol/L]; 173 mg/dL [153-198 mg/dL]; p < 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU (p < 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively (p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively (p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30.
In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12615000216516).
评估 ICU 糖尿病患者实施宽松与常规血糖控制的可行性、生化疗效和安全性。
前瞻性、开放标签、连续时期研究。
澳大利亚一家三级医院的 22 张混合 ICU。
我们比较了在 15 个月内收治的 350 例连续糖尿病患者，其中 150 例接受宽松血糖控制，另 150 例接受常规血糖控制。
如果血糖大于 14 mmol/L（目标：10-14 mmol/L[180-252mg/dL]），则给予宽松控制组患者胰岛素治疗。如果血糖大于 10 mmol/L（目标：6-10 mmol/L[108-180mg/dL]），则给予常规控制组患者胰岛素治疗。
我们评估了血糖分离、胰岛素需求、低血糖（血糖≤3.9 mmol/L[70mg/dL]）、肌酐和白细胞计数水平以及临床结局。宽松控制组的中位（四分位间距）时间加权平均血糖浓度显著高于常规控制组（11.0mmol/L[8.7-12.0mmol/L]；198mg/dL[157-216mg/dL]）（9.6mmol/L[8.5-11.0mmol/L]；173mg/dL[153-198mg/dL]；p<0.001）。总体而言，132 例宽松控制组患者（37.7%）和 188 例常规控制组患者（53.7%）在 ICU 中接受了胰岛素治疗（p<0.001）。低血糖分别发生在 6.6%和 8.6%的患者中（p=0.32）。在糖化血红蛋白 A1c 大于或等于 7%的 314 例患者中，低血糖分别发生在 4.1%和 9.6%的患者中（p=0.053）。两组肌酐和白细胞计数的变化轨迹相似。多变量分析显示，血糖控制与死亡率、机械通气时间或 ICU 至第 30 天的无机械通气天数之间无独立关联。
在 ICU 糖尿病患者中，在实施宽松血糖控制、给予胰岛素治疗和糖化血红蛋白 A1c 大于或等于 7%的患者中，低血糖的发生率降低，而不会对血清肌酐、白细胞计数反应或其他临床结局产生负面影响。（试验注册：澳大利亚和新西兰临床试验注册中心；ACTRN12615000216516）
