Bellomo Rinaldo
1Department of Intensive Care, Austin Hospital, The University of Melbourne, 145 Studley Rd., Heidelberg, Melbourne, 3084 Australia.
2Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Melbourne, Australia.
J Intensive Care. 2018 Nov 8;6:71. doi: 10.1186/s40560-018-0336-2. eCollection 2018.
The optimal level of glycemic control in ICU patients has been the subject of intense investigation over the last 20 years. A pivotal study (the NICE-SUGAR study) involving more than 6,000 patients has established a target between 8 and 10 mmol/l (144 to 180 mg/dl) as the current standard of care. However, this study did not address whether patients with diabetes should be treated differently and, in particular, whether in such patients a higher glucose target should be used.
The last decade has seen multiple studies aiming to describe the association between glycemia in mortality according to whether patients have or do not have diabetes and whether, if they have diabetes, pre-ICU admission glucose control (assessed by glycated hemoglobin A1c (HbA1c) levels) affects the relationship between acute glycemia and outcome. All such studies (now involving thousands and thousands of patients) have consistently shown that diabetic patients have a different relationship between acute glycemia and mortality. In particular, in diabetic patients, increasing glucose levels up to 15 mmol/l (270 mg/dl) or more are not associated with increased risk of death. In patients with a high HbA1c (> 7%) prior to ICU admission, targeting a glucose level below 10 mmol/l (180 mg/dl) is associated with increased risk compared with permissive hyperglycemia. Finally, a recent controlled study comparing a glucose target between 10 and 14 mmol/l (180 to 252 mg/dl) to a glucose target between 6 and 10 mmol/l (180 mg/dl) in diabetic patients found no advantage from tighter glycemia control. A randomized controlled study called LUCID is now underway to test the hypothesis that permissive hyperglycemia might be safer in diabetic patients admitted to the ICU.
Until the results of the LUCID trial are available, the burden of evidence is in favour with targeting a more relaxed level of glycemia in diabetic patients (10-14 mmol/l; 180-252 mg/dl), especially in those with poor pre-admission glycemic control.
在过去20年里，重症监护病房（ICU）患者血糖控制的最佳水平一直是深入研究的主题。一项涉及6000多名患者的关键研究（NICE-SUGAR研究）确定8至10毫摩尔/升（144至180毫克/分升）的目标为当前的护理标准。然而，这项研究没有涉及糖尿病患者是否应采取不同的治疗方法，特别是在这类患者中是否应采用更高的血糖目标。
在过去十年中，多项研究旨在描述根据患者是否患有糖尿病以及如果患有糖尿病，ICU入院前的血糖控制情况（通过糖化血红蛋白A1c（HbA1c）水平评估），血糖与死亡率之间的关联是否会影响急性血糖与预后之间的关系。所有这些研究（目前涉及成千上万的患者）一致表明，糖尿病患者急性血糖与死亡率之间的关系有所不同。特别是，在糖尿病患者中，血糖水平升高至15毫摩尔/升（270毫克/分升）或更高与死亡风险增加无关。在ICU入院前HbA1c水平较高（>7%）的患者中，将血糖水平控制在10毫摩尔/升（180毫克/分升）以下与允许性高血糖相比，死亡风险增加。最后，一项最近的对照研究比较了糖尿病患者10至14毫摩尔/升（180至252毫克/分升）的血糖目标与6至10毫摩尔/升（180毫克/分升）的血糖目标，发现更严格的血糖控制并无优势。一项名为LUCID的随机对照研究正在进行中，以检验允许性高血糖对入住ICU的糖尿病患者可能更安全这一假设。
在LUCID试验结果出来之前，证据支持针对糖尿病患者采用更宽松的血糖控制水平（10 - 14毫摩尔/升；180 - 252毫克/分升），特别是那些入院前血糖控制不佳的患者。
