Division of Pulmonary and Critical Care, Intermountain Medical Center, Murray, UT; Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT.
Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia Vagelos University College of Physicians and Surgeons, New York, NY.
Chest. 2019 Nov;156(5):878-886. doi: 10.1016/j.chest.2019.05.016. Epub 2019 Jun 12.
In addition to hyperglycemia, hypoglycemia, and glycemic variability, reduced time in targeted blood glucose range (TIR) is associated with increased risk of death in critically ill patients. This relation between TIR and mortality may be confounded by diabetic status and antecedent glycemic control.
This study retrospectively analyzed critically ill patients managed with the same IV insulin protocol at multiple centers. The percentage of TIR between 70 and 139 mg/dL was calculated. Patients with diabetic ketoacidosis, patients who had < 10 blood glucose readings, and patients with repeat admissions were excluded. The highest recorded glycosylated hemoglobin value in the preceding 3 months or up to 1 month following admission were used as a surrogate for the patient's preexisting glucose control. Stratified regression analyses were performed for 30-day mortality, with covariates of age, sex, TIR ≥ 80%, Acute Physiology Score, and Charlson Comorbidity Index.
A total of 9,028 patients, 53.2% of whom had diabetes, were studied. Median TIR was 84.1% for nondiabetic patients and 64.5% for patients with diabetes. Mortality was lower in those with TIR > 80% compared with those with TIR ≤ 80% (12.4% vs 19.2%; P < .001). TIR > 80% was independently associated with reduced mortality in nondiabetic patients (OR, 0.52; P < .001), patients with diabetes (OR, 0.69; P = .001), and patients with well-controlled disease (OR, 0.50; P < .001) but not in patients with poorly controlled disease (OR, 0.86; P = .40).
TIR was independently associated with mortality in critically ill patients, particularly those with good antecedent glucose control.
除高血糖、低血糖和血糖变异性外，目标血糖范围内时间（TIR）减少与危重症患者死亡风险增加相关。TIR 与死亡率之间的这种关系可能受到糖尿病状态和既往血糖控制的影响。
本研究回顾性分析了在多个中心接受相同静脉胰岛素方案治疗的危重症患者。计算了 70 至 139mg/dL 之间 TIR 的百分比。排除糖尿病酮症酸中毒患者、血糖读数<10 次的患者和再次入院的患者。既往 3 个月内或入院后 1 个月内记录的最高糖化血红蛋白值用作患者既往血糖控制的替代指标。进行了 30 天死亡率的分层回归分析，协变量为年龄、性别、TIR≥80%、急性生理学评分和 Charlson 合并症指数。
共纳入 9028 例患者，其中 53.2%患有糖尿病。非糖尿病患者的 TIR 中位数为 84.1%，糖尿病患者的 TIR 中位数为 64.5%。与 TIR≤80%的患者相比，TIR>80%的患者死亡率更低（12.4%比 19.2%；P<0.001）。TIR>80%与非糖尿病患者（OR，0.52；P<0.001）、糖尿病患者（OR，0.69；P=0.001）和疾病控制良好的患者（OR，0.50；P<0.001）死亡率降低独立相关，但与疾病控制不佳的患者（OR，0.86；P=0.40）无关。
TIR 与危重症患者的死亡率独立相关，特别是那些既往血糖控制良好的患者。
