Intensive insulin therapy in the medical ICU
Intensive insulin therapy in the medical ICU
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DOI：
10.1056/nejmoa052521
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发表时间：
2006-02-02
影响因子：
158.5
通讯作者：
Bouillon, R
中科院分区：
文献类型：
--
作者：
Van den Berghe, G;Wilmer, A;Bouillon, R
背景：强化胰岛素治疗可降低外科重症监护室（ICU）患者的发病率和死亡率，但其在内科ICU患者中的作用尚不清楚。入院时，患者被随机分配到严格的血糖水平正常化组（80至110 mg/dl [4.4至6.1 mmol/L]），使用胰岛素输注或常规治疗（当血糖水平超过215 mg/dl [12 mmol/L]时施用胰岛素，当水平下降到180毫克/分升[10毫摩尔/升]以下时逐渐减少输注）。结果：在对1200例患者的意向治疗分析中，强化胰岛素治疗降低了血糖水平，但没有显著降低住院死亡率（常规治疗组为40.0%，强化治疗组为37.3%，P=0.33）。然而，通过预防新获得的肾损伤、加速脱离机械通气以及加速从ICU和医院出院，发病率显著降低。虽然入院时无法预测在ICU的住院时间，但在433例在ICU住院少于3天的患者中，接受强化胰岛素治疗的患者死亡率较高。相比之下，在767例患者在ICU停留了三天或更长时间，在386谁接受强化胰岛素治疗的住院死亡率从52.5%降低到43.0%（P=0.009）和发病率也reduced.CONCLUSIONS：强化胰岛素治疗显着降低发病率，但不是所有患者在内科ICU死亡率。虽然治疗3天或3天以上的患者随后死亡和疾病的风险降低，但这些患者在治疗前无法识别。需要进一步的研究来证实这些初步数据。
BACKGROUND:Intensive insulin therapy reduces morbidity and mortality in patients in surgical intensive care units (ICUs), but its role in patients in medical ICUs is unknown.METHODS:In a prospective, randomized, controlled study of adult patients admitted to our medical ICU, we studied patients who were considered to need intensive care for at least three days. On admission, patients were randomly assigned to strict normalization of blood glucose levels (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) with the use of insulin infusion or to conventional therapy (insulin administered when the blood glucose level exceeded 215 mg per deciliter [12 mmol per liter], with the infusion tapered when the level fell below 180 mg per deciliter [10 mmol per liter]). There was a history of diabetes in 16.9 percent of the patients.RESULTS:In the intention-to-treat analysis of 1200 patients, intensive insulin therapy reduced blood glucose levels but did not significantly reduce in-hospital mortality (40.0 percent in the conventional-treatment group vs. 37.3 percent in the intensive-treatment group, P=0.33). However, morbidity was significantly reduced by the prevention of newly acquired kidney injury, accelerated weaning from mechanical ventilation, and accelerated discharge from the ICU and the hospital. Although length of stay in the ICU could not be predicted on admission, among 433 patients who stayed in the ICU for less than three days, mortality was greater among those receiving intensive insulin therapy. In contrast, among 767 patients who stayed in the ICU for three or more days, in-hospital mortality in the 386 who received intensive insulin therapy was reduced from 52.5 to 43.0 percent (P=0.009) and morbidity was also reduced.CONCLUSIONS:Intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy. Further studies are needed to confirm these preliminary data.