Continuous glucose monitoring in the neonatal intensive care unit: not quite ready for 'plug and play'.
Continuous glucose monitoring in the neonatal intensive care unit: not quite ready for 'plug and play'.
复制标题
新生儿重症监护病房的连续血糖监测：尚未做好“即插即用”的准备。
DOI：
10.1136/archdischild-2018-315899
复制
发表时间：
2019
期刊：
影响因子：
--
通讯作者：
Rozance,PaulJoseph
中科院分区：
文献类型：
--
作者：
Hernandez,TeriL;HayJr,WilliamW;Rozance,PaulJoseph
在极低出生体重（VLBW）婴儿人群中，高血糖浓度与死亡率增加、脑损伤、早产儿视网膜病变和神经发育结局恶化相关。然而，通过持续胰岛素输注或联合胰岛素和/或降低葡萄糖输注速率预防或治疗该人群高血糖症的试验因更频繁的低葡萄糖浓度发作而变得复杂。虽然这些事件的长期意义尚不清楚，但大多数人认为在胰岛素治疗高血糖期间应避免这些事件。新出现的数据进一步将增加的血液变异性与受损的长期结局联系起来。在极早产、极低出生体重婴儿中使用连续（组织间）血糖监测（CGM）有可能最大限度地降低低血糖和高血糖的发生率和严重程度，并增加关键发育期的血糖稳定性，通过预防这些常见但可能有害的代谢紊乱，为改善这些儿童的长期神经认知结局提供新的机会。Thomson等1报告了一项单中心研究的结果，其中评估了CGM用于极早产儿的可行性。研究分为两个阶段。在第一阶段，通过比较20名婴儿的实时（RT）CGM（Paradigm Veo，Medtronic MiniMed）与床旁（POC）血糖浓度（Statstrip，Nova Biomedical）来评估准确性。在第二阶段，进行了一项试点研究，其中20名婴儿被随机分配至非盲RT-CGM，并根据CGM值与标准新生儿护理的临床指南规定护理决策。在标准护理组中，使用设盲回顾性记录CGM（iPro 2，Medtronic MiniMed）测量婴儿间质葡萄糖浓度，同时使用标准护理医院方案管理葡萄糖。这些研究的目的是生成数据，为随机试验提供信息，以评估揭盲RT-CGM在这些婴儿护理中的影响。与作者之前的报告相比，使用单一的高精度POC葡萄糖测量方法进行所有校准提高了RT-CGM和间歇采样葡萄糖浓度之间的一致性。2此外，本研究的结果与其他研究3和4相似：CGM传感器耐受性良好，被护理婴儿的工作人员接受，并且当与基于RT-CGM数据的临床决策算法结合时，允许临床医生将这些早产儿的葡萄糖浓度保持在更窄的范围内。最后一个特征，结合CGM发现隐匿性低血糖发作的能力，是考虑在极低出生体重婴儿护理中使用CGM的重要原因。CGM最初开发用于成人和年龄较大的糖尿病儿童，作为个性化治疗的一种方式。通常，出于此目的，CGM设备不向患者提供真实的葡萄糖浓度。糖尿病患者使用间歇性POC葡萄糖手指针刺、饮食/生活方式改变和药物治疗的组合来管理血糖浓度，同时使用CGM记录血糖浓度。随后，根据纳入POC葡萄糖浓度的算法分析记录的CGM数据，以确定用于评估治疗反应的高血糖模式。在过去的20年里，这些生物传感器和算法经历了令人印象深刻的技术修订，导致了更高的...
In the very low birthweight (VLBW) infant population, high glucose concentrations have been associated with increased mortality, brain injury, retinopathy of prematurity and worse neurodevelopmental outcomes. However, trials to prevent or treat hyperglycaemia in this population with continuous insulin infusions or a combination of insulin and/or reductions in the glucose infusion rate have been complicated by more frequent episodes of low glucose concentrations. While the long-term significance of these episodes is unknown, most would agree that they should be avoided during treatment of hyperglycaemia with insulin. Emerging data further associate increased glycaemic variability with impaired longterm outcomes. Use of continuous (interstitial) glucose monitoring (CGM) in very preterm, VLBW infants has the potential to minimise the incidence and severity of hypoglycaemia and hyperglycaemia and increase glycaemic stability during critical developmental periods, providing new opportunities to improve long-term neurocognitive outcomes in these children by preventing these common but potentially harmful metabolic disorders. Thomson et al 1 report the results of a single-centre study in which feasibility of CGM for very preterm infants was assessed. The study was divided into two phases. In the first phase, accuracy was assessed by comparison of real-time (RT) CGM (Paradigm Veo, Medtronic MiniMed) to point-of-care (POC) blood glucose concentrations (Statstrip, Nova Biomedical) in 20 infants. In the second phase, a pilot study was conducted in which 20 infants were randomised to unblinded RT-CGM in conjunction with a clinical guideline dictating care decisions based on the CGM values versus standard neonatal care. In the standard care arm, infant interstitial glucose concentrations were measured with a blinded retrospective recording CGM (iPro2, Medtronic MiniMed) while glucose was managed using the standard of care hospital protocol. The goal of these studies was to generate data to inform a randomised trial evaluating the impact of unblinded RT-CGM in the care of these infants. Using a single highly accurate POC glucose measurement method for all calibrations improved the agreement between RT-CGM and intermittently sampled glucose concentration compared with the authors' previous report. 2 Moreover, the results from this study are similar to other studies 3 4: the CGM sensor was well tolerated, was acceptable to staff caring for the infants, and when combined with an algorithm informing clinical decisions based on RT-CGM data, allowed clinicians to keep glucose concentrations in these preterm infants within a more narrow range. This last feature, combined with the ability of CGM to uncover episodes of occult hypoglycaemia, is an important reason why the use of CGM in the care of the VLBW infant has been considered. CGM was initially developed for use in adults and older children with diabetes mellitus as a way to personalise treatment. Typically, for this purpose, CGM devices did not provide glucose concentrations in real time to the patient. People with diabetes managed blood glucose concentrations using a combination of intermittent POC glucose fingersticks, dietary/lifestyle modifications and medications while glucose concentrations were recorded with a CGM. Retrospectively, the recorded CGM data were analysed according to algorithms that incorporated the POC glucose concentrations to determine patterns of glycaemia that were used to assess responses to treatments. Over the past 20 years, these biosensors and algorithms have undergone impressive technological revisions that have resulted in higher …