The Interaction of Acute and Chronic Glycemia on the Relationship of Hyperglycemia, Hypoglycemia, and Glucose Variability to Mortality in the Critically Ill*
The Interaction of Acute and Chronic Glycemia on the Relationship of Hyperglycemia, Hypoglycemia, and Glucose Variability to Mortality in the Critically Ill*
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DOI：
10.1097/ccm.0000000000004599
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发表时间：
2020-12-01
影响因子：
8.8
通讯作者：
Preiser, Jean-Charles
中科院分区：
文献类型：
--
作者：
Krinsley, James S.;Rule, Peter;Preiser, Jean-Charles
目的：确定危重患者入院前糖化血红蛋白（HbA 1c）水平、血糖指标与死亡率之间的关系。设计：回顾性队列研究。设置：大学附属成人内科-外科ICU。患者：研究包括2011年10月11日至2019年11月30日期间入院的5，567例有4次或4次以上血糖检测和HbA 1c水平的危重患者。2014年9月14日之前入院的患者的目标血糖水平为90-120 mg/dL（n = 1，614）和80-140 mg/dL或110-160 mg/dL（对于血红蛋白A1 c小于7%或大于或等于7%的患者）（n = 3，953）。干预：无。测量和主要结果：患者按血红蛋白A1 c：小于6.5分层。（n = 4，406）、6.5-7.9%（n = 711）和≥ 8.0%（n = 450）。血红蛋白A1 c水平的增加与平均血糖、葡萄糖变异性（通过变异系数测量）和低血糖的显著增加相关（p分别为趋势< 0.0001、< 0.0001和0.0010）。在血红蛋白A1 c低于6.5%的患者中，死亡率随着平均死亡率的增加而增加;然而，在血红蛋白A1 c大于或等于8.0%的患者中，观察到相反的关系（趋势p分别< 0.0001和0.0027）。仅在血红蛋白A1 c低于6.5%的患者中，血糖变异性增加与死亡率增加独立相关。在血红蛋白A1 c低于6.5%和6.5-7.9%的患者中，低血糖与较高的死亡率独立相关，但在血红蛋白A1 c大于或等于8.0%的患者中则无关。平均血糖140-180和大于或等于180 mg/dL与血红蛋白A1 c低于6.5%的患者的较高死亡率独立相关（各P < 0.0001）。血红蛋白A1 c大于或等于8.0%的患者在第二个时代接受治疗，平均血糖大于或等于180 mg/dL是独立相关的死亡率降低的风险（p = 0.0358）。结论：入院前血红蛋白A1 c，反映在ICU入院时，有一个显着的影响ICU的关系，死亡率。对增加平均血糖的不同反应支持ICU中血糖控制实践的个性化方法。
Objectives:To determine the relationship between preadmission glycemia, reflected by hemoglobin A1c level, glucose metrics, and mortality in critically ill patients.Design:Retrospective cohort investigation.Setting:University affiliated adult medical-surgical ICU.Patients:The investigation included 5,567 critically ill patients with four or more blood glucose tests and hemoglobin A1c level admitted between October 11, 2011 and November 30, 2019. The target blood glucose level was 90-120 mg/dL for patients admitted before September 14, 2014 (n = 1,614) and 80-140 mg/dL or 110-160 mg/dL for patients with hemoglobin A1c less than 7% or greater than or equal to 7% (n = 3,953), respectively, subsequently.Interventions:None.Measurements and Main Results:Patients were stratified by hemoglobin A1c: less than 6.5.(n = 4,406), 6.5-7.9% (n = 711), and greater than or equal to 8.0% (n = 450). Increasing hemoglobin A1c levels were associated with significant increases in mean glycemia, glucose variability, as measured by coefficient of variation, and hypoglycemia (p for trend < 0.0001, < 0.0001, and 0.0010, respectively). Among patients with hemoglobin A1c less than 6.5%, mortality increased as mean glycemia increased; however, among patients with hemoglobin A1c greater than or equal to 8.0%, the opposite relationship was observed (p for trend < 0.0001 and 0.0027, respectively). Increasing glucose variability was independently associated with increasing mortality only among patients with hemoglobin A1c less than 6.5%. Hypoglycemia was independently associated with higher mortality among patients with hemoglobin A1c less than 6.5% and 6.5-7.9% but not among those with hemoglobin A1c greater than or equal to 8.0%. Mean blood glucose 140-180 and greater than or equal to 180 mg/dL were independently associated with higher mortality among patients with hemoglobin A1c less than 6.5% (p < 0.0001 for each). Among patients with hemoglobin A1c greater than or equal to 8.0% treated in the second era, mean blood glucose greater than or equal to 180 mg/dL was independently associated with decreased risk of mortality (p = 0.0358).Conclusions:Preadmission glycemia, reflected by hemoglobin A1c obtained at the onset of ICU admission, has a significant effect on the relationship of ICU glycemia to mortality. The different responses to increasing mean glycemia support a personalized approach to glucose control practices in the ICU.