Tight blood glucose control with insulin in the ICU - Facts and controversies
Tight blood glucose control with insulin in the ICU - Facts and controversies
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DOI：
10.1378/chest.06-3121
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发表时间：
2007-07-01
期刊：
影响因子：
9.6
通讯作者：
Van den Berghe, Greet
中科院分区：
文献类型：
--
作者：
Vanhorebeek, Ilse;Langouche, Lies;Van den Berghe, Greet
最近，应激性高血糖的概念出现。在危重病人是适应性的，有益的反应已受到挑战。两项大型随机研究表明，通过强化胰岛素治疗维持正常血糖可以有效预防这些患者的发病率并降低死亡率。从那时起，人们开始质疑这种疗法在一般人群和特定亚群中的有效性，以及这种疗法在短期低血糖发作和大剂量胰岛素治疗的潜在危害方面的安全性。这些问题将根据现有证据系统地加以解决。重症监护期间强化胰岛素治疗可有效降低危重疾病的死亡率和发病率。现有的随机研究表明，在意向治疗分析中，预期这种治疗可使住院死亡风险绝对降低3%至4%。为了确认这种生存益处并将其分配为统计显著性，未来的研究应该有足够的动力，因此样本量应该至少为5000。当患者接受强化胰岛素治疗至少3天时，死亡风险的绝对降低增加到约8%。迄今为止的数据表明，需要将血糖控制到严格的正常水平才能获得最大的临床效益。这种治疗会增加低血糖的风险，但目前尚不清楚这在重症监护环境中是否真的有害。
Recently, the concept that stress hyperglycemia. in critically ill patients is an adaptive, beneficial response has been challenged. Two large randomized studies demonstrated that maintenance of normoglycemia with intensive insulin therapy substantially prevents morbidity and reduces mortality in these patients. Since then, questions have been raised about the efficacy in general and in specific subgroups, and about the safety of this therapy with regard to potential harm of brief hypoglycemic episodes and of high-dose insulin administration. These issues are systematically addressed in relation to the available evidence. Intensive insulin therapy during intensive care is effective in reducing the mortality and morbidity of critical illness. The available randomized studies show that an absolute reduction in risk of hospital death of 3 to 4 % is to be expected from this therapy in an intention-to-treat analysis. In order to confirm this survival benefit and assign it as statistically significant, future studies should be adequately powered, and hence sample size should be at least 5,000. The absolute reduction in the risk of death increases to approximately 8 % when patients are treated with intensive insulin for at least 3 days. Data available thus far indicate that blood glucose control to strict normoglycemia is required to obtain the most clinical benefit. The risk of hypoglycemia increases with this therapy, but it remains unclear whether this is truly harmful in the setting of critical care.