\ Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study
\ Liberal Glucose Control in ICU Patients With Diabetes: A Before-and-After Study
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DOI：
10.1097/ccm.0000000000003087
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发表时间：
2018-06-01
影响因子：
8.8
通讯作者：
Martensson, Johan
中科院分区：
文献类型：
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作者：
Luethi, Nora;Cioccari, Luca;Martensson, Johan
目的：评估ICU糖尿病患者自由血糖控制与常规血糖控制的可行性、生化疗效和安全性。设计：前瞻性、开放标签、序贯期研究。设置：澳大利亚一家三级医院的22床混合ICU。患者：我们比较了350例连续入院超过15个月的糖尿病患者，他们接受了自由血糖控制，干预前对照人群为350例。干预措施：如果血糖大于14 mmol/L（目标：10 - 14 mmol/L [180 - 252 mg/dL]），则自由对照患者接受胰岛素治疗。常规对照组患者接受胰岛素治疗，如果血糖大于10 mmol/L（目标：6 - 10 mmol/L [108 - 180 mg/dL]）。测量和主要结果：我们评估了血糖分离，胰岛素需求，低血糖发生率（血糖3.9 mmol/L [70 mg/dL]），肌酐和白色细胞计数水平，以及临床结果。自由对照组的中位（四分位距）时间加权平均血糖浓度（11.0 mmol/L [8.7 - 12.0 mmol/L]; 198 mg/dL [157 - 216 mg/dL]）显著高于常规对照组（9.6 mmol/L [8.5 - 11.0 mmol/L]; 173 mg/dL [153 - 198 mg/dL]; p <0.001）。总体而言，132名自由对照患者（37.7%）和188名传统对照患者（53.7%）在ICU接受胰岛素治疗（p <0.001）。低血糖发生率分别为6.6%和8.6%（p = 0.32）。在糖化血红蛋白A1c ≥ 7%的314例患者中，低血糖发生率分别为4.1%和9.6%（p = 0.053）。各组肌酐和白色细胞计数的变化趋势相似。在多变量分析中，我们发现血糖控制与死亡率、机械通气持续时间或到第30天的无ICU天数之间没有独立的相关性。在ICU糖尿病患者中，在自由血糖控制、胰岛素给药期间，以及血红蛋白A1c大于或等于7%的患者中，低血糖的患病率降低，而不会对血清肌酐产生负面影响，白色细胞计数反应或其他临床结果。（试验注册：澳大利亚新西兰临床试验注册处; ACTRN12615000216516）。
Objectives: To assess the feasibility, biochemical efficacy, and safety of liberal versus conventional glucose control in ICU patients with diabetes.Design: Prospective, open-label, sequential period study.Setting: A 22-bed mixed ICU of a tertiary hospital in Australia.Patients: We compared 350 consecutive patients with diabetes admitted over 15 months who received liberal glucose control with a preintervention control population of 350 consecutive patients with diabetes who received conventional glucose control.Interventions: Liberal control patients received insulin therapy if glucose was greater than 14 mmol/L (target: 10-14 mmol/L [180-252mg/dL]). Conventional control patients received insulin therapy if glucose was greater than 10 mmol/L (target: 6-10 mmol/L [108-180mg/dL]).Measurements and Main Results: We assessed separation in blood glucose, insulin requirements, occurrence of hypoglycemia (blood glucose 3.9 mmol/L [70mg/dL]), creatinine and white cell count levels, and clinical outcomes. The median (interquartile range) time-weighted average blood glucose concentration was significantly higher in the liberal control group (11.0 mmol/L [8.7-12.0 mmol/L]; 198mg/dL [157-216mg/dL]) than in the conventional control group (9.6 mmol/L [8.5-11.0 mmol/L]; 173mg/dL [153-198mg/dL]; p < 0.001). Overall, 132 liberal control patients (37.7%) and 188 conventional control patients (53.7%) received insulin in ICU (p < 0.001). Hypoglycemia occurred in 6.6% and 8.6%, respectively (p = 0.32). Among 314 patients with glycated hemoglobin A1c greater than or equal to 7%, hypoglycemia occurred in 4.1% and 9.6%, respectively (p = 0.053). Trajectories of creatinine and white cell count were similar in the groups. In multivariable analyses, we found no independent association between glucose control and mortality, duration of mechanical ventilation, or ICU-free days to day 30.Conclusions: In ICU patients with diabetes, during a period of liberal glucose control, insulin administration, and among patients with hemoglobin A1c greater than or equal to 7%, the prevalence of hypoglycemia was reduced, without negatively affecting serum creatinine, the white cell count response, or other clinical outcomes. (Trial Registration: Australian New Zealand Clinical Trials Registry; ACTRN12615000216516).