血糖变异度与重症患者预后不良的相关性

Association between glucose variability and poor prognosis in critically ill patients

目的 探索血糖变异系数与重症患者死亡的关系.方法 2011年8月至2012年4月首都医科大学附属复兴医院重症医学科预计住重症监护病房（ICU）时间不少于24 h的患者145例,计算平均血糖水平（MGL）、标准差（SD）及血糖变异系数（CV）.同时搜集是否确诊糖尿病、低血糖事件、激素及胰岛素用量、机械通气及肾脏替代治疗及ICU住院天数.根据28 d是否存活分为病死组及存活组,比较两组间CV值的差异及其与病死率的相关性.结果 入选145例患者中存活组85例,病死率41.4％.研究期间共获取血糖标本4 581份（31.6份/例）.存活组与病死组性别、伴随糖尿病、胰岛素及激素治疗差异无统计学意义.病死组年龄、非手术比例、APACHEⅡ评分及住ICU期间最大SOFA评分较存活组高（P＜0.05）.两组7d内累积激素用量、日均胰岛素用量、机械通气比例及MGL无差异,死亡组7d内发生低血糖的人数、CV值及肾脏替代治疗比例较存活组高、28 d内非机械通气及非ICU住院时间短.相关性分析显示,CV值与28 d病死率相关,ORl.260（95％ CI0.953～1.665,P=0.024）,非糖尿病组此相关性更为明显.结论 血糖变异度对重症患者的不良预后有良好的预测价值,非糖尿病患者尤甚,重症患者的血糖波动对病情恶化有提示作用,低血糖事件需高度重视,增加监测频率可更早发现血糖大幅度变化,利于早期敏感地判断病情变化并调整治疗.

Objective To explore the association between glucose variability and poor prognosis in critically ill patients.Methods This prospective study was undertaken in a 24-bed intensive care unit （ICU）.A total of 145 patients staying for over 24 hours in ICU were enrolled.Their arterial levels of blood glucose were measured four times daily routinely.And the mean glucose level （MGL）,standard deviation （SD） and coefficient of variation （CV） were calculated.The incidence of moderate hypoglycemia （MH）,severe hypoglycemia （SH）,total dosage of hormone,average daily dosage of insulin,duration of renal replacement-therapy （RRT）,mechanical ventilation and ICU free days were also recorded.They were divided into survival （n =85） and nonsurvival （n =60） groups according to survival or not at 28 days.And CV was compared between two groups and the relationship of CV and mortality examined.Results The nonsurvival group had higher CV value accompanied by higher RRT proportion,higher incidences of MH and SH,shorter free mechanical ventilation time and free ICU stay.The higher CV value was found in surviving nondiabetics.However,no significant difference existed in diabetes group.Conclusion Critically ill patients have higher CV of glucose variability especially in non-diabetic patients.Blood glucose fluctuations denote a worse prognosis.And hypoglycemia should raise a high alert.Frequent blood glucose monitoring is beneficial to detecting the changes of condition and adjusting treatment regimens accordingly.