危重患者的血糖监测与管理

Monitoring and management of blood glucose of patients with critical illness

目的了解河北省重症患者血糖监测及管理情况,寻找实践与循证医学证据间的差距,制定有效的方案和改进措施,以更好地指导危重患者血糖管理,改善预后。方法收集河北省25所三级甲等医院的重症医学科(intensive care unit,ICU)自2015年5月15日~7月15日收治的重症患者。采用问卷调查方式,对每例入选患者填写《河北省重症患者急性胃肠损伤评估与营养支持现状调查—病例报告表》,填写血糖监测表中的"每日血糖最高值及最低值,血糖波动幅度等指标,根据患者28 d生存或死亡分为生存组和死亡组,应用t检验、COX生存分析,应用受试者工作特征(receiver operating characteristic,ROC)曲线进行数据统计。结果 11例(3.4%)的重症患者未行血糖监测。其余患者血糖的平均水平为(6.6±1.1)mmol/L。研究期间,有3 500人次(27%)的血糖值超过10 mmol/L,有152人次(1.2%)的血糖值<3.5 mmol/L,血糖波动的平均值为(9.2±3.2)mmol/L。除年龄外,28 d死亡组与生存组中,APACHEⅡ评分、SOFA评分、血糖最高值、血糖最低值及血糖波动值均有统计学差异,血糖波动值这一指标对于预测28 d病死率较好(曲线下面积最大0.874)。较高的APACHEⅡ评分可能对28 d病死率危害最大(RR 1.222)。结论重症医师应提高对危重患者血糖监测的重视程度,应用胰岛素控制血糖,维持血糖稳定,避免大幅度波动。血糖波动值能够较好的预测重症患者28 d病死率。

Objective To investigate the monitoring and management circumstance of blood glucose of patients with critical illness in Hebei province in order to better guide blood sugar management in patients with critical illness and improve the prognosis of patients by looking for the gap between practice and evidence-based medicine to set up effective scheme and improvement measures. Methods The patients with critical illness in ICU of 25 tertiary hospital in Hebei province from May15,2015 to July 15,2015 were enrolled in the investigation. A database of information was built by the Epidata,which were collected from questionnaires named ＂ The survey of acute gastrointestinal injury assessment and nutritional support current situation to critically ill patients in Hebei province-case report＂. The patients were divided into survival group and death group.T test,COX survival analysis and ROC curve analysis were used to analyze the data statistically by means of software SPSS24. 0. Results Among the patients,11 patients（ 3. 4%） did not receive blood glucose monitoring. The average levels of blood glucose were（ 6. 6 ± 1. 1） mmol/L. During the investigation,the blood glucose levels of 3500 patients（ 27%） were more than10 mmol/L,which in 152 patients（ 1. 2%） were below 3. 5 mmol/L,with the average fluctuation range of blood glucose being（ 9. 2 ± 3. 2） mmol/L. Except for patient＇s age,there were significant differences in APACHEⅡscore,SOFA score,maximum value of blood glucose,minimum value of blood glucose and fluctuating value of blood glucose between 28-day death group and survival group. The fluctuation range of blood glucose could better predict 28-day mortality（ AUC = 0. 874）. Moreover there was a close correlation between higher APACHE Ⅱ scores and 28-day mortality in patients with critical illness（ RR 1. 222）.Conclusion Clinicians should pay much attention to blood glucose monitoring in patients with critical illness,use insulin to control blood sugar,keep blood glucose stable and avoid sharp fluctuation of blood glucose levels,moreover,blood glucose fluctuation can predict 28-day mortality better.