低血糖患者发生昏迷风险因素研究

Study on risk factors for coma in patients with hypoglycemia

目的研究低血糖值患者(≤3.9 mmol/L)发生昏迷概率及其风险因素。方法回顾性收集2020年1月至2022年12月,经急救医生检测血糖值≤3.9 mmol/L且年龄≥20岁的患者,收集患者基线资料、现场采集的临床数值和治疗结果。通过格拉斯哥昏迷评分(Glasgow coma scale,GCS)判定患者是否昏迷,GCS≤8分为昏迷组,GCS>8分为非昏迷组,其中对昏迷组患者现场复苏后资料进一步分析,探讨其影响患者苏醒的因素。按照年龄分为8组,将24 h分为7个时段,将血糖值分成6组计算各组昏迷发生率,构建多因素logistic回归模型分析低血糖患者发生昏迷的独立危险因素。结果共收集754例血糖≤3.9 mmol/L的患者,425例发生昏迷,329例未昏迷,昏迷概率为56.37%(95%CI:52.82%~59.91%)。昏迷组患者年龄较大(P<0.001),且糖尿病病史占比高于非昏迷组(82.12%vs.67.78%,P<0.001)。所有患者年龄(73.05±15.20)岁,其中61~90岁是低血糖及昏迷患者高发年龄段。时间分布上,0~6时、6~9时和14~18时是低血糖及昏迷高发时段。低血糖诱因主要为胰岛素注射后能量摄入减少(12.07%)、胰岛素使用不当(6.37%)和能量摄入减少(6.23%),71.09%的患者诱因不明。18.44%患者在低血糖发生前使用了胰岛素,其在昏迷组中比例高于非昏迷组(22.12%vs.13.68%,P=0.003)。所有患者初测血糖值为(2.13±0.85)mmol/L,昏迷组的血糖值低于非昏迷组(P<0.001),血糖值对应昏迷发生概率分别为:1.1~1.5 mmol/L(72.97%)、1.6~2.0 mmol/L(68.90%)、2.1~2.5 mmol/L(54.10%)、2.6~3.0 mmol/L(38.20%)、3.1~3.5 mmol/L(37.50%)和3.6~3.9 mmol/L(19.40%)。多因素回归分析显示,年龄(OR=1.021,95%CI:1.010~1.033,P<0.001)、发病前使用胰岛素(OR=1.948,95%CI:1.142~3.323,P=0.014)和血糖浓度(OR=0.426,95%CI:0.347~0.522,P<0.001)是低血糖患者发生昏迷的独立预测因素。调查发现,静脉推注50%葡萄糖溶液等措施后,425例昏迷患者中有215例苏醒(50.58%),苏醒时长为(18.43±9.09)min,苏醒组患者年龄和初测血糖值均低于未苏醒组(均P<0.05),同时复测血糖值却高于未苏醒组(P=0.002)。结论低血糖患者昏迷概率高,胰岛素使用是常见诱因,应合理使用胰岛素以预防低血糖及昏迷的发生。

Objective To investigate the incidence and risk factors of coma in patients with hypoglycemia(≤3.9 mmol/L).Methods A retrospective study was conducted.Patients aged 20 years and older with blood glucose levels≤3.9 mmol/L,and measured by emergency physicians from January 2020 to December 2022 were collected.Baseline patient data,clinical values collected on-site,and treatment outcomes were analyzed.The Glasgow Coma Scale(GCS)was used to determine if patients were comatose,with GCS≤8 classified as the coma group and GCS>8 as the non-coma group.Further analysis was conducted on the resuscitated coma group to identify factors affecting patient recovery.Patients were divided into eight age groups,seven time periods within 24 h,and six blood glucose level groups to calculate the incidence of coma.A multivariate logistic regression model was constructed to analyze independent risk factors for coma in hypoglycemic patients.Results A total of 754 patients with blood glucose levels≤3.9 mmol/L were collected,with 425 cases of coma and 329 non-coma cases,resulting in a coma probability of 56.37%(95%CI:52.82%-59.91%).Patients in the coma group were older(P<0.001)and had a higher prevalence of diabetes compared to the non-coma group(82.12%vs.67.78%,P<0.001).The age of all patients was(73.05±15.20)years,with the 61-90 years age groups being the most prone to hypoglycemia and coma.In terms of time distribution,the high-incidence periods for hypoglycemia and coma were 0-6 o’clock,6-9 o’clock,and 14-18 o’clock.The primary causes of hypoglycemia included reduced energy intake after insulin injection(12.07%),improper use of insulin(6.37%),and reduced energy intake(6.23%),with 71.09%of cases having unknown causes.Additionally,18.44%of patients used insulin before the onset of hypoglycemia,with a higher proportion in the coma group compared to the non-coma group(22.12%vs.13.68%,P=0.003).The initial blood glucose level of all patients was(2.13±0.85)mmol/L,with lower levels observed in the coma group compared to the non-coma group(P<0.001).The probabilities of coma occurrence corresponding to blood glucose levels were:1.1-1.5 mmol/L(72.97%),1.6-2.0 mmol/L(68.90%),2.1-2.5 mmol/L(54.10%),2.6-3.0 mmol/L(38.20%),3.1-3.5 mmol/L(37.50%),and 3.6-3.9 mmol/L(19.40%).Multivariate logistic regression analysis indicated that age(OR=1.021,95%CI:1.010-1.033,P<0.001),insulin use before onset(OR=1.948,95%CI:1.142-3.323,P=0.014),and blood glucose concentration(OR=0.426,95%CI:0.347-0.522,P<0.001)were independent predictors of coma in hypoglycemic patients.The investigation revealed that after intravenous injection of 50%glucose solution,215 of 425 coma patients regained consciousness(50.58%),and the recovery time was(18.43±9.09)min.Patients in the recovery group were younger and had lower initial blood glucose levels compared to the non-recovery group(both P<0.05),while recovery group re-measured blood glucose levels were higher than those in the non-recovery group(P=0.002).Conclusions The probability of coma in hypoglycemic patients was high,with insulin use being a common trigger.Proper use of insulin is essential to prevent hypoglycemia and coma.