Body is in stress, the body a variety of elevated blood sugar hormones such as adrenaline, glucocorticoid, glucagon, growth hormone significantly increased, leading to stress hyperglycemia, which is especially evident in diabetic patients. Critically ill surgical patients, regardless of history of diabetes, this time there is always insulin resistance and hyperglycemia. In recent years, the hospital is combined with intensive insulin therapy in critically ill patients in clinical trials of glucose control in these patients and treatment goals.
Blood sugar control standard of concern
2001, van den Berghe, Belgium, etc. of Leuven found that strict control of critically ill surgical ICU patients with glucose in the normal range (4.4 ~ 6.1mmol / L) can reduce mortality, the results were published, caused widespread concern. However, van den Berghe, a study such as the subsequent medical ICU outcome in critically ill patients have shown that intensive treatment group the main outcome indicators of hospital mortality (37.3%) and the conventional treatment group (40.0%) was not significantly decreased, but intensive treatment can reduce the incidence of complications, shorter mechanical ventilation time and hospital stay.
Diabetes treatment guidelines in many countries are included in the results of the study. 2009 American Diabetes Association (ADA) guidelines for blood glucose control in critically ill patients required as close as possible 6.1mmol / L. 2007 version of the Chinese type 2 diabetes prevention and treatment guidelines have also pointed out that the need for intensive care after surgery or mechanical ventilation in patients with high blood glucose (> 6.1mmol / L), by continuous infusion of insulin and blood glucose control as much as possible in the 4.5 ~ 6.0mmol / L range can improve the prognosis; but also that the more conservative target blood glucose (6.0 ~ 10.0mmol / L) in some cases more appropriate.
Strict control of blood sugar risk
Similar studies (such as GLUCONTROL, etc.) were found in critically ill patients Intensive Glucose did not benefit, VISEP studies or even because of strengthening the control of blood glucose group, the incidence of low blood sugar is too high and forced an early halt. 2008, published in "JAMA" A meta-analysis has drawn a different conclusion, namely, for critically ill patients, and strengthen control of blood sugar has nothing to do with hospital mortality, and increase the risk of hypoglycaemia, but can reduce sepsis the risk.
March 2009 "New England Journal of Medicine" published in the NICE-SUGAR trial results, the findings Leuven questioned. The pilot selected the 6104 total of comprehensive surgical critical patients were randomly divided into the intensive blood glucose group (n = 3054) and conventional blood glucose group (n = 3050). Intensive Glucose blood glucose control in the 4.5 ~ 6.0mmol / L, conventional blood glucose blood glucose control in ≤ 10.0mmol / L. 90 days showed enhanced mortality was higher than the conventional hypoglycemic hypoglycemic group (P = 0.02), and the incidence of severe hypoglycemia (6.8%) compared with conventional blood glucose group (0.5%) was significantly higher (P <0.001 ). The results of the ICU glucose control in critically ill patients have a significant impact strategy would negate the strict control of blood glucose in critically ill patients in clinical strategy.
Critically ill patients with different blood glucose goals and prognosis, further study reveals. In short, the goal blood glucose control in critically ill patients is inconclusive, but should prevent the two extremes, that is, uncontrolled high blood sugar, or too stringent control of blood sugar.
Consensus of foreign blood glucose control
NICE-SUGAR study findings, experts on the glycemic control in critically ill patients is extremely concerned about the consistent view is that blood glucose control can not be too strict. American Medical Association and the American Diabetes Endocrine Society (AACE / ADA) jointly issued a consensus of inpatient glycemic control, indicating that their current views of handling these patients. Points are as follows:
Glycemic control in critically ill patients with blood glucose in critically ill patients 1.ICU continued> 10mmol / L, they should start insulin therapy. 2. If for insulin treatment for most patients blood glucose should be maintained at 7.8 ~ 10.0mmol / L. 3. Insulin infusion to control blood glucose in critically ill patients and to maintain the ideal treatment. 4. Recommend effective and safe use of insulin infusion program to reduce the incidence of low blood sugar. 5. Must closely monitor blood glucose, blood sugar control in order to achieve the best results and to avoid hypoglycemia.
Non-hospital glycemic control in critically ill patients hospitalized at present no information on blood glucose control in patients with non-critical prospective, randomized controlled trials reported. Recommendations are as follows: 1. Recommended for non-critical patients insulin treatment, in compliance under the premise of safe fasting blood glucose should be as much as possible <7.8mmol / L, and random blood glucose <10.0mmol / L. 2. Of the hospital before the strict blood sugar control and blood sugar stable patients, strict glycemic control is appropriate. 3. On dying patients, or those who suffer from a variety of serious diseases, control of blood sugar should not be too strict. 4. Recommended subcutaneous injection of insulin, combined with blood sugar level, eating and other factors, to achieve and maintain blood glucose control targets. 5. Does not encourage use of adjustable amount of insulin infusion devices for the hospital's single insulin therapy. 6. On the need for treatment of high blood sugar most of the hospitalized patients were not suitable for non-insulin antidiabetic therapy.
Treatment of hyperglycemia in critically ill patients should be evaluated and adjusted every day to ensure the smoothness of blood glucose. Blood sugar can be used to predict the volatility of ICU mortality. High blood glucose variability is ICU strong predictor of death in patients with elevated blood sugar mean the combination of forecasting more efficient. Even if the blood glucose concentration is higher, lower blood glucose variability also has a protective effect.