急重症患者及敗血症患者之血糖控制－一個持續爭論的議題

Glycemic Control in Critically Ill and Septic Patients-A Subject of Continuing Debate

傅彬貴(Pin-Kuei Fu) ； 李博仁(Bor-Jen Lee)

《內科學誌》 22卷2期 (2011/04) Pp. 121-132

https://doi.org/10.6314/JIMT.2011.22(2).06

摘要

Stress-induced hyperglycemia, caused by excessive counter-regulatory hormones and cytokines induced insulin resistance, is a common phenomenon in critically ill patients. Hyperglycemia and insulin resistance are also associated with increased mortality. Accordingly, control of hyperglycemia in sepsis and critically ill patients is suggested to be a very effective therapeutic approach. However, randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia significantly. In 2001, with the publication of the Leuven study revealed tight sugar control (blood sugar controlled within range of 80-110 mg/dL) was associated with reduction in the mortality and morbidity of critically ill patients in surgical intensive care units, there has been substantial growing interest in glycemic control among these patients. Subsequent trials (2006 Leuven study, 2008 de la Rosa G study and 2008 Arabia study) have failed to confirm a mortality benefit with intensive insulin therapy among critically ill patients. The findings of 2009 Glucocontrol study and the NICE-SUGAR study investigators even highlight that tight glucose control in the critically ill patients might actually increase morality and the events of severe hypoglycemia significantly. For the study of patients with sepsis (2008 VISEP Study and the 2010 COIITSS Study) also found that ”sepsis patients underwent strict glycemic control does not reduce hospital mortality.” In this article, we gave an overview to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit. In addition, we summarized the current practical guideline of glucose control for physicians in treating these septic and critically ill patients. The conclusions of sugar control in critically ill patients are ”the survival benefits of intensive insulin control in critically ill patients remains controversial”; the optimal levels of blood sugar for sepsis and critically ill patients are within the ranges of 150-180 mg/dL”; ”strict control of blood glucose in 80-110 mg/dL increased the risk of severe hypoglycemia (＜40 mg/dL) significantly in septic and critically ill patients.”

關鍵字

壓力性高血糖 ； 急重症 ； 敗血症 ； 嚴格血糖控制

並列摘要

Stress-induced hyperglycemia, caused by excessive counter-regulatory hormones and cytokines induced insulin resistance, is a common phenomenon in critically ill patients. Hyperglycemia and insulin resistance are also associated with increased mortality. Accordingly, control of hyperglycemia in sepsis and critically ill patients is suggested to be a very effective therapeutic approach. However, randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia significantly. In 2001, with the publication of the Leuven study revealed tight sugar control (blood sugar controlled within range of 80-110 mg/dL) was associated with reduction in the mortality and morbidity of critically ill patients in surgical intensive care units, there has been substantial growing interest in glycemic control among these patients. Subsequent trials (2006 Leuven study, 2008 de la Rosa G study and 2008 Arabia study) have failed to confirm a mortality benefit with intensive insulin therapy among critically ill patients. The findings of 2009 Glucocontrol study and the NICE-SUGAR study investigators even highlight that tight glucose control in the critically ill patients might actually increase morality and the events of severe hypoglycemia significantly. For the study of patients with sepsis (2008 VISEP Study and the 2010 COIITSS Study) also found that ”sepsis patients underwent strict glycemic control does not reduce hospital mortality.” In this article, we gave an overview to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit. In addition, we summarized the current practical guideline of glucose control for physicians in treating these septic and critically ill patients. The conclusions of sugar control in critically ill patients are ”the survival benefits of intensive insulin control in critically ill patients remains controversial”; the optimal levels of blood sugar for sepsis and critically ill patients are within the ranges of 150-180 mg/dL”; ”strict control of blood glucose in 80-110 mg/dL increased the risk of severe hypoglycemia (＜40 mg/dL) significantly in septic and critically ill patients.”

並列關鍵字

Stress induced hyperglycemia ； Critically ill ； Sepsis ； Tight sugar control