外科重症病患使用全靜脈營養發生高血糖之相關性研究

Research on Hyperglycemia after Total Parenteral Nutrition in Critically Ill Surgical Patients

鄭玉琳(Yu-Lin Cheng)

指導教授 ： 顏銘宏

高雄醫學大學/藥學院/藥學研究所碩士在職專班/碩士(2014年)

https://doi.org/10.6832/KMU.2014.00028

摘要

背景：全靜脈營養（total parenteral nutrition, TPN）已被證實可改善住院期間發生營養不良病人的營養狀態，有研究指出高血糖是接受TPN的病人最常發生的併發症，而近來許多的隨機實驗與統合分析皆指出重症病人若產生高血糖（hyperglycemia）會增加病人的死亡率與產生共病症的發生率。而非糖尿病的重症病人使用TPN也可能產生高血糖。我們的研究目的是要探討TPN的葡萄糖輸注速率量、使用天數與病人基礎的血糖值應與TPN發生高血糖併發症有關連性，及是否影響病人的臨床結果。
目的：以病歷回溯性研究設計，探討非糖尿病的重症病患接受TPN與高血糖的相關性研究。
方法：本次研究為回溯性的病歷研究，主要以電子病歷回溯性收集2010/06~2012/06於南部某區域教學醫院使用TPN的外科重症病房（sugary intensive care unit, SICU）非糖尿病病人資料，以住入SICU後第一次血糖值，將使用TPN的病人分成2組，分別為高血糖組與正常血糖組，觀察使用TPN期間不同血糖變化與給予TPN的葡萄糖量、天數與其對臨床結果如：住重症病房（intensive care unit, ICU）天數、病人死亡率……等之關係，是否具統計學上的差異性。
研究結果：以病歷回溯性研究納入符合條件者共156位。再依據入ICU後第一天且未使用TPN測的血糖值140mg/dL為基準分為2組，正常血糖組（normoglycemia group）為血糖值小於140mg/dL共63人；血糖值大於等於140mg/dL的稱為高血糖組（hyperglycemia group）共93人。期間根據院內SICU的血糖控制建議指引控制血糖，發現兩組使用TPN期間hyperglycemia組與normoglycemia組於ICU期間兩組的平均血糖值分別為174.25±40.98 mg/dL與152.59±35.18 mg/dL（P < 0.001）；此結果顯示非糖尿病病人術後若發生高血糖，再併用TPN溶液，則之後發生高血糖的機會將較術後血糖為正常組來的高。於兩組的死亡率分析結果hyperglycemia組佔59.26%，另外normoglycemia組佔40.74%（P = 1.00），兩組並無統計學上顯著差異。將各項變數與平均血糖值的相關性分析結果為：病人的基準血糖值每增加1 mg/dL，其使用TPN期間的平均血糖將增加0.27 mg/dL（P < 0.001）；病人每增加TPN使用天數 1天，其平均血糖將增加0.60 mg/dL（P = 0.041）。具統計學上顯著之差異。
結論：本研究發現增加TPN使用天數與病人的基準血糖值的高低，對於非糖尿病的重症病患來說，皆會增加病人發生高血糖的危險因子。因此使用TPN期間就算是非糖尿病病人，其血糖控制也是很重要的臨床照護重點觀察指標。

關鍵字

靜脈營養 ； 全靜脈營養 ； 外科加護病房 ； 重症病患 ； 高血糖

並列摘要

Background: The beneficial effects of total parenteral nutrition（TPN）in improving the nutrition status of malnourished patients during hospital stays have been well established. Hyperglycemia is a common complication in patients receiving TPN. Recently, many randomized trials and meta-analyses have reported the increased mortality and morbidity rates in patients suffering hyperglycemia. TPN might cause hyperglycemia in patients with no diabetes mellitus past-history. Therefore, we aimed to examine the risk factors associated with hyperglycemia and how they can affect the clinical outcomes in critically ill patients with no history of diabetes mellitus.
Objective: This retrospective study was conducted to determine whether the amount of dextrose from TPN was related to the development of hyperglycemia and the clinical outcome in no diabetes mellitus history patients.

Method: We retrospectively collected the data of the patients receiving TPN in surgical intensive care unit (SICU) between June 2010 and June 2012. The following parameters were analyzed : the patients’ demographic characteristics, blood glucose level, TPN related information (the daily mean, maximum and minimum blood glucose level, related insulin infusion rate, TPN used days), days of ICU stay and mortality .
Results: We enrolled totally 156 patients and divided them into two groups according to their baseline blood glucose of ICU care < 140 mg/dL as the normoglycemia group (n = 63) vs ≧140 mg/dL as the hyperglycemia group (n = 93). During the SICU stayed period, the mean blood glucose levels of hyperglycemic group were significantly increased than normoglycemic group (174.25±40.98 mg/dL vs 152.59±35.18 mg/dL (P < 0.001). There was no significant difference of mortality rate between the two groups, however. Multiple linear regression analysis showed that the mean blood sugar level was related to age, APACH II score, baseline blood glucose, TPN used days and dextrose delivery rate. According to the related analysis, the baseline blood glucose levels increased 1 mg/dL, the averaged blood sugar levels would increase 0.27 mg/dL during the TPN used period (P < 0.001). Furthermore, the TPN administration was raised 1 day, the averaged blood sugar levels would increase 0.60 mg/dL (P = 0.041).
Conclusion: Our study showed that prolonged TPN used days and patients baseline blood sugar might be associated with the development of hyperglycemia risk factor in SICU patients without a history of diabetes mellitus. Our study helps identify the high risk group of hyperglycemia in SICU patients received TPN.

並列關鍵字

Parenteral nutrition ； Total parenteral nutrition ； Surgical intensive care unit ； Critically ill patients ； Hyperglycemia

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