【文章內(nèi)容簡介】 usion of insulin in saline. 靜脈注射胰島素控制血糖 In the group of patients assigned to undergo conventional glucose control, insulin was administered if the blood glucose level exceeded 180 mg per deciliter (10.0 mmol per liter)。 insulin administration was reduced and then discontinued if the blood glucose level dropped below 144 mg per deciliter (8.0 mmol per liter). 在傳統(tǒng)治療(zh236。li225。o)組如果血糖水平超過10.0mmol/L。應(yīng)用胰島素。如果血糖水平低于8.0mmol/L胰島素用量減少，然后停止,第二十四頁，共六十二頁。,NICE SUGAR研究(y225。njiū) ：結(jié)論,經(jīng)過總計(jì)6030例患者的校驗(yàn)，強(qiáng)化血糖控制在81108 mg/dl者的所有主要或次要考察指標(biāo)都顯著差于常規(guī)治療組（血糖述評(píng)180 mg/dl） 強(qiáng)化血糖控制組90天病死率明顯升高 (27.5% vs. 24.9%, p = 0.02， 根據(jù)危險(xiǎn)因素進(jìn)行校正后病死率仍有顯著差異 ； 強(qiáng)化血糖控制組存活時(shí)間縮短 (HR 1.11, 95%CI 1.01 – 1.23, p = 0.04，強(qiáng)化血糖控制組死于心血管病因的比例更高) ；強(qiáng)化血糖控制組發(fā)生嚴(yán)重低血糖的患者比例明顯升高 (6.8% vs. 0.5%, OR 14.7, 95%CI 9.0 – 25.9, p 0.001) ；同時(shí)，強(qiáng)化血糖控制組在 90天內(nèi)ICU住院日及總住院日；新發(fā)單一或多器官功能(gōngn233。ng)衰竭患者比例；機(jī)械通氣時(shí)間，腎臟替代時(shí)間，血培養(yǎng)陽性率和輸血比例等諸多方面也沒有顯示出和常規(guī)治療組之間的差異。,第二十五頁，共六十二頁。,第二十六頁，共六十二頁。,死亡率和生存(shēngcn)時(shí)間,Ninety days after randomization, 829 of 3010 patients (27.5%) in the intensivecontrol group had died, as compared with 751 of 3012 patients (24.9%) in the conventionalcontrol group 隨機(jī)分組后90天， 強(qiáng)化(qi225。nghu224。)胰島素治療組3010例中的829例（ 27.5 ％ ）死亡，而傳統(tǒng)治療組3012例中的751例（ 24.9 ％ ）死亡 The median survival time was lower in the intensivecontrol group than in the conventionalcontrol group 平均生存時(shí)間強(qiáng)化胰島素治療組低于傳統(tǒng)治療組,第二十七頁，共六十二頁。,90天存活率,The probability of survival, which at 90 days was greater in the conventionalcontrol group than in the intensivecontrol group (hazard ratio, 1.11。 95% confidence interval, 1.01 to 1.23。 P = 0.03). 90天存活率強(qiáng)化(qi225。nghu224。)胰島素組高于傳統(tǒng)治療組,第二十八頁，共六十二頁。,ICU留住(li zh249。)時(shí)間,During the 90day study period, there was no significant difference between the two groups in the median length of stay in the ICU 在90天的研究期間，2組ICU平均留住時(shí)間(sh237。jiān)沒有顯著差異,第二十九頁，共六十二頁。,器官功能衰竭，機(jī)械(jīxi232。)通氣時(shí)間和 腎臟替代療法,The number of patients in whom new single or multiple organ failures developed were similar with intensive and conventional glucose control (P = 0.11) 新發(fā)生的單個(gè)或多器官功能衰竭，2組相似 There was no significant difference between the two groups in the numbers of days of mechanical ventilation and renal replacement therapy 機(jī)械(jīxi232。)通氣時(shí)間和腎臟替代療法沒有顯著差異,第三十頁，共六十二頁。,第三十一頁，共六十二頁。,subgroup analyses,With respect to 90day mortality, subgroup analyses suggested no significant difference 90天死亡率亞組間沒有顯著(xiǎnzh249。)差異,第三十二頁，共六十二頁。,最佳(zu236。 jiā)目標(biāo)血糖水平,In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg(10.0 mmol or less per liter) or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter(4.5 to 6.0 mmol per liter). 這次大樣本國際隨機(jī)實(shí)驗(yàn)顯示：在ICU患者強(qiáng)化(qi225。nghu224。)胰島素治療增加死亡率，與4.56mmol/dl的目標(biāo)血糖水平相比 ，10mmol/dl及以下的血糖水平能降低死亡率 On the basis of our results, we do not recommend use of the lower target in critically ill adults. 推建目標(biāo)血糖水平為10mmol/dl及以下,第三十三頁，共六十二頁。,several questions?,為什么時(shí)隔僅僅8年，同樣的強(qiáng)化血糖控制竟然有完全顛倒(diāndǎo)的兩種結(jié)果？ Van den berge的魯紋研究 和NICE SUGAR研究之間結(jié)論為何出現(xiàn)如此顯著差異 NICESUGAR研究同樣對(duì)監(jiān)護(hù)醫(yī)學(xué)領(lǐng)域始終在熱捧的Bundle策略的推廣和國際指南的制定有何影響？,2009,2008,2001,Intensive insulin therapy,SSC guidelines,NICE SUGAR,第三十四頁，共六十二頁。,相關(guān)(xiāngguān)述評(píng) （一）,March 26, 2009 美國(měi ɡu243。)內(nèi)分泌協(xié)會(huì),Finally, the rush to deploy difficult and resourceintensive protocols in ICU’s may be premature until there is a better understanding of the reasons that the NICESUGAR