美国医师协会（ACP）指南不再建议强化血糖控制！
美国医师协会（ACP）指南不再建议强化血糖控制！今天《Annals of internal medicine》 发表了“住院患者应用强化胰岛素控制血糖的临床实践指南”
Abstract
Description: The American College of Physicians (ACP) developed this guideline to present the evidence for the link between the use of intensive insulin therapy to achieve different glycemic targets and health outcomes in hospitalized patients with or without diabetes mellitus.
Methods: Published literature on this topic was identified by using MEDLINE and the Cochrane Library. Additional articles were obtained from systematic reviews and the reference lists of pertinent studies, reviews, and editorials, as well as by consulting experts; unpublished studies on ClinicalTrials.gov were also identified. The literature search included studies published from 1950 through March 2009. Searches were limited to English-language publications. The primary outcomes of interest were short-term mortality and hypoglycemia. This guideline grades the evidence and recommendations by using the ACP clinical practice guidelines grading system.
Recommendation 1: ACP recommends not using intensive insulin therapy to strictly control blood glucose in non–surgical intensive care unit (SICU)/medical intensive care unit (MICU) patients with or without diabetes mellitus (Grade: strong recommendation, moderate-quality evidence).无论是否合并糖尿病，对非外科/内科ICU患者ACP都不推荐强化胰岛素疗法严格控制血糖（推荐等级：强烈，证据级别：中级）
Recommendation 2: ACP recommends not using intensive insulin therapy to normalize blood glucose in SICU/MICU patients with or without diabetes mellitus (Grade: strong recommendation, high-quality evidence).
无论是否合并糖尿病，ACP都不建议SICU和MICU患者，通过强化胰岛素治疗使血糖正常化（推荐等级：强烈，证据级别：高级）
Recommendation 3: ACP recommends a target blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients (Grade: weak recommendation, moderate-quality evidence). SICU或MICU患者若应用胰岛素，ACP推荐的血糖水平为7.8-11.1(140-200 mg/dl)， （推荐等级：弱，证据级别：中级）
该指南的建立基础是同期发表的系统综述：
Intensive Insulin Therapy in Hospitalized Patients: A Systematic Review。
Background: The benefits and harms of intensive insulin therapy (IIT) titrated to strict glycemic targets in hospitalized patients remain uncertain.
Purpose: To evaluate the benefits and harms of IIT in hospitalized patients.
Data Sources: MEDLINE and Cochrane Database of Systematic Reviews from 1950 to January 2010, reference lists, experts, and unpublished sources.
Study Selection: English-language randomized, controlled trials comparing protocols titrated to strict or less strict glycemic targets.
Data Extraction: Two reviewers independently abstracted data from each study on sample, setting, glycemic control interventions, glycemic targets, mean glucose levels achieved, and outcomes. Results were grouped by patient population or setting. A random-effects model was used to combine trial data on short-term mortality (≤28 days), long-term mortality (90 or 180 days), infection, length of stay, and hypoglycemia. The Grading of Recommendations Assessment, Development, and Evaluation system was used to rate the overall body of evidence for each outcome.
Data Synthesis: In a meta-analysis of 21 trials in intensive care unit, perioperative care, myocardial infarction, and stroke or brain injury settings, IIT did not affect short-term mortality (relative risk, 1.00 ). No consistent evidence showed that IIT reduced long-term mortality, infection rates, length of stay, or the need for renal replacement therapy. No evidence of benefit from IIT was reported in any hospital setting, although the best evidence for lack of benefit was in intensive care unit settings. Data combined from 10 trials showed that IIT was associated with a high risk for severe hypoglycemia (relative risk, 6.00 ; P < 0.001). Risk for IIT-associated hypoglycemia was increased in all hospital settings.
Limitations: Methodological shortcomings and inconsistencies limit the data in perioperative care, myocardial infarction, and stroke or brain injury settings. Differences in insulin protocols and patient and hospital characteristics may affect generalizability across treatment settings.
Conclusion: No consistent evidence demonstrates that IIT targeted to strict glycemic control compared with less strict glycemic control improves health outcomes in hospitalized patients. Furthermore, IIT is associated with an increased risk for severe hypoglycemia. 回复 1# 蓝鱼o_0
大家需要明确的是，是指非外科/内科ICU患者，外科手术患者还是要强调围术期血糖控制的。 "外科手术患者还是要强调围术期血糖控制的"这个观点还是有循证医学依据的，因此，该文献还是明确了这个事实的。 回复 2# 楚楚
对于围术期的血糖控制在《医院感染预防与控制操作规程》一书中外科手术部位感染预防控制SOP中要求是:充分控制糖尿病手术患者的血糖水平,尤其避免术前高血糖。从字面理解应是在术前应把血糖控制在正常吧？但在硕本连读外科教材上的要求是:糖尿病病人血糖控制在轻度升高状态15.6-11.2mmol/L较为适宜,此时尿糖+-++,这样既不至因胰岛素过多而发生低血糖也不至因胰岛素过少而发生酸中毒. 请教楚楚老师,从院感角度来说，围术期血糖控制具体范围多少为宜？ 回复 4# 明月松间照
我查阅文献，选择的血糖控制范围是：“4.4－6.1mmol/L”。 回复 2# 楚楚
谢谢楚楚老师的回复！
您回复很及时，我想就您的这个答复进一步补充解释一下：
ACP明确说明了在非外科ICU和内科ICU中不推荐。参考最新的研究报道“Intensive Insulin Therapy in Hospitalized Patients: A Systematic Review。”（详细请见新帖，已翻译摘要）
在文中，作者根据不同的setting进行了subgroup analysis.研究显示，无论在ICU 或者 NON-ICU，IIT均不能显著改善预后。
里面有三篇研究设计SICU，（相对危险度分别为0.66（0.48-0.92）；0.53（0.17-1.96）,0.40（0.08-2.01））。有人也许会问，后两篇研究不是说这个关联并无统计学意义。
但是考虑到主效应很小，所以对研究篇幅是有要求的。由于数据量不足，不能进行combined effect估计。所以ACP目前并未推荐“在SICU中，IIT不能改善预后这个”结论。（已经用统计软件验证过，STATA11。0，error command: insufficient data）。
希望能便于战友们理解！ 回复 5# 一枝梅
请问梅版查阅的文献出自何处,能否告之?谢谢!这两者之间也差得太远了啊! 回复 4# 明月松间照
目前国外的指南是建议控制在200mg/dl即11.1mmol/L以下，个人理解就是患者的随机血糖不要达到糖尿病的血糖诊断水平吧 回复 8# 楚楚
谢谢楚楚老师！目前我院的外科系统医生遇到糖尿病患者需手术的基本上都会请糠尿病的专病医生会诊，他们会给出一个血糖控制方案，专病医生比我们有更多的经验和理论基础，所以，对于这种专业性很强的问题，我更相信他们，呵呵！ 回复 9# 明月松间照
从预防SSI的角度，对糖尿病人与非糖尿病人，其血糖控制水平是不是要求达到同样的水平，可能需要更进一步了解下。这就是论坛的好处，在一来一往的交流中激发灵感，从中大家都获得了知识。有兴趣的会员不妨查查相关文献，回答一下这个疑问哦{:1_7:} 回复 10# 楚楚
是啊,尤其是"在一来一往的交流中激发灵感，从中大家都获得了知识",而且这种知识的获得比从书上得来的记忆更深刻. 这是好资料~谢谢楼主的分享~ {:1_3:}这个问题确实值得探讨和研究 蓝鱼o_0 发表于 2011-2-16 12:59 static/image/common/back.gif
回复 2# 楚楚
谢谢楚楚老师的回复！
但没看到它对外科手术病人围术期血糖控制的建议啊，按您的理解也是不推荐严格控制血糖吗？ SICU是指的外科围术的病人吗？
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