关于围手术期血糖控制方案的Meta分析

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Peri-operative glycaemic control regimens for preventing surgical site infection.pdf (1.54 MB, 下载次数: 53)

2012-3-18 13:33 上传

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该文摘要：

Peri-operative glycaemic control regimens for preventing surgical site infections in adults


BACKGROUND: Surgical site infections (SSIs) are associated with significant morbidity, mortality, and resource utilization and are potentially preventable. Peri-operative hyperglycaemia has been associated with increased SSIs and previous recommendations have been to treat glucose levels above 200 mg/dL. However, recent studies have questioned the optimal glycaemic control regimen to  prevent SSIs. Whether the benefits of strict or intensive glycaemic control with  insulin infusion as compared to conventional management outweigh the risks remains controversial. OBJECTIVES: To summarise the evidence for the impact of glycaemic control in the peri-operative period on the incidence of surgical site  infections, hypoglycaemia, level of glycaemic control, all-cause and infection-related mortality, and hospital length of stay and to investigate for differences of effect between different levels of glycaemic control. SEARCH STRATEGY: A search strategy was developed to search the following databases: Cochrane Wounds Group Specialised Register (searched 25 March 2009), The Cochrane Central Register of Controlled Trials, The Cochrane Library 2009, Issue 1; Ovid MEDLINE (1950 to March Week 2 2009); Ovid EMBASE (1980 to 2009 Week 12) and EBSCO CINAHL (1982 to March Week 3 2009). The search was not limited by language or publication status. SELECTION CRITERIA: Randomised controlled trials (RCTs) were  eligible for inclusion if they evaluated two (or more) glycaemic control regimens in the peri-operative period (within one week pre-, intra-, and/or post-operative) and reported surgical site infections as an outcome. DATA COLLECTION AND ANALYSIS: The standard method for conducting a systematic review in accordance with the Cochrane Wounds Group was used. Two review authors independently reviewed the results from the database searches and identified relevant studies. Two review authors extracted study data and outcomes from each  study and reviewed each study for methodological quality. Any disagreement was resolved by discussion or by referral to a third review author. MAIN RESULTS: Five RCTs met the pre-specified inclusion criteria for this review. No trials evaluated strict glycaemic control in the immediate pre-operative period or outside the intensive care unit. Due to heterogeneity in patient populations, peri-operative period, glycaemic target, route of insulin administration, and definitions of outcome measures, combination of the results of the five included  trials into a meta-analysis was not appropriate. The methodological quality of the trials was variable. In terms of outcomes, only one trial demonstrated a significant reduction in SSIs with strict glycaemic control, but the quality of this trial was difficult to assess as a result of poor reporting; furthermore the baseline rate of SSIs was high (30%). The other trials were either underpowered to detect a difference in SSIs, due to a low baseline rate (less than or equal to 5%), or did not report SSIs as a single outcome but as part of a composite. Of the three trials reporting hypoglycaemia (which was not consistently defined) all had a higher rate in the strict glycaemic control group but none attributed significant morbidity to the hypoglycaemia. Adequacy of glucose control between groups was measured differently among studies. Studies could not be compared due  to differences in target ranges, and were susceptible to measurement bias due to  differences in frequency of measurement and lack of blinding by the providers following the glycaemic protocols. Infection-related mortality was not reported in any of the trials, and no trials demonstrated a significant difference in all-cause mortality. Length of hospital stay was significantly reduced in the strict glycaemic control groups in only one trial. AUTHORS' CONCLUSIONS: There is insufficient evidence to support strict glycaemic control versus conventional management (maintenance of glucose < 200 mg/dL) for the prevention of SSIs. No trials were found that evaluated strict glycaemic control in the immediate pre-operative period or outside the setting of an intensive care unit. The trials were limited by small sample size, inconsistencies in the definitions of the outcome measures and methodological quality. Further large randomised trials are  required to address this question and may be most appropriately performed in patients at high risk for SSIs.

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对于摘要的简要翻译：

围手术期高血糖与SSI发生率增高有关，以往建议当血糖值高于200 mg/dL需进行治疗，近期研究对预防SSI的血糖最佳控制方案提出了质疑。“严格”血糖控制是否优于传统血糖控制方法观点不一。因此，该文分析了围手术期不同血糖控制方案对SSI的影响。纳入了5项比较术前、术中以及术后血糖控制的随机对照临床试验。其中没有一项试验是评价术前或出ICU后严格血糖控制效果的。由于患者人群、围手术期血糖控制时间、血糖控制目标、胰岛素给予方式、效应测量的定义等方面存在明显的异质性，因此无法对纳入试验的结果进行合并分析。这5项试验的方法学质量各不相同。如只有一项发现严格血糖控制可显著减少术后发生SSI，但由于报告的质量较低因此难以评价该试验的质量。此外，该试验的基线SSI水平较高（30%）。而其他的试验要么是由于基线SSI发生率低（<5%）、把握度不够而无法发现SSI发生率的差异，要么是未将SSI作为单独的结局指标而是将其作为综合结局的一个组成部分而报告。在报告有低血糖的3项试验中（低血糖的定义还不一），所有严格血糖控制组都有较高的SSI发生率，但其原因均非由低血糖所致。对于是否有效控制了血糖，不同研究的测定方法也不一。由于目标范围不同，无法对这些研究进行比较。由于测定频率不同且没有采用盲法因此可能存在测定偏倚。没有一项研究报告了与感染相关的死亡率，也没有一项研究表明在all-cause mortality有明显差异，仅有一项研究发现严格血糖控制组住院时间显著缩短。所有的试验均未评价术前以及出ICU后严格血糖控制作用。而且所有试验都有样本量小、结局测定定义不一致、以及方法学质量较低的缺点。因此，作者认为没有足够的证据可以支持严格血糖控制比传统血糖控制（血糖值< 200 mg/dL）在预防SSI时更为有效。需要大规模的临床试验来确定严格血糖控制对SSI的预防效果。

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放飞梦想 发表于 2012-3-18 13:46

                               
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对于摘要的简要翻译：

围手术期高血糖与SSI发生率增高有关，以往建议当血糖值高于200 mg/dL需进行治疗， ...

值得认真学习的一篇文献，只是...英文的，想要读懂有很大难度。
如果国内有做这项的多中心研究就好了。