Glucose Control in the (Neuro) Intensive Care Unit

M. Moussouttas
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Abstract

Introduction The vexing question of optimal glucose level in the intensive care unit has long perplexed intensivists. Hyperglycemia is a natural response to physiologic stress,1 and in the critically ill patient has been attributed to inflammatory processes, insulin counter-regulatory hormones, organ dysfunction, iatrogenic carbohydrate or medication related hyperglycemia, and insulin resistance as evidenced by concurrently elevated insulin levels.1 Hyperglycemia occurs in 50-75% of patients admitted to an ICU, and has been associated with various adverse outcomes including increased mortality, organ dysfunction, susceptibility to infections, and neurological complications.1,2 On the cellular level, tissue/organ damage is theorized to be mediated via the production of toxic polyol metabolites and reactive oxygen species,3 with compromise of mitochondrial/cellular function.1 At the opposite extreme, hypoglycemia is acutely detrimental and clearly mandates avoidance. Glucose variability has also been linked to adverse outcomes,4 and insulin administration itself has been associated with increased mortality.5 As such, it is believed that resolution of hypoglycemia, and not insulin administration, is the determinant of improved outcomes.5
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(神经)重症监护病房的血糖控制
长期以来,重症监护病房的最佳血糖水平一直困扰着重症监护医师。高血糖是对生理应激的自然反应1,在危重患者中,可归因于炎症过程、胰岛素反调节激素、器官功能障碍、医源性碳水化合物或药物相关高血糖,以及胰岛素抵抗(胰岛素水平升高)50-75%的ICU住院患者发生高血糖,并与各种不良结局相关,包括死亡率增加、器官功能障碍、易感感染和神经系统并发症。在细胞水平上,组织/器官损伤被认为是通过产生有毒的多元醇代谢物和活性氧来介导的,并损害线粒体/细胞功能在另一个极端,低血糖是非常有害的,显然需要避免。血糖变异性也与不良结果有关4,胰岛素本身也与死亡率增加有关5因此,人们认为低血糖的解决,而不是胰岛素的使用,是改善预后的决定因素
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