嚴格血糖控制對接受全靜脈營養治療住院病人併發症之影響

全靜脈營養為腸胃道功能障礙或無法接受腸道營養病人重要的支持性療法，但卻可能誘發高血糖、感染等不良生理反應。許多研究證明嚴格控制重症病人的血糖可以降低感染率、加護病房住院天數與死亡率。而本院於2006年8月依據美國糖尿病學會之血糖控制指引將全靜脈營養病人的血糖制範圍，由原本180mg/dL-250mg/dL降至110-180mg/Dl，然而，對於接受全靜脈營養治療容易引發高血糖的病人，嚴格血控制與住院期間的併發症之相關研究並不多見。

Total parenteral nutrition (TPN) is a major supportive treatment in critically ill patients who could not tolerate enteric feeding. TPN treatment had been associated with adverse effects including infection and hyperglycemia. Numerous studies have documented that strict glycemic control in critical ill patient can reduce infection, length of stay in intensive care units and mortality. However, there are fewer reports regarding the associations of hyperglycemia with strict glycemic control and adverse outcomes during hospitalization in patients receiving TPN. In August 2006, our hospital followed the American Diabetes Association guidelines adjusting range of glycemic control from 180-250 mg/dL to 110-180mg/dL in patients treated with TPN. The purpose of the present study was to examine the effects of strict glycemic control on complications in patients receiving TPN treatment. In this non-concurrent comparison study we retrospectively reviewed the chart records of 323 patients who received TPN treatment during the period between June 2004 and July 2008. A total of 189 patients were recruited after excluding those who did not match the inclusion criteria. The effectiveness of different extent of strict blood glucose control (target of 180-250 mg/dL before August 2006, n=97 and target of 110-180mg/dL after August 2006, n=92) in reducing the clinical complications during TPN use were examined. Our results showed that there was no significant difference in mortality, infections, and sepsis between the two groups (p>0.05) during their hospitalization. In multiple logistic regression models adjusted for age, gender, and diabetes, mortality was predicted by APACHE II scores (OR=1.05, 95%CI=1.00-1.10), duration of TPN use (OR=1.02, 95%CI=1.00-1.04), and mean blood glucose>180 mg/dL during TPN use (OR=3.10, 95%CI=1.08-8.89). Risk of hypoglycemia was higher in the group targeted for 110-180 mg/dL(p<0.001). Hypoglycemia was associated with increased risk of infections (OR=3.13, 95%CI=1.05-9.36), however, hypoglycemia was not found to be related to mortality. Further studies should be carried out prospectively to confirm these findings.