耐糖能障害を生じた重症救急患者の血糖値と予後 人工膵を用いた厳密な血糖管理例の検討
【方法】人工膵 (AP: 日機装社製) を用いた血糖管理施行90例をAP開始後早期 (入院約3日後: E期) と約1週後 (入院約10日後: L期) の2期に分け, 血糖値と予後の関連を検討した。1日平均血糖値 (BGm) 150, 175, 200mg/dLを基準点とし基準点以下, 以上の症例を比較した。即ち各々BGm150以下の群 (150b群) と150以上の群 (150a群) , 175b群と175a群, 200b群と200a群に分け2群間で死亡率と死亡率関連要因を比較した。 【結果】死亡率はE期は200b群は200a群に比べ (29%vs56%, p<0.05) , L期は17...
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| Published in | 蘇生 Vol. 26; no. 1; pp. 10 - 17 |
|---|---|
| Main Authors | , |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本蘇生学会
20.03.2007
The Japanese Society of Reanimatology |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0288-4348 1884-748X |
| DOI | 10.11414/jjreanimatology1983.26.10 |
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| Abstract | 【方法】人工膵 (AP: 日機装社製) を用いた血糖管理施行90例をAP開始後早期 (入院約3日後: E期) と約1週後 (入院約10日後: L期) の2期に分け, 血糖値と予後の関連を検討した。1日平均血糖値 (BGm) 150, 175, 200mg/dLを基準点とし基準点以下, 以上の症例を比較した。即ち各々BGm150以下の群 (150b群) と150以上の群 (150a群) , 175b群と175a群, 200b群と200a群に分け2群間で死亡率と死亡率関連要因を比較した。 【結果】死亡率はE期は200b群は200a群に比べ (29%vs56%, p<0.05) , L期は175b群は175a群に比べ (28%vs50%, p<0.05) 低かったが, 他の要因に有意差はなかった。 【結語】BGmを早期で200以下, 10日後で175以下を目標とした血糖管理が予後を改善する可能性が考えられた。 |
|---|---|
| AbstractList | ( (Purpose) ) : To clarify the beneficial blood glucose (BG) level in severely critical ill patients with glucose intolerance. ( (Materials and Methods) ) : Ninety patients were investigated. Their BG control was performed by means of artificial pancreas (AP), STG22. The patients were evaluated at two phases, early phase (E phase about 3 days after admission) and late phase (L phase : about 1 week after E phase) . Based on the daily mean BG level (BGm), patients were classified into 2 groups, i. e., high group (a) and low group (b), which were compared with. Three blood glucose points were selected, on 150, 175, and 200mg/dL (ex. group 150b means the patients with BGm below 150mg/dL) . Parameters studied were included in sex, age, underlying diseases, the amount of administered glucose (G) and insulin (I), rate of septic patients, severity, and mortality. ( (Results) ) : (1) E phase (n=84) ; Group 200b (n=68) had lower glucose, insulin level, and lower mortality (29 vs 56%, p<0.05) as compared to group 200a (n=16) . Other parameters above shown were not significantly different between group 200b and group 200a. (2) L phase (n=88) ; Group 175b (n=58) had lower insulin and lower mortality (28 vs 50%, p<0.05) as compared to group 175a (n=30) . Other parameters were not significantly different between group 175b and group 175a. ( (Interpretation and conclusions) ) : BG control aiming at the BC level lower than 200mg/dL at early stage and that lower than 175mg/dL at about 10 days after admission may link to the improvement of the outcome of the severely critical ill patients from the viewpoint of glucose metabolic state.
【方法】人工膵 (AP: 日機装社製) を用いた血糖管理施行90例をAP開始後早期 (入院約3日後: E期) と約1週後 (入院約10日後: L期) の2期に分け, 血糖値と予後の関連を検討した。1日平均血糖値 (BGm) 150, 175, 200mg/dLを基準点とし基準点以下, 以上の症例を比較した。即ち各々BGm150以下の群 (150b群) と150以上の群 (150a群) , 175b群と175a群, 200b群と200a群に分け2群間で死亡率と死亡率関連要因を比較した。【結果】死亡率はE期は200b群は200a群に比べ (29%vs56%, p<0.05) , L期は175b群は175a群に比べ (28%vs50%, p<0.05) 低かったが, 他の要因に有意差はなかった。【結語】BGmを早期で200以下, 10日後で175以下を目標とした血糖管理が予後を改善する可能性が考えられた。 【方法】人工膵 (AP: 日機装社製) を用いた血糖管理施行90例をAP開始後早期 (入院約3日後: E期) と約1週後 (入院約10日後: L期) の2期に分け, 血糖値と予後の関連を検討した。1日平均血糖値 (BGm) 150, 175, 200mg/dLを基準点とし基準点以下, 以上の症例を比較した。即ち各々BGm150以下の群 (150b群) と150以上の群 (150a群) , 175b群と175a群, 200b群と200a群に分け2群間で死亡率と死亡率関連要因を比較した。 【結果】死亡率はE期は200b群は200a群に比べ (29%vs56%, p<0.05) , L期は175b群は175a群に比べ (28%vs50%, p<0.05) 低かったが, 他の要因に有意差はなかった。 【結語】BGmを早期で200以下, 10日後で175以下を目標とした血糖管理が予後を改善する可能性が考えられた。 |
| Author | 原口, 義座 星野, 正己 |
| Author_FL | 星野 正己 原口 義座 |
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| References | 25) 星野正巳, 水島岩徳, 原口義座: 血中グルコースモニタ. 救急・集中治療18: 383-387, 2006 24) Hoshino M, Haraguchi Y, Hirawawa H, et al : Measurement of insulin clearance and factors affecting insulin clearance in septic patients with glucose intolerance - analysis under strict blood glucose control by means of bedside-type artificial pancreas-Chiba Med J 82 : 149-161, 2006 18) Mackenzie I, Ingle S, Zaidi S, et al : Tight glycemic control : a survey of intensive care practice in large English hospitals. Intensive Care Med 31: 1136, 2005 12) Laird AM, Miller PR, Kilgo PD, et al : Relationship of Early Hyperglycemia to Mortality in Trauma Patients. J Trauma 56 : 1058-1062, 2004 38) Krogh-Madsen R, Moller K, Dela F, et al: Effect of hyperglycemia and hyperinsulinemia on the response of IL-6, TNF-α, and FFAs to low-dose endotoxemia in humans. Am J Physiol Endocrinol Metab 286 E766 E772, 2004 35) Langouche L, Vanhorebeek I, Vlasselaers D, et al : Intensive insulin therapy protects the endothelium of critically ill patients. J Clin Invest 115: 2277-2286, 2005 37) Das UN : Is insulin an anti-inflammatory molecule? Nutrition 17 : 409-413, 2001 8) 星野正巳, 原口義座: Glucose Control. 特集Surviving sepsis Campaign Guidelinesを巡って. ICUとCCU28: 853-857, 2004 39) Mesotten D, Swinnen JV, Vanderhoydonc F, et al : Contribution of Circulating Lipids to the Improved Outcome of Critical Illness by Glycemic Control with Intensive Insulin Therapy. J Clin Endocrinol Metab 89 : 219-226, 2004 13) Layer S, Preston S, Turner D, et al : Implementing intensive insulin therapy : Development of and audit of the bath insulin protocol. Anaesth Intensive Care 32 : 311-316, 2004 3) Van den Berghe G, Wouters P, Weekers F, et al : Intensive insulin therapy in the critically ill patients. N Eng J Med 345 : 1359-1367, 2001 21) Malhotra A : Intensive Insulin in Intensive Care. N Engl J Med 354 : 516-518, 2006 28) Michie HR : Metabolism of sepsis and multiple organ failure. World J Surg 20 : 460-464, 1996 32) Yudkin JS : Abnormalities of coagulation and fibrinolysis in insulin resistance. Evidence for a common antecedent? Diabetes Care 22 : C25-30, 1999 5) Finney SJ, Zekveld C, Elia A, et al : Glucose control and mortality in critically ill patients. JAMA 290 2041-2047, 2003 7) Dellinger RP, Carlet JM, Masur H, et al : Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32 : 858-873, 2004 15) Brunkhorst FM, Kuhnt E, Engel C, et al: Intensive insulin therapy in patient with severer sepsis and septic shock is associated with an increased rate of hypoglycemia-results from a randomized multicenter study (VISEP) [abstract] . Infection 33 : 19-20, 2005 23) 星野正巳, 原口義座, 平澤博之, ほか: 高度耐糖能障害を伴う重症救急患者の耐糖能評価法-ICU入室早期におけるグルコースクランプ法から求めた末梢グルコース代謝速度からの検討-. 外科と代謝・栄養37: 283-295, 2003 19) Angus DC, Abraham E : Intensive Insulin Therapy in Critical Illness. Am J Respir Crit Care Med 172 : 1358-1359, 2005 17) Coursin DB, Murray MJ : How Sweet is Euglycemia in Critically Ill Patients? Mayo Clin Proc 78 : 1460-1462, 2003 11) Van den Berghe G, Wouters PJ, Bouillon R, et al: Outcome benefit of intensive insulin therapy in the critically ill : Insulin dose versus glycemic control. Crit Care Med 31: 359-366, 2003 14) Kanji S, Singh A, Tierney M, et al : Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults. Intensive Care Med 30 : 804-810, 2004 30) QiC, Pekala PH : Tumor necrosis factor-α-induced insulin resistance in adipocytes. Proc Soc Exp Biol Med 223 : 128-135, 2000 29) Mollar DE : Potential role of TNF-α in the pathogenesis of insulin resistance and type 2 diabetes. Trends Endocrinol Metab 11 : 212-217, 2000 36) Vanhorebeek I, De Vos R, Mesotten D, et al : Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients. Lancet 365 : 53-59, 2005 22) Hoshino M, Haraguchi Y, Hirasawa H, et al : Close relationship of tissue plasminogen activator-plasminogen activator inhibitor-1 complex with multiple organ dysfunction syndrome investigated by means of the artificial pancreas. Crit Care 5 : 88-99, 2001 31) Epstein FH : Glucose transporters and insulin action. Implications for insulin resistance and diabetes mellitus. N Engl J Med 341 : 248-257, 1999 20) Polderman KH, Girbes ARJ : Intensive insulin therapy : Of harm and health, of hypes and hypoglycemia. Crit Care Med 34 : 246-248, 2006 16) Bhatia A, Cadman B, Mackenzie I : Hypoglycemia and Cardiac Arrest in a Critically ill Patient on Strict Glycemic Control. Anesth Analg 102: 549-551, 2006 33) Chambrier C, Laville M, Berrada KR, et al : Insulin sensitivity of glucose and fat metabolism in severe sepsis. Clin science 99 : 321-328, 2000 2) Furnary AP, Zerr KJ, Grunkemeier GL, et al : Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67 : 352-362, 1999 27) Vincent JL, de Mendonca A, Cantraine F, et al : Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units. Crit Care Med 26 : 1793-1800, 1998 10) Taylor JH, Beilman GJ: Hyperglycemia in the Intensive Care Unit : NoLonger Just a Marker of Illness Severity. Surg Infect 6 : 233-245, 2005 9) 星野正巳, 原口義座, 上野博一, ほか: シンポジウム過大な侵襲時の血糖管理. 耐糖能障害を生じた重症救急患者の人工膵による血糖管理. 体液・代謝管理21: 45-52, 2005 34) Agwunobi AO, Reid C, Maycock P, et al : Insulin resistance and substrate utilization in human endotoxemia. J Clin Endocrinol Metabolism 85 : 3770-3778, 2000 1) Malmberg K : Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus : DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 314: 1512-1515, 1997 26) Bone RC, Balk RA, Cerra FB, et al : Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101 : 1644-1655, 1992 4) Van den Berghe G, Wilmer A, Hermans G, et al : Intensive insulin therapy in the Medical ICU. N Eng J Med 354 : 449-461, 2006 6) Krinsley JS : Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 79 : 992-1000, 2004 |
| References_xml | – reference: 15) Brunkhorst FM, Kuhnt E, Engel C, et al: Intensive insulin therapy in patient with severer sepsis and septic shock is associated with an increased rate of hypoglycemia-results from a randomized multicenter study (VISEP) [abstract] . Infection 33 : 19-20, 2005 – reference: 17) Coursin DB, Murray MJ : How Sweet is Euglycemia in Critically Ill Patients? Mayo Clin Proc 78 : 1460-1462, 2003 – reference: 22) Hoshino M, Haraguchi Y, Hirasawa H, et al : Close relationship of tissue plasminogen activator-plasminogen activator inhibitor-1 complex with multiple organ dysfunction syndrome investigated by means of the artificial pancreas. Crit Care 5 : 88-99, 2001 – reference: 12) Laird AM, Miller PR, Kilgo PD, et al : Relationship of Early Hyperglycemia to Mortality in Trauma Patients. J Trauma 56 : 1058-1062, 2004 – reference: 7) Dellinger RP, Carlet JM, Masur H, et al : Surviving Sepsis Campaign Management Guidelines Committee. Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32 : 858-873, 2004 – reference: 34) Agwunobi AO, Reid C, Maycock P, et al : Insulin resistance and substrate utilization in human endotoxemia. J Clin Endocrinol Metabolism 85 : 3770-3778, 2000 – reference: 39) Mesotten D, Swinnen JV, Vanderhoydonc F, et al : Contribution of Circulating Lipids to the Improved Outcome of Critical Illness by Glycemic Control with Intensive Insulin Therapy. J Clin Endocrinol Metab 89 : 219-226, 2004 – reference: 23) 星野正巳, 原口義座, 平澤博之, ほか: 高度耐糖能障害を伴う重症救急患者の耐糖能評価法-ICU入室早期におけるグルコースクランプ法から求めた末梢グルコース代謝速度からの検討-. 外科と代謝・栄養37: 283-295, 2003 – reference: 16) Bhatia A, Cadman B, Mackenzie I : Hypoglycemia and Cardiac Arrest in a Critically ill Patient on Strict Glycemic Control. Anesth Analg 102: 549-551, 2006 – reference: 30) QiC, Pekala PH : Tumor necrosis factor-α-induced insulin resistance in adipocytes. Proc Soc Exp Biol Med 223 : 128-135, 2000 – reference: 6) Krinsley JS : Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 79 : 992-1000, 2004 – reference: 28) Michie HR : Metabolism of sepsis and multiple organ failure. World J Surg 20 : 460-464, 1996 – reference: 25) 星野正巳, 水島岩徳, 原口義座: 血中グルコースモニタ. 救急・集中治療18: 383-387, 2006 – reference: 33) Chambrier C, Laville M, Berrada KR, et al : Insulin sensitivity of glucose and fat metabolism in severe sepsis. Clin science 99 : 321-328, 2000 – reference: 2) Furnary AP, Zerr KJ, Grunkemeier GL, et al : Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg 67 : 352-362, 1999 – reference: 8) 星野正巳, 原口義座: Glucose Control. 特集Surviving sepsis Campaign Guidelinesを巡って. ICUとCCU28: 853-857, 2004 – reference: 13) Layer S, Preston S, Turner D, et al : Implementing intensive insulin therapy : Development of and audit of the bath insulin protocol. Anaesth Intensive Care 32 : 311-316, 2004 – reference: 9) 星野正巳, 原口義座, 上野博一, ほか: シンポジウム過大な侵襲時の血糖管理. 耐糖能障害を生じた重症救急患者の人工膵による血糖管理. 体液・代謝管理21: 45-52, 2005 – reference: 18) Mackenzie I, Ingle S, Zaidi S, et al : Tight glycemic control : a survey of intensive care practice in large English hospitals. Intensive Care Med 31: 1136, 2005 – reference: 19) Angus DC, Abraham E : Intensive Insulin Therapy in Critical Illness. Am J Respir Crit Care Med 172 : 1358-1359, 2005 – reference: 37) Das UN : Is insulin an anti-inflammatory molecule? Nutrition 17 : 409-413, 2001 – reference: 36) Vanhorebeek I, De Vos R, Mesotten D, et al : Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients. Lancet 365 : 53-59, 2005 – reference: 11) Van den Berghe G, Wouters PJ, Bouillon R, et al: Outcome benefit of intensive insulin therapy in the critically ill : Insulin dose versus glycemic control. Crit Care Med 31: 359-366, 2003 – reference: 14) Kanji S, Singh A, Tierney M, et al : Standardization of intravenous insulin therapy improves the efficiency and safety of blood glucose control in critically ill adults. Intensive Care Med 30 : 804-810, 2004 – reference: 20) Polderman KH, Girbes ARJ : Intensive insulin therapy : Of harm and health, of hypes and hypoglycemia. Crit Care Med 34 : 246-248, 2006 – reference: 31) Epstein FH : Glucose transporters and insulin action. Implications for insulin resistance and diabetes mellitus. N Engl J Med 341 : 248-257, 1999 – reference: 5) Finney SJ, Zekveld C, Elia A, et al : Glucose control and mortality in critically ill patients. JAMA 290 2041-2047, 2003 – reference: 29) Mollar DE : Potential role of TNF-α in the pathogenesis of insulin resistance and type 2 diabetes. Trends Endocrinol Metab 11 : 212-217, 2000 – reference: 3) Van den Berghe G, Wouters P, Weekers F, et al : Intensive insulin therapy in the critically ill patients. N Eng J Med 345 : 1359-1367, 2001 – reference: 26) Bone RC, Balk RA, Cerra FB, et al : Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101 : 1644-1655, 1992 – reference: 35) Langouche L, Vanhorebeek I, Vlasselaers D, et al : Intensive insulin therapy protects the endothelium of critically ill patients. J Clin Invest 115: 2277-2286, 2005 – reference: 10) Taylor JH, Beilman GJ: Hyperglycemia in the Intensive Care Unit : NoLonger Just a Marker of Illness Severity. Surg Infect 6 : 233-245, 2005 – reference: 21) Malhotra A : Intensive Insulin in Intensive Care. N Engl J Med 354 : 516-518, 2006 – reference: 38) Krogh-Madsen R, Moller K, Dela F, et al: Effect of hyperglycemia and hyperinsulinemia on the response of IL-6, TNF-α, and FFAs to low-dose endotoxemia in humans. Am J Physiol Endocrinol Metab 286 E766 E772, 2004 – reference: 4) Van den Berghe G, Wilmer A, Hermans G, et al : Intensive insulin therapy in the Medical ICU. N Eng J Med 354 : 449-461, 2006 – reference: 27) Vincent JL, de Mendonca A, Cantraine F, et al : Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units. Crit Care Med 26 : 1793-1800, 1998 – reference: 32) Yudkin JS : Abnormalities of coagulation and fibrinolysis in insulin resistance. Evidence for a common antecedent? Diabetes Care 22 : C25-30, 1999 – reference: 1) Malmberg K : Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus : DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 314: 1512-1515, 1997 – reference: 24) Hoshino M, Haraguchi Y, Hirawawa H, et al : Measurement of insulin clearance and factors affecting insulin clearance in septic patients with glucose intolerance - analysis under strict blood glucose control by means of bedside-type artificial pancreas-Chiba Med J 82 : 149-161, 2006 |
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| Snippet | 【方法】人工膵 (AP: 日機装社製) を用いた血糖管理施行90例をAP開始後早期 (入院約3日後: E期) と約1週後 (入院約10日後: L期) の2期に分け, 血糖値と予後の関連を検討した。1日平均血糖値 (BGm) 150, 175, 200mg/dLを基準点とし基準点以下,... ( (Purpose) ) : To clarify the beneficial blood glucose (BG) level in severely critical ill patients with glucose intolerance. ( (Materials and Methods) ) :... |
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| SubjectTerms | Artificial pancreas Blood glucose control Critical care outcome Sepsis 予後 人工膵 救急医学 敗血症 血糖管理 |
| Subtitle | 人工膵を用いた厳密な血糖管理例の検討 |
| Title | 耐糖能障害を生じた重症救急患者の血糖値と予後 |
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| ispartofPNX | 蘇生, 2007/03/20, Vol.26(1), pp.10-17 |
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