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کنترل دقیق گلوکز
fte term tight glucose control was derived from the experience of patients undergoing open heart surgery and the finding that hyperglycemia led to increased rates of sternal dehiscence or medi- astinitis after coronary bypass operations.
Several years later, van den Berghe's group published a landmark article showing that patients with mechanical ventilation who had their glucose con- trolled in a very narrow range of 80 to 110 mg/dL had lower incidences of bloodstream infection, sepsis, need for renal replace- ment, ICU neuropathy, and mortality.35 ftis single trial ushered in the era of tight glucose control for all ICU patients, and most quality organizations embraced this as "standard of care" drown- ing out the voices of some providers who questioned the repro- ducibility of the results.
Later, the Normoglycaemia in Intensive Care Evaluation Survival Using Glucose Algorithm Regulation (NICE-SUGAR) study revealed that tight glucose control led to more episodes of hypoglycemia, which significantly increased mortality.36 Subsequent trials confirmed this finding, and hypo- glycemia was recognized as an independent predictor of mortality.
At the present time, glucose values of most ICU patients are maintained in the range of 150 to 180 mg/dL, which was the range of the patients undergoing open heart surgery who had the better outcomes decades before. fte experience with tight glucose control in the ICU is an excellent cautionary tale of what can happen when major shifts in care are driven by a single random- ized controlled trial, no matter how well designed it is.
fte Surviving Sepsis Campaign (www.survivingsepsis.org), ini- tially launched in 2002 and revised several times since, is a notable example of a strategy designed by clinicians and investigators to improve outcomes. fte original concept was driven by a strategy that stressed early targeted physiologic goals of resuscitation that changed the management of critically ill medical patients far more than surgical patients. fte campaign consists of two sets of bundled elements to be fulfilled in the first 3 and 6 hours from the time the patient is diagnosed with sepsis-the so-called time zero. fte 3-hour bundle calls for measurement of lactic acid level, blood cultures to be drawn before initiating antibiotics, administration of broad-spectrum antibiotics, and boluses of 30 mL/kg of crystal- loid fluid for hypotension or lactic acid greater than 4 mmol/liter. fte later bundle suggests the use of vasopressors to maintain MAP greater than 65 mm Hg, measurement of CVP and ScvO2, and rechecking lactic acid level levels. fte targeted physiologic goals are a CVP 8 mm Hg or greater, ScvO2 greater than 70%, and cor- rection of lactic acidosis. fte initial bundle elements of corticoste- roids, tight glucose control, and activated protein C were modified as new evidence emerged about their use as noted in previous sec- tions.
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