重症患者の血糖管理

Acute hyperglycemia is common in critically ill patients. In acute illness,“stress”in response to tissue injury or infection can have profound effects on carbohydrate metabolism. This type of hyperglycemia occurs despite elevation in insulin levels（insulin resistance）. It is well-known that stress-induced hyperglycemia reflects severity of illness and is associated with mortality and morbidity in various patient groups. Until２００1, stress induced hyperglycemia was believed to be a beneficial physiological response which promoted cellular glucose uptake. A single center prospective randomized control trial has shown that ventilated post-operative ICU patients allocated to intensive insulin therapy（IIT）（target glucose : 80-110 mg/dl）, had a 43 percent risk reduction in ICU mortality when compared with patients receiving conventional glucose control（target glucose level : 180-210 mg/dL）. In the Surviving Sepsis Campaign guidelines３０）, maintenance of blood glucose levels less than 150 mg/dl using continuous infusion of insulin and glucose was recommended with a Grade D recommendation. Using this approach, frequent glucose measurements（after introducing lowering blood glucose（every 30-60 mins）and on a regular basis（every 4 hrs）once the blood glucose concentration has stabilized）was also recommended. Using current available evidence, target blood glucose range for critically ill patients would be around 150 mg/dL and insulin should be started when blood glucose become ＞180 mg/dL. To provide safe blood glucose management, physicians should create well-developed insulin protocol and understand the reliability of blood glucose measurements on each device.