NEJM：血糖的严密控制不会改善处于心脏手术期间儿童的健康状况

近日，国际著名杂志New England Journal of Medicine上的一篇研究报告指出，对处于心脏手术期间的婴儿和儿童进行严密的血糖控制（tight glycemic control）并不会降低其感染风险以及改善其恢复状况。接受心脏手术的婴儿和儿童，其通常会表现出高血糖的症状，这或许和健康问题，甚至死亡有关。尽管临床试验的结果比较庞杂，对于成年人重症监护的一些研究显示，使用胰岛素控制血糖会导致低的感染率，并且可以缩短住院时间。

因此这项研究对比了接受开放心脏手术的980名儿童的严密血糖控制和标准的血糖控制准则，严密的血糖控制包括有规律地监控胰岛素注入以达到维持正常血糖的水平。通过比较标准的护理疗法，严密型的血糖控制并不能够降低感染的发生，其也不能缩短重症监护（ICU）的时间。

儿童们经常不得不接受遵循成年人的一套内服药或者疗法来进行治疗，但是对于成年有益处的疗法并不见得也对儿童有好处，研究者Michael这样说，他还表示，我们的研究重点强调了儿科临床研究的重要性及其意义。

这项研究在哈佛大学医学院等几家医院进行，从出生到36个月大的婴儿或儿童被随机进行严密的血糖控制或者标准的ICU流程，研究者持续追踪观察30天。当标准治疗组不接受胰岛素时，接受胰岛素的严密血糖控制组可以使得机体恢复正常的血糖水平。所有的参与组都会进行持续的低血糖症状，但是严密控制血糖组会很快达到正常的血糖水平。

“我们的研究步骤可以很快地达到胰岛素控制水平，但是这并不能改善儿童的健康状况，未来我们将会继续深入研究，或许我们这种疗法仅仅对一部分人群有益。”研究者Michael这样说。

编译自：Blood Sugar Control Does Not Help Infants and Children Undergoing Heart Surgery, Study Finds

doi:10.1056/NEJMoa1206044
PMC:
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Tight Glycemic Control versus Standard Care after Pediatric Cardiac Surgery

Michael S.D. Agus, M.D., Garry M. Steil, Ph.D., David Wypij, Ph.D., John M. Costello, M.D., M.P.H., Peter C. Laussen, M.B., B.S., Monica Langer, M.D., Jamin L. Alexander, B.A., Lisa A. Scoppettuolo, M.S., Frank A. Pigula, M.D., John R. Charpie, M.D., Ph.D., Richard G. Ohye, M.D., and Michael G. Gaies, M.D., M.P.H. for the SPECS Study Investigators

Background In some studies, tight glycemic control with insulin improved outcomes in adults undergoing cardiac surgery, but these benefits are unproven in critically ill children at risk for hyperinsulinemic hypoglycemia. We tested the hypothesis that tight glycemic control reduces morbidity after pediatric cardiac surgery.

Methods In this two-center, prospective, randomized trial, we enrolled 980 children, 0 to 36 months of age, undergoing surgery with cardiopulmonary bypass. Patients were randomly assigned to either tight glycemic control (with the use of an insulin-dosing algorithm targeting a blood glucose level of 80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) or standard care in the cardiac intensive care unit (ICU). Continuous glucose monitoring was used to guide the frequency of blood glucose measurement and to detect impending hypoglycemia. The primary outcome was the rate of health care–associated infections in the cardiac ICU. Secondary outcomes included mortality, length of stay, organ failure, and hypoglycemia.

Results A total of 444 of the 490 children assigned to tight glycemic control (91%) received insulin versus 9 of 490 children assigned to standard care (2%). Although normoglycemia was achieved earlier with tight glycemic control than with standard care (6 hours vs. 16 hours, P<0.001) and was maintained for a greater proportion of the critical illness period (50% vs. 33%, P<0.001), tight glycemic control was not associated with a significantly decreased rate of health care–associated infections (8.6 vs. 9.9 per 1000 patient-days, P=0.67). Secondary outcomes did not differ significantly between groups, and tight glycemic control did not benefit high-risk subgroups. Only 3% of the patients assigned to tight glycemic control had severe hypoglycemia (blood glucose <40 mg per deciliter [2.2 mmol per liter]).

Conclusions Tight glycemic control can be achieved with a low hypoglycemia rate after cardiac surgery in children, but it does not significantly change the infection rate, mortality, length of stay, or measures of organ failure, as compared with standard care. (Funded by the National Heart, Lung, and Blood Institute and others; SPECS ClinicalTrials.gov number, NCT00443599.)