背景:维持危重患者的血糖控制可能会影响预后,如生存,感染,和神经肌肉恢复,但是目标血液水平是均衡的,监测频率,和方法。
目的:目的是更新2012年重症监护医学学会和美国重症监护医学院(ACCM)指南,并对文献进行新的系统回顾,为临床医生提供可操作的指导。
■共有22个多专业工作组,由临床医生和患者/家庭倡导者组成,方法学家应用了ACCM指南标准操作程序手册中描述的过程,以制定基于证据的建议,与建议评估等级保持一致,发展,和评估方法(等级)方法。在准则的所有阶段都严格遵守利益冲突政策,包括小组选择和投票。
方法:我们对每个人群进行了系统评价,干预,比较器,以及与危重患儿(≥42周龄调整胎龄至18岁)和成人的血糖管理相关的结局问题,包括启动胰岛素治疗的触发因素,给药途径,监测频率,协议维护的明确决策支持工具的作用,和葡萄糖测试方法。我们找到了最好的证据,统计总结了证据,然后使用分级方法评估证据质量。我们使用证据决策框架来制定建议,无论是强还是弱,还是良好的实践声明。此外,“在我们的实践中,”当现有证据不足以支持一项建议时,就会包括声明,但是小组认为描述他们的实践模式可能是合适的。确定了未来研究的其他主题。
结果:本指南更新了危重患者使用胰岛素输注治疗高血糖的指南。它旨在让成人和儿科从业者重新评估当前的做法,并直接研究文献不足的领域。专家组发表了七项与未经选择的成年人的血糖控制有关的声明(两项良好实践声明,四个有条件的建议,一份研究声明)和七份针对儿科患者的声明(两份良好实践声明,一个强烈推荐,一个有条件的建议,两个“在我们的实践中”的陈述,和一份研究声明),提供有关特定子集种群的更多详细信息。
结论:指南小组在明确的临床决策支持工具和血糖不稳定期间的频繁(≤1小时)监测间隔以最小化低血糖和针对目标强化葡萄糖水平的指导下,成人和儿童对胰岛素输注用于急性高血糖管理的偏好达成共识。这些建议旨在考虑患者的现有临床状况。需要进一步的研究来评估个性化血糖指标的作用。连续葡萄糖监测系统,明确的决策支持工具,和标准化的血糖控制指标。
Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods.
The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians.
The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the
guidelines, including panel selection and voting.
We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, \"In our practice\" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research.
This
guideline is an update of the
guidelines for the use of an insulin infusion for the management of
hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two \"In our practice\" statements, and one research statement), with additional detail on specific subset populations where available.
The
guidelines panel achieved
consensus for adults and children regarding a preference for an insulin infusion for the acute management of
hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient\'s existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.