血糖波动对危重患儿预后影响的前瞻性研究

Prospective study on the effect of glycemic variability on the prognosis of critically ill children

摘要:

目的：探究血糖波动与危重患儿不良预后的关系，寻找代表血糖波动的最优指标。方法：前瞻性收集2020年1月1日至2020年8月31日重庆医科大学附属儿童医院重症医学科（pediatric intensive care unit，PICU）收治的280例危重患儿资料，以入PICU后28 d转归情况分为生存组和死亡组，记录入住PICU后72 h内的生理参数及结局资料，运用受试者工作特征（receiver operating characteristic，ROC）曲线及logistic回归分析等统计学方法进行统计分析。结果：①不同血糖波动指标中，血糖标准差（standard deviation，SD）（AUC=0.759，95%CI=0.688~0.830，P<0.001）和血糖不稳定指数（glycemic lability index，GLI）（AUC=0.752，95%CI=0.680~0.825，P<0.001）对预后具有更好的评价效能。多因素logistic回归分析显示，调整了疾病严重程度、血管活性药物评分、心肺复苏等其他影响死亡率的混杂因素及平均血糖后，SD所代表的血糖波动（OR=3.356，95%CI=1.536~7.332，P=0.002），PIM（pediatric index of mortality）评分（OR=1.155，95%CI=1.023~1.303，P=0.020）及PICU住院时间（OR=0.895，95%CI=0.837~0.956，P=0.001）是PICU患儿28 d死亡率的独立危险因素。②进一步将平均血糖水平及血糖波动分层分析，高血糖波动组的死亡率均高于低血糖波动组，具有低平均血糖同时具有高血糖波动的患儿死亡率最高。结论：危重患儿血糖波动是独立于平均血糖的死亡危险因素，SD、GLI可能是代表血糖波动的优势指标。临床医生关注平均血糖水平的同时更要关注血糖波动。

Abstract:

Objective：To explore the effect of glycemic variability（GV） on the prognosis of critically ill children and to find the best indicators of GV. Methods：A total of 280 critically ill children admitted to the pediatric intensive care unit（PICU） of the Children’s Hospital of Chongqing Medical University from January 1st，2020 to August 31st，2020 were prospectively included in the study. The patients were divided into survivors or non-survivors according to the 28-day outcomes after PICU admission. Physiological parameters and outcomes data were recorded for 72 h after PICU admission，and the statistical analyses were made by several statistical methods such as the receiver operating characteristic（ROC） curve and logistic regression analysis. Results：①In different indicators of GV，glycemic standard deviation（SD）（AUC=0.759，95%CI=0.688-0.830，P<0.001） and glycemic lability index（GLI）（AUC=0.752，95%CI=0.680-0.825，P<0.001） were superior to the others for the prognosis. Multivariate logistic regression analysis also showed that SD（OR=3.356，95%CI=1.536-7.332，P=0.002），PIM（pedi－atric index of mortality） scores（OR=1.155，95%CI=1.023-1.303，P=0.020） and stay of PICU（OR=0.895，95%CI=0.837-0.956，P=0.001） showed an independent association with PICU 28-day mortality. ②Different from adult studies，there was a heteroge－neous effect of GV on children，and subgroup analysis disaggregated by tertiles of Mean and GV revealed that critically ill children in the lowest tertile of the Mean and in the highest tertile of GV had significantly highest mortality. Conclusion：GV can increase the risk of mortality in critically ill children，and among all glucose parameters，SD and GLI may be the dominant predictors representing for GV. Clinicians should pay more attention to GV as well as average blood glucose.