低血糖與住院的糖尿病患死亡率有關

作者：Laurie Barclay, MD  
出處：WebMD醫學新聞

　　July 13, 2009 — 根據7月份糖尿病照護期刊的一篇回溯世代研究結果，一般病房的糖尿病患者，低血糖與增加住院天數(LOS)及較高死亡率有關。
　　
　　布萊根婦女醫院的Michael E. Matheny醫師等人寫道，低血糖與加護病房內多類病患的不佳結果有關。還不知道非重症的糖尿病患是否有同樣的風險。在本研究中，我們的目標在於檢視發生低血糖是否與一般病房之糖尿病患者的死亡率較高有關。
　　
　　在2003年1月至2004年8月間，總共有2,582名糖尿病患與4,368名病患在一間教學醫院的一般病房住院，研究者使用多變項分析，檢視發生低血糖的次數與嚴重度和住院病患死亡率、LOS、出院後一年內死亡率等的關係。
　　
　　低血糖的定義為血糖值小於等於50 mg/dL，有7.7%住院患者發生。每發生一次的低血糖，增加LOS達2.5天(P < .0001)，住院期間死亡機率增加達85.3% (P = .009)，出院後一年內死亡機率增加達65.8%(P = .0003)。住院期間紀錄的最低血糖值每降低10-mg/dL，住院期間死亡機率增加達三倍(P = .0058)。
　　
　　研究作者寫道，一般病房的糖尿病住院患者常發生低血糖。低血糖病患會增加LOS，且住院和出院後的死亡率均較高。應該對這些高風險的病患進行監測，以降低發生低血糖的頻率。
　　
　　研究限制包括回溯型分析，無法推測因果關係；只納入波士頓的單一教學醫院；未區分第1和第2型糖尿病。其他限制包括，缺乏個別病患的營養資料、缺乏立即的臨床後遺症資料、使用重點照護血糖值數據。
　　
　　研究作者結論表示，需採取額外照護來預防此類高風險病患的低血糖事件，需特別注意以達成抗高血糖處方和營養攝取。同時，一般病房之糖尿病患的低血糖應被視為趨近臨床惡化的警訊。因此可作為需要增加照護、更多積極治療、轉到加護病房、案例控制的指標。
　　
　　糖尿病行動研究與教育基金會和國家醫學圖書館支持本研究。研究作者宣告沒有相關財務關係。

Hypoglycemia Linked With Mortality in Hospitalized Diabetic Patients

By Laurie Barclay, MD
Medscape Medical News

July 13, 2009 — In diabetic patients hospitalized in the general ward, hypoglycemia is common and is associated with an increased length of stay (LOS) and higher mortality rate, according to the results of a retrospective cohort study reported in the July issue of Diabetes Care.

"Hypoglycemia is associated with adverse outcomes in mixed populations of patients in intensive care units," write Michael E. Matheny, MD, MS, MPH, from the Brigham and Women's Hospital in Boston, Massachusetts, and colleagues. "It is not known whether the same risks exist for diabetic patients who are less severely ill. In this study, we aimed to determine whether hypoglycemic episodes are associated with higher mortality in diabetic patients hospitalized in the general ward."

Between January 2003 and August 2004, a total of 2582 patients with diabetes had a total of 4368 admissions to the general ward of a teaching hospital. Using multivariable analysis, the investigators examined associations between the number and severity of hypoglycemic episodes and inpatient mortality, LOS, and mortality within 1 year after hospital discharge.

Hypoglycemia, defined as a blood glucose level of 50 mg/dL or less, occurred in 7.7% of admissions. For every additional day with hypoglycemia, there was an increase in LOS by 2.5 days (P < .0001), in the odds of inpatient death by 85.3% (P = .009), and in the odds of death within 1 year from discharge by 65.8% (P = .0003). For every 10-mg/dL decrease in the lowest blood glucose level recorded during hospitalization, the odds of death during hospitalization were increased 3-fold (P = .0058).

"Hypoglycemia is common in diabetic patients hospitalized in the general ward," the study authors write. "Patients with hypoglycemia have increased LOS and higher mortality both during and after admission. Measures should be undertaken to decrease the frequency of hypoglycemia in this high-risk patient population."

Limitations of this study include retrospective analysis, precluding determination of causality; inclusion only of patients admitted to a single academic hospital in Boston; and inability to distinguish type 1 from type 2 diabetes. Other limitations include lack of nutrition information for individual patients, lack of data regarding immediate clinical sequelae, and use of point-of-care blood glucose levels.

"Extra care should be taken to prevent hypoglycemic events in this population already at high risk for adverse events, with particular attention being paid to matching the antihyperglycemic regimen to the nutritional intake," the study authors conclude. "At the same time, hypoglycemia among diabetic patients in the general ward could be interpreted as a warning sign of an impending clinical deterioration. It could therefore serve as a useful indicator for the necessity of increased monitoring, more aggressive treatment of infections, transitioning to a more intensive care setting, and case management."

This study was supported in part by grants from the Diabetes Action Research and Education Foundation and the National Library of Medicine. The study authors have disclosed no relevant financial relationships.

Diabetes Care. 2009;32:1153-1157.