實證醫學競賽： CAT 摘要

1. 實證醫學競賽： CAT 摘要 組別：A

2. 比賽題目 • 58歲，罹患第二型糖尿病的陳先生，因肝膿瘍合併敗血性休克住進加護病房治療。 • 你值班發現病人目前血糖值為249 mg/dL • CR交待不要讓病人血糖低於180，以免發生低血糖； • 但新陳代謝科醫師建議血糖要keep在110以下 • ICU護理人員問你：「請問病人的血糖要如何控制比較好呢？」

3. 臨床問題 • P: Type II DM, liver abcess, septic shock, ICU, adult • I: Glycemic control below 180mg/dl • C:Glycemic control below 110mg/dl • O:Duration of hospital stay, morbidity, mortality, major complications

4. 問題類型 • ✓治療 • □診斷 • □傷害 • □預後

5. 訂定 PICO • P: Sepsis, hyperglycemic adult • I: Tight blood glucose control(≤110) • C: Moderate or no control of blood glucose • O: Mortality Rate

6. 資料庫來源 • Pubmed- search abstracts • OVID- full text articles

7. 搜尋之關鍵字 • “Blood glucose”[MeSH Terms] AND • “Sepsis”[MeSH Terms]

8. 搜尋之歷程 • 於Pubmed用“Blood glucose”[MeSH Terms] AND “Sepsis”[MeSH Terms]搜尋： • 未限制條件時=584篇文章 • 限制條件: English, All adult 共101篇

9. 文獻研讀：第1篇 • 題目及出處：Benefits and Risks of Tight Glucose Control in Critically Ill Adults:JAMA. 2008;300(8):933-944 • 研究設計：Meta-analysis • 研究結果分析： • Randomized controlled trials totaling 8432 patients contributed data for this meta-analysis. • There was also no significant difference in mortality when stratified by glucosegoal ([1] very tight:110 mg/dL; 23% vs 25.2%; RR, 0.90; 95% CI, 0.77-1.04; or[2] moderately tight: 150 mg/dL; 17.3% vs 18.0%; RR, 0.99; 95% CI, 0.83-1.18) orintensive care unit setting ([1] surgical: 8.8% vs 10.8%; RR, 0.88; 95% CI, 0.63-1.22;

10. 文獻研讀：第1篇 • 研究結果分析(續)： • Tight glucose control was not associated with significantly decreased risk for new need for dialysis (11.2% vs 12.1%; RR, 0.96; 95% CI, 0.76-1.20), but was associated with significantly decreased risk of septicemia (10.9% vs 13.4%; RR, 0.76; 95% CI, 0.59-0.97), and significantly increased risk of hypoglycemia(glucose 40 mg/dL; 13.7% vs 2.5%; RR, 5.13; 95% CI, 4.09-6.43). • 結論：A statistically significantassociation with reduction insepticemia, the reduction may have beenin less severe episodes of septicemia,given the lack of an associated reductionin hospital mortality.

15. 參考資料：證據等級和臨床建議

16. 文獻研讀：第2篇 題目： Blood glucose control in patients with severe sepsis and septic shock 出處： World J Gastroenterol. 2009 September 7; 15(33): 4132–4136. Published online 2009 September 7. doi: 10.3748/wjg.15.4132. 研究設計： Systemic review/meta-analysis

17. 結論： • It is now suggested that tight glycemic control with a target blood glucose level of 90-110 mg/dL does not improve clinical outcome. • Less strict glycemic control with a target blood glucose level of 140-180 mg/dL is more effective.

18. 如何應用於臨床？ • 將實證應用到臨床時，你會如何建議？ • 在因敗血症而入加護病房的病人，過度的血糖控制（小於110mg/dl)對病人預後並沒有明顯的好處，而血糖控制在110-150之間對病人相對有較大的好處

19. 可能出現之困境或陷阱 • 臨床應用是否會遭遇困境或有哪些陷阱？ • 目前的研究並沒有針對敗血症做血糖 • 目前的研究，血糖控制較不偏向於將血糖做嚴格的控制,較偏向於將血控控制在較高的level,但並沒有明確的Glucose level

20. 參考資料 pubmed

21. 參考資料：證據的強度

22. 參考資料：證據等級和臨床建議

23. 參考資料