罹患肺炎且低血糖患者死亡風險非常高
作者：Jim Kling
出處：WebMD醫學新聞
April 13, 2010（華盛頓特區）－研究者於醫院醫學學會（SHM）2010年年會上報告，低血糖患者如果同時有肺炎的話，死亡風險增加。
聖安東尼奧德州健康科學中心的住院醫師Sean Garcia表示，有低血糖與肺炎的患者應該接受嚴密監測，不論他們肺炎特定風險系統評分多少，根據這些風險評估系統，他們一般會出院。
他表示，根據傳統評分系統CURB-65與肺炎嚴重度指標，這些病患的30天死亡率介於9%~27%。
Garcia醫師向Medscape內科學表示，已發表的研究顯示，低血糖與老年病患死亡風險，以及敗血症病患或大腸桿菌菌血症、還有兒童罹患肺炎之間是有相關性的。
他向年會與會者表示，我想要評估低血糖與成人肺炎之間可能的關連性。
Garcia醫師與其同事們將血糖值低於70 mg/dl定義為低血糖，他們回顧了787位被診斷罹患社區性肺炎的病歷，這些病患中，22位（2.8%）在住院時有低血糖。有低血糖患者，相較於沒有低血糖患者，未校正的死亡率為27.3%相較於8.6%。
在住院時，罹患社區性肺炎患者接受死亡風險評估。超過一半（55%）被評估為低死亡風險，33%為中度風險、12%為高風險。
Garcia醫師表示，處於相對低風險的肺炎病患一般接受感染治療，且並不會注意到低血糖的風險。
Garcia醫師指出，基礎醫學研究結果顯示，這兩者之間的關係可能與身體對壓力的反應有關。我們並不知道為什麼會這樣，但是很顯然地，低血糖是肺炎患者死亡率的一個顯著指標。
SHM醫師發言人，同時也是麻州布萊根婦女醫院駐診醫師的Danielle Scheurer醫師表示，一個完整的照護計畫，包括駐診醫師定時訪視，對高風險病患來說是必須的。
Scheurer醫師表示，我們的角色在於找出每位病患需要多密集的醫療服務，且來自於低血糖的死亡風險增加是需要特別注意的一個很好的例子。她指出，類似這樣的病例通常是很複雜的，需要醫師能夠改變現實世界的照護計畫。
Garcia醫師建議，低血糖且罹患肺炎患者應該持續接受血糖監測以及疾病的任何變化，或許在恢復單位或至少在一個嚴密監測的環境會比較好。
Scheurer醫師附帶表示，多專業照護的特點在於重複決策的能力。
最重要的是，Garcia醫師與Scheurer表示，處於高死亡風險的患者不應該出院。
這項研究沒有接受外在商業贊助。Garcia與Scheurer醫師表示沒有相關資金上的往來。
Patients With Pneumonia and Hypoglycemia Have a Very High Risk for Mortality
By Jim Kling
Medscape Medical News
April 13, 2010 (Washington, DC) — Patients who have low blood sugar are at increased risk for mortality if they contract pneumonia. The comorbidity quadruples their risk for death, and hospitalists can play a key role in the management of these patients, investigators reported here at Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting.
Patients with hypoglycemia and pneumonia should be closely monitored, regardless of the level of risk reflected on pneumonia-specific risk systems, and even if, according to these risk assessment systems, they would normally be discharged, said Sean Garcia, MD, a hospitalist at the University of Texas Health Sciences Center in San Antonio.
The 30-day mortality risk ranges from 9% to 27%, according to the traditional scoring measures of CURB-65 and the Pneumonia Severity Index, he reported.
Dr. Garcia told Medscape Internal Medicine that published studies have shown a link between hypoglycemia and risk for mortality in elderly patients and in patients with sepsis or Escherichia coli in the blood, and in children with pneumonia.
"I wanted to assess the possible connection between low blood sugar and adult pneumonia," he told meeting attendees.
As their definition of hypoglycemia, Dr. Garcia and his colleagues used blood glucose levels lower than 70?mg/dL. They reviewed the medical records of 787 patients diagnosed with community-acquired pneumonia. Of those, 22 (2.8%) had hypoglycemia on admission to the hospital. The unadjusted mortality for hypoglycemic patients was 27.3%, and for normoglycemic patients was 8.6%.
On hospital admission, patients with pneumonia were assessed for risk for mortality. More than half (55%) had a low risk for mortality, 33% had a moderate risk, and 12% had a high risk.
Dr. Garcia said that patients at otherwise low risk for mortality with pneumonia are generally treated for the infection, and little attention is paid to the risk posed by hypoglycemia.
"Basic science research suggests that the link between the 2 may have something to do with the body's response to stress," said Dr. Garcia. "We don't know exactly why, but this study makes it pretty clear that low blood sugar is a significant marker of mortality for patients with pneumonia," he said.
A comprehensive care plan, including round the clock monitoring by a hospitalist, is needed for patients who have this high mortality risk, said Danielle Scheurer, MD, physician spokesperson for SHM and a hospitalist at Brigham and Women's Hospital in Boston, Massachusetts.
"Our role is to identify the intensity of service that is required for each patient, and the increased mortality risk from hypoglycemia is a good example of the need for this specialized attention," said Dr. Scheurer. "Cases like this are always complicated and require the physician to be able to make changes in the care plan in real time," she said.
Dr. Garcia recommended that patients with low blood sugar and pneumonia be monitored continually for blood sugar readings and any progression of the disease, perhaps in a step-down hospital unit or, at minimum, a closely monitored setting.
"The hallmark of multidisciplinary care is the ability to have repeated decision-making," Dr. Scheurer added.
Above all, said Drs. Garcia and Scheurer, patients who have this high a risk for mortality should not be discharged from the hospital.
The study did not receive commercial support. Dr. Garcia and Dr. Scheurer have disclosed no relevant financial relationships.
Hospital Medicine 2010: Society of Hospital Medicine (SHM) Annual Meeting. Abstract?55. Presented April?9, 2010.
