Гликемия у пациентов отделений общего профиля

[Samitin]

В JCEM [J Clin Endocrinol Metab, January 2012, 97(1):16–38, Management of Hyperglycemia in Hospitalized Patients in Non-Critical Care Setting: An Endocrine Society Clinical Practice Guideline, [Ссылки доступны только зарегистрированным пользователям ]] опубликовано руководство TES по контролю гликемии упациентов отделений общего профиля (не реанимационных).

Приведу несколько выдержек:

We recommend that patients without a history of diabetes with BG greater than 7.8 mmol/liter (140 mg/dl) be monitored with bedside point of care (POC) testing for at least 24 to 48 h. Those with BG greater than 7.8 mmol/ liter require ongoing POC testing with appropriate therapeutic intervention.

We recommend that in previously normoglycemic patients receiving therapies associated with hyperglycemia, such as corticosteroids or octreotide, enteral nutrition (EN) and parenteral nutrition (PN) be monitored with bedside POC testing for at least 24 to 48 h after initiation of these therapies. Those with BG measures greater than 7.8 mmol/liter (140 mg/dl) require ongoing POC testing with appropriate therapeutic intervention.

We recommend that all inpatients with known diabetes or with hyperglycemia (>7.8 mmol/liter) be assessed with a hemoglobin A1C (HbA1C) level if this has not been performed in the preceding 2–3 months.

Werecommend a premeal glucose target of less than 140 mg/dl (7.8 mmol/liter) and a random BG of less than 180 mg/dl (10.0 mmol/liter) for the majority of hospitalized patients with non-critical illness.

We suggest that glycemic targets be modified according to clinical status. For patients who are able to achieve and maintain glycemic control without hypoglycemia, a lower target range may be reasonable. For patients with terminal illness and/or with limited life expectancy or at high risk for hypoglycemia, a higher target range (BG < 11.1 mmol/liter or 200 mg/dl) may be reasonable.

For avoidance of hypoglycemia, we suggest that antidiabetic therapy be reassessed when BG values fall below 5.6 mmol/liter (100 mg/dl). Modification of glucose-lowering treatment is usually necessary whenBGvalues are below 3.9 mmol/liter (70 mg/dl).

We recommend insulin therapy as the preferred method for achieving glycemic control in hospitalized patients with hyperglycemia.

We suggest the discontinuation of oral hypoglycemic agents and initiation of insulin therapy for the majority of patients with type 2 diabetes at the time of hospital admission for an acute illness.

We suggest that prolonged use of sliding scale insulin (SSI) therapy be avoided as the sole method for glycemic control in hyperglycemic patients with history of diabetes during hospitalization.

We recommend that scheduled sc insulin therapy consist of basal or intermediate-acting insulin given once or twice a day in combination with rapid- or short-acting insulin administered before meals in patients who are eating.

Обращает внимание рекомендация исследования гликированного гемоглобина при выявлении гликемии более 7,8 ммоль/л, а также довольно жесткие целевые уровни гликемии в течение суток - до 10 ммоль/л (если сравнивать с рекомендациями для реанимационных отделений, где максимальный допустимый уровень глюкозы - 11 ммоль/л). Кроме того, указано, что режим многократных инъекций инсулина короткого действия является менее предпочтительным у больных с сахарным диабетом в сравнении с интенсифицированной схемой с использованием пролонга.
Правда, необходимо отметить, что большинство приведенных рекомендаций имеет средний или низкий уровень доказательности.