Tuesday, December 30, 2008

Top 10 issues in hospital medicine for 2008, issue 5: what do we know about glycemic control in hospitalized patients?

Less than we thought we did this time last year, which wasn’t much. Since that time, non-evidence for strict glycemic control has been reported at such a dizzying pace I’ve barely been able to keep up with it. My posts from the past year are here, here, here, here and here.

At the close of 2008 what do we have to support glycemic control in hospitalized patients? Little more than observational studies, pathyphysiologic rationale and common sense. Based on such rationale, what we know reduces down to this:

Hyperglycemia is common in hospitalized patients, many of whom did not have a prior diagnosis of diabetes. It should not be ignored.

Sliding scale insulin should not be the sole means of glycemic control in hospitalized patients. Basal coverage should be included in the regimen.

Insulin drip protocols are appealing for ICU patients because of their rapidity of action, the flexibility they afford and the fact that subcutaneous insulin absorption is unreliable in hypoperfusion states.

Glycemic control does matter, but the best treatment targets are not known, and probably vary from one clinical state to another (sepsis, stroke, acute coronary syndrome, perioperative period).

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