Department of Internal Medicine, Division of Diabetes, University of Nebraska Medical Center, Omaha, Nebraska 68198-3020, USA.
J Clin Endocrinol Metab. 2011 Sep;96(9):2652-62. doi: 10.1210/jc.2011-0255.
Glucose control improves outcomes in the hospitalized patient, particularly patients on prolonged ventilator support, after acute myocardial infarction or after coronary artery bypass surgery. An iv insulin algorithm is the standard of care for initial treatment of significant hyperglycemia in the hospitalized patient, and it can be transitioned to periodic sc insulin once the patient is more stable. However, illness, medications, the endocrine and inflammatory response to stress, and pain can all contribute to insulin resistance and further aggravate preexisting insulin resistance caused by obesity. Glucose treatment goals have been established to guide the rapy, but achieving those goals can be more challenging in the presence of severe insulin resistance. When target glucose values are not achieved with established insulin algorithms, the practitioner should evaluate for potential causes of insulin resistance from technical factors that cause "pseudo-insulin resistance" as well as other modifiable factors, such as electrolyte disorders, parenteral and enteral nutrition, or other medications. Published glucose guidelines provide glucose "goals" to guide changes in the insulin algorithm, but these goals may be difficult to achieve in all individuals. We propose a stepwise approach to evaluate and treat severe insulin resistance in the hospitalized patient in order to achieve glucose goals in a timely fashion.
血糖控制可改善住院患者的预后，尤其是急性心肌梗死或冠状动脉旁路手术后需要长时间接受呼吸机支持的患者。静脉内胰岛素方案是治疗住院患者严重高血糖的标准治疗方法，当患者病情更稳定后，可以过渡到定期皮下胰岛素。然而，疾病、药物、应激时的内分泌和炎症反应以及疼痛均可导致胰岛素抵抗，并进一步加重肥胖引起的固有胰岛素抵抗。已制定血糖治疗目标以指导治疗，但在严重胰岛素抵抗的情况下，实现这些目标可能更具挑战性。当既定胰岛素方案无法实现目标血糖值时，临床医生应评估导致“假性胰岛素抵抗”的技术因素以及其他可改变的因素（如电解质紊乱、肠外和肠内营养或其他药物），以确定胰岛素抵抗的潜在原因。已发表的血糖指南提供了指导胰岛素方案改变的血糖“目标”，但这些目标在所有个体中可能难以实现。我们提出了一种逐步评估和治疗住院患者严重胰岛素抵抗的方法，以便及时实现血糖目标。
