"Жесткий" контроль гликемии в интенсивной терапии

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Результаты важного [Ссылки доступны только зарегистрированным пользователям ] у нехирургических пациентов ICU опубликованы в последнем NEJM.

Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006 Feb 2;354(5):449-461.
BACKGROUND: Intensive insulin therapy reduces morbidity and mortality in patients in surgical intensive care units (ICUs), but its role in patients in medical ICUs is unknown. METHODS: In a prospective, randomized, controlled study of adult patients admitted to our medical ICU, we studied patients who were considered to need intensive care for at least three days. On admission, patients were randomly assigned to strict normalization of blood glucose levels (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) with the use of insulin infusion or to conventional therapy (insulin administered when the blood glucose level exceeded 215 mg per deciliter [12 mmol per liter], with the infusion tapered when the level fell below 180 mg per deciliter [10 mmol per liter]). There was a history of diabetes in 16.9 percent of the patients. RESULTS: In the intention-to-treat analysis of 1200 patients, intensive insulin therapy reduced blood glucose levels but did not significantly reduce in-hospital mortality (40.0 percent in the conventional-treatment group vs. 37.3 percent in the intensive-treatment group, P=0.33). However, morbidity was significantly reduced by the prevention of newly acquired kidney injury, accelerated weaning from mechanical ventilation, and accelerated discharge from the ICU and the hospital. Although length of stay in the ICU could not be predicted on admission, among 433 patients who stayed in the ICU for less than three days, mortality was greater among those receiving intensive insulin therapy. In contrast, among 767 patients who stayed in the ICU for three or more days, in-hospital mortality in the 386 who received intensive insulin therapy was reduced from 52.5 to 43.0 percent (P=0.009) and morbidity was also reduced. CONCLUSIONS: Intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy. Further studies are needed to confirm these preliminary data. (ClinicalTrials.gov number, NCT00115479.)

Наверное, еще много будет комментариев по этой работе, но [Ссылки доступны только зарегистрированным пользователям ] мне показался весьма интересным. В конце его автором сформулирована наиболее приемлемая, как мне показалось, на сегодняшний день тактика tight glycemic control:

In my opinion, a reasonable approach would be to provide adequate exogenous insulin to achieve target glucose values of less than 150 mg per deciliter (8.3 mmol per liter), at least during the first three days in the ICU. If critical illness persists beyond three days despite the provision of other proven therapies and resuscitation, a goal of normoglycemia (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) could then be considered, to maximize the potential benefits. This approach would allow time for a gradual increase in calories in enteral feedings, which should minimize hypoglycemic complications.

Интересно, насколько в отечественной практике реально достижение таких жестких показателей гликемии без угрозы частых гипогликемических состояний? Может быть, кто-то работает по определенным протоколам? Как при этом кормите пациентов?