RESUMO
Hyperglycemia is common in critical illness and leads to increased morbidity and mortality. Controversy exists whether tight glycemic control via intensive insulin therapy can safely and effectively improve outcomes. In this review article, we will sort through the pertinent evidence base to identify salient, yet emergent, paradigms to guide management. To this end, we will discuss underlying biologic mechanisms relevant to hyperglycemia and insulinization in critical illness, summarize results of major randomized controlled clinical trials for glycemic control in the intensive care unit (ICU), and fill in the gaps with necessary information. We will conclude with specific messages, not only reflecting our own clinical experiences, but amenable to implementation in different ICU settings.
Assuntos
Glicemia/análise , Cuidados Críticos/métodos , Estado Terminal , Gerenciamento Clínico , Hiperglicemia/tratamento farmacológico , Hipoglicemia/prevenção & controle , Adaptação Fisiológica , Protocolos Clínicos , Cuidados Críticos/economia , Complicações do Diabetes/sangue , Complicações do Diabetes/fisiopatologia , Dislipidemias/tratamento farmacológico , Dislipidemias/etiologia , Humanos , Hiperglicemia/economia , Hiperglicemia/etiologia , Hiperglicemia/fisiopatologia , Hiperglicemia/prevenção & controle , Hipoglicemia/etiologia , Insulina/efeitos adversos , Insulina/farmacologia , Insulina/uso terapêutico , Unidades de Terapia Intensiva , Medicare/economia , Estudos Multicêntricos como Assunto , Apoio Nutricional , Estresse Oxidativo/efeitos dos fármacos , Guias de Prática Clínica como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Estresse Fisiológico/fisiologia , Estados UnidosRESUMO
Recent guidelines for the evaluation of thyroid nodules clarify the diagnostic algorithm while also reporting important differences. The performance of fine needle aspiration (FNA) for cytological examination follows serum TSH determination and thyroid ultrasonography. Thyroid scintigraphy is recommended following a low TSH value and/or FNA yielding an indeterminate follicular cytology. The use of thyroid ultrasonography is the source of some controversy: though it is recommended as a principal first test, its real-time use to guide FNA ranges from routine to only following an FNA yielding an inadequate or nondiagnostic cytological result. In clinical practice, the proportion of physicians utilizing ultrasonography, scintigraphy and FNA varies and frequently deviates from recommended guidelines. The development of guidelines is necessary to bring about consistency and optimization to the diagnostic work-up of thyroid nodules. It is likely that novel diagnostic procedures, such as molecular markers, large needle aspiration biopsy and thyroid imaging with tracers beyond conventional radioactive iodine or (99m)Tc pertechnetate, will lead to improved performance and implementation of guidelines.