Journal: Crit Care Med 36(12):1-12, 2008. 28 References
Reprint: Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University, King Abdulaziz Medical City, PO Box 22490, Intensive Care Department, MC 1425, Riyadh, 11426 (YM Arabi, MD, FCCP, FCCM)
Faculty Disclosure: Abstracted by S. Ouellette, who has nothing to disclose.
In 2001, Van den Berghe et al. reported that intensive insulin therapy (IIT) in surgical intensive care unit (ICU) patients was associated with a reduction in morbidity and mortality. The study, which was stopped early at interim analysis, ignited great interest leading to calls to adopt this therapy as a standard of care for ICU patients. Caution was raised after a multicenter study of IIT in patients with severe sepsis because of significant increase in hypoglycemia without improved survival. In addition, Van den Berghe et al. reported the results on a similar study in medical ICU patients and found no overall reduction in mortality with IIT. However, they found that patients with ICU stay >3 days had reduced mortality with IIT. Because of concerns about trials stopped early for benefit, it was suggested that the potential benefit of IIT shown in surgical patients may have been inflated. It was also suggested that the second trial in medical patients ran a similar risk by overemphasizing post hoc results and secondary end points.
The purpose of this study was to examine whether IIT is beneficial in reducing mortality in medical (nonoperative) and surgical (postoperative) ICU patients. A total of 523 patients were randomly assigned to receive IIT (target blood glucose of 4.4-6.1 mmol/L or 80-110 mg/dL) or conventional insulin therapy (target blood glucose 10-11.1 mmol/L or 180-200 mg/dL). The primary endpoint was intensive care unit mortality. Secondary endpoints included hospital mortality, intensive care unit and hospital length of stay, mechanical ventilation duration, the need for renal replacement therapy and packed red cell transfusion, and the rates of ICU acquired infections as well as the rate of hypoglycemia (defined as blood glucose ≤ 2.2 mmol/L or 40 mg/dL). There was no significant difference in ICU mortality between the groups. Hypoglycemia occurred more frequently in the IIT group. There was no difference between groups in any secondary end points. Based on these results, investigators do not recommend universal application of IIT in ICU patients. |
