Endocrine Critical Care

Intensive insulin therapy

van den Berghe, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-1377.  Oft-cited RCT found patients in a surgical intensive care unit receiving intensive insulin therapy (blood glucose 80-110 mg/dl) had improved ICU mortality (4.6% vs. 8% in conventional group).  Although the study was performed in an SICU population, patients in the ICU > 5 days and patients with multi-organ failure related to sepsis showed the greatest benefit, which suggested the results were applicable to the MICU.
PMID:  11794168
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van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006; 354:449-61. RCT of 1200 MICU patients found those randomized to intense therapy had reduced risk of acute renal injury and shorter duration of ICU stay, but no difference in mortality. Of note, patients with ICU stays < 3 days had higher mortality than controls while those with stays > 3 days had reduced mortality with intensive control.
PMID:  16452557
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Finfer S, Chittock DR, Su SY, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283-97. The NICE-SUGAR trial randomized 6,104 MICU and SICU patients with anticipated ICU stay of > 3 days to tight (81 – 108 mg/dl) or conventional (144 - 180 mg/dl) glucose control and found 90-day mortality of 27.5% with tight control vs. 24.9% with conventional (p = 0.02). The groups did not differ in secondary outcomes including duration of hospital and ICU stay or need for dialysis. In contrast, the van den Berghe studies targeted a glucose of under 215 mg/dl in the control group, had greater use of parenteral nutrition, and were performed at a single center.
PMID:  19318384
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