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Tight Blood Glucose Control With Insulin in the ICU^*

Facts and Controversies

^* From the Department of Intensive Care Medicine, Katholieke Universiteit Leuven, Leuven, Belgium.

Correspondence to: Greet Van den Berghe, MD, PhD, Department of Intensive Care Medicine, University Hospital Gasthuisberg, Herestraat 49, B-3000 Leuven, Belgium; e-mail: greet.vandenberghe{at}med.kuleuven.be

Abstract

Recently, the concept that stress hyperglycemia in critically ill patients is an adaptive, beneficial response has been challenged. Two large randomized studies demonstrated that maintenance of normoglycemia with intensive insulin therapy substantially prevents morbidity and reduces mortality in these patients. Since then, questions have been raised about the efficacy in general and in specific subgroups, and about the safety of this therapy with regard to potential harm of brief hypoglycemic episodes and of high-dose insulin administration. These issues are systematically addressed in relation to the available evidence. Intensive insulin therapy during intensive care is effective in reducing the mortality and morbidity of critical illness. The available randomized studies show that an absolute reduction in risk of hospital death of 3 to 4% is to be expected from this therapy in an intention-to-treat analysis. In order to confirm this survival benefit and assign it as statistically significant, future studies should be adequately powered, and hence sample size should be at least 5,000. The absolute reduction in the risk of death increases to approximately 8% when patients are treated with intensive insulin for at least 3 days. Data available thus far indicate that blood glucose control to strict normoglycemia is required to obtain the most clinical benefit. The risk of hypoglycemia increases with this therapy, but it remains unclear whether this is truly harmful in the setting of critical care.

Key Words: critical illness • hyperglycemia • insulin • morbidity • mortality

Related Editorial

Glycemic Control in Critically Ill Patients: Leuven and Beyond

James Krinsley
Chest 2007 132: 1-2. [Full Text] [PDF]

This article has been cited by other articles:

				S. M. Smith and D. S. Hagg Glucose Variance in ICU Patients Receiving Insulin Infusions Chest, May 1, 2008; 133(5): 1288 - 1288. [Full Text] [PDF]

				G. W. Soo Hoo, I. Vanhorebeek, and G. Van den Berghe Tight Blood Glucose Control in the ICU: How Best To Measure Glucose Control? Chest, January 1, 2008; 133(1): 316 - 317. [Full Text] [PDF]

				J. Krinsley Glycemic Control in Critically Ill Patients: Leuven and Beyond Chest, July 1, 2007; 132(1): 1 - 2. [Full Text] [PDF]