Chest -- eLetters for Hamdulay et al., 129 (3) 800-804

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selected reports:
Shahir S. Hamdulay, Ali Al- Khafaji, and Hugh Montgomery
Glucose-Insulin and Potassium Infusions in Septic Shock
Chest 2006; 129: 800-804 [Abstract] [Full text] [PDF]

eLetters: Submit a response to this article

Electronic letters published:

Is intensive insulin therapy safe in the critically ill?: Mohamed Y Rady (15 March 2006)

Is intensive insulin therapy safe in the critically ill? 15 March 2006

Mohamed Y Rady,
Professor
Critical Care Medicine, Mayo Clinic College of Medicine, Mayo Clinic Arizona
Send letter to journal:
Re: Is intensive insulin therapy safe in the critically ill?

rady.mohamed {at}mayo.edu Mohamed Y Rady

The authors described two similar cases of severe reversible cardiac depression, temporally related to exposure to chemotherapy agents for treatment of lymphoma or prior to haploidentical bone marrow transplantation. Both cases required continuous venovenous hemofiltration, which had been reported to result in reversal of septic shock and hemodynamic improvement over time because of plasma clearance of myocardial depressant cytokines (1). It could be argued that the hemodynamic recovery witnessed was not related to insulin-glucose infusion but was explained by time dependent plasma clearance of inflammatory cytokines because of earlier initiation of continuous renal replacement therapy.
There are several studies that indicate that indiscriminate intensive insulin therapy can result in attributable mortality. The CREATE-ECLA randomized controlled trial in acute myocardial infarction, reported that insulin therapy at blood glucose below 7 mmol/L (or 140 mg/dL) increased the mortality rate to 8.3% ( control mortality rate 6.6% , P<0.01)(2). Murcia et al reported that the cumulative risk for total mortality including cardiovascular mortality and morbidity increased with insulin treatment in diabetic patients with acute myocardial infarction and left ventricular failure (3). Several studies had reported independent risk for death from insulin treatment in acute critical illness (4-6). In a recent study by Van den Berghe et al, intensive insulin therapy in patients with short length of stay in the intensive care unit and low severity of illness had much higher mortality (27%) compared to conventional insulin therapy (19%), P<0.01 (7). The premature and indiscriminate use of intensive insulin therapy in the intensive care unit based on recent recommendations (8) without robust scientific evidence may have resulted in preventable death across the United States.
1. Honore PM, Jamez J, Wauthier M, et al. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med. 2000;28(11):3581-3587.
2. The CREATE-ECLA Trial Group Investigators. Effect of Glucose- Insulin-Potassium Infusion on Mortality in Patients With Acute ST-Segment Elevation Myocardial Infarction: The CREATE-ECLA Randomized Controlled Trial. JAMA. 2005;293(4):437-446.
3. Murcia AM, Hennekens CH, Lamas GA, et al. Impact of Diabetes on Mortality in Patients With Myocardial Infarction and Left Ventricular Dysfunction. Arch Intern Med. 2004;164(20):2273-2279.
4. Van den Berghe G, Wouters PJ, Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359-366.
5. Finney SJ, Zekveld C, Elia A, Evans TW. Glucose control and mortality in critically ill patients. JAMA. 2003;290(15):2041-2047.
6. Rady MY, Johnson DJ, Patel BM, Larson JS, Helmers RA. Influence of Individual Characteristics on Outcome of Glycemic Control in Intensive Care Unit Patients With or Without Diabetes Mellitus. Mayo Clin Proc. . 2005;80:1558-1567
7. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive Insulin Therapy in the Medical ICU. N Engl J Med. 2006;354(5):449-461.
8. Garber AJ, Moghissi ES, Bransome ED, Jr., et al. American College of Endocrinology position statement on inpatient diabetes and metabolic control. Endocrine Practice. 2004;10(1):77-82.