We asked whether the relationship between oxygen delivery and oxygen consumption is different between patients who have sepsis and normal (n = 6) or increased (n = 8) concentrations of plasma lactate. We determined oxygen consumption using analysis of respiratory gases while increasing oxygen delivery using a dobutamine infusion. The relationship between oxygen delivery and consumption was y = 124 + 0.043 * x in the normal lactate group and y = 131 - 0.003 * x in the high lactate group (95% CI for differences in slopes, -0.003 to 0.096; p < or = 0.05 for slope, normal versus high lactate). In the normal lactate group, direct oxygen consumption increased by only 8 +/- 6 ml/min/m2 after dobutamine infusion (from 144 +/- 26 to 153 +/- 22 ml/min/m2, p < or = 0.02) despite an average increase of 220 +/- 80 ml/min/m2 in oxygen delivery (from 446 +/- 91 to 666 +/- 90 ml/min/m2, p < or = 0.01). The oxygen extraction ratio fell from 0.27 +/- 0.03 to 0.21 +/- 0.02 after dobutamine (p < or = 0.017). In the high lactate group, direct oxygen consumption decreased by 1 +/- 6 ml/min/m2 after dobutamine (from 131 +/- 33 to 130 +/- 35 ml/min/m2, p > 0.60) despite an average increase of 168 +/- 138 ml/min/m2 in oxygen delivery (from 467 +/- 194 to 635 +/- 300 ml/min/m2, p < or = 0.01). The oxygen extraction ratio fell from 0.30 +/- 0.14 to 0.26 +/- 0.12 after dobutamine (p < or = 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)
INTROduCTION The benefits, harms and feasibility of intensive insulin therapy in critically ill patients remain unclear. Several single center studies have attempted to demonstrate the benefit of intensive insulin therapy in critically ill patients with variable results. ObjECTIvEs We conducted a pilot randomized trial to assess the feasibility, safety and clinical outcomes of preprinted glucose management algorithms before the initiation of a large multicenter trial. PATIENTs ANd mEThOds Within 48 hours of admission to the intensive care unit, we randomized mechanically ventilated patients to either the "high" group (target serum glucose concentration 9-11 mmol/l) or the "low" group (target serum glucose concentration 5-7 mmol/l). To assess feasibility we measured the time to reach target glucose range, time in target range, morning glucose concentrations, average daily glucose concentrations, and number of crossovers. To assess safety, we measured the number of hypoglycemic events (serum glucose <2.2 mmol/l), and other serious adverse events such as cardiac arrests and seizures. REsuLTs Sixty-eight patients were enrolled (35 in the high group and 33 in the low group). During the first week, the median proportions of time spent in the target range were 35.7% and 53.0% for the high and low groups, respectlively (p = 0.0001). Morning glucose concentrations were 8.3 ±1.6 mmol/l and 6.2 ±1.2 mmol/l. One (2.9%) and 8 (24.2%) episodes of hypoglycemia (<2.2 mmol/l) occurred in the high and low groups, reflecting 0.002 and 0.03 hypoglycemic events per patient-day, respectlively. CONCLusIONs This pilot trial of intensive insulin therapy identified numerous challenges that helped in the preparation of an inter national multicenter randomized trial of intensive insulin therapy to evaluate benefits and harms.
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