Insulin Therapy for Critically Ill Hospitalized Patients

Pittas, Anastassios G.; Siegel, Richard D.; Lau, Joseph

doi:10.1001/archinte.164.18.2005

Cited by 258 publications

(39 citation statements)

References 65 publications

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“…Intensive control of blood glucose has been used in a number of acute settings with variable results. A meta-analysis of 35 (n = 8,478) clinical trials of acute insulin administration revealed a statistically significant 15% reduction in mortality comparing insulin intervention with controls (RR 0.85, 95% CI: 0.75–0.97) [50]. Analysis of sub-groups revealed a 29% mortality benefit for strict glucose control (RR 0.71, 95% CI: 0.54–0.93), while studies in which insulin was administered without a target reduction in glycaemia found no mortality benefit [50].…”

Section: Hyperglycaemia and Critical Illnessmentioning

confidence: 99%

“…A meta-analysis of 35 (n = 8,478) clinical trials of acute insulin administration revealed a statistically significant 15% reduction in mortality comparing insulin intervention with controls (RR 0.85, 95% CI: 0.75–0.97) [50]. Analysis of sub-groups revealed a 29% mortality benefit for strict glucose control (RR 0.71, 95% CI: 0.54–0.93), while studies in which insulin was administered without a target reduction in glycaemia found no mortality benefit [50]. Similarly, those studies in which insulin was administered as GKI showed no statistically significant benefit, while studies administering insulin in other ways (mostly as sliding scale) did show a 27% mortality reduction (RR 0.73, 95% CI: 0.56–0.95) [50].…”

Section: Hyperglycaemia and Critical Illnessmentioning

confidence: 99%

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Hyperglycaemia in Acute Stroke – To Treat or Not to Treat

Quinn

Lees²

2009

Cerebrovasc Dis

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Diabetes is common amongst patients with stroke and is associated with poorer outcome. Post-stroke hyperglycaemia is also recognised in up to half of the patients, and is independently associated with adverse sequelae: both increased mortality and poorer functional outcomes. Neither the aetiology nor the pathophysiology of such hyperglycaemia is fully understood. Both direct neurological toxicity and systemic consequences are postulated to occur. A distinction between occult diabetes and non-diabetic hyperglycaemia seems important as prognosis and effect of intervention differ in these two groups. The optimal management of the milder forms of hyperglycaemia associated with acute stroke is unknown. Randomised trial data remain limited but presently offer no strong support for aggressive intervention in stroke, though in other critical illness settings tight control of blood sugar appears beneficial. Studies based in coronary care and high dependency units have shown a possible beneficial effect of insulin, but evidence for intervention in acute stroke is at best limited. However, if glucose management is to be undertaken, this should be instituted while there is still salvageable tissue and the glucose reduction must be substantial. Intravenous insulin may be more effective than glucose-potassium-insulin infusion. Both interventions carry a risk of hypoglycaemia and any proposed intervention must balance safety, convenience and glycaemic control. Until further trial data are available, consensus guidelines may be followed, which are generally conservative for blood glucose levels below 10 mM (180 mg/dl).

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Section: Hyperglycaemia and Critical Illnessmentioning

confidence: 99%

Section: Hyperglycaemia and Critical Illnessmentioning

confidence: 99%

Hyperglycaemia in Acute Stroke – To Treat or Not to Treat

Quinn

Lees²

2009

Cerebrovasc Dis

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“…A growing body of evidence indicates that treatment of hyperglycemia improves clinical outcome (11). In a prospective randomized trial in Leuven, postoperative patients were treated with an intensive insulin protocol (12).…”

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confidence: 99%

Multicentric, Randomized, Controlled Trial to Evaluate Blood Glucose Control by the Model Predictive Control Algorithm Versus Routine Glucose Management Protocols in Intensive Care Unit Patients

et al. 2006

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OBJECTIVE -To evaluate a fully automated algorithm for the establishment of tight glycemic control in critically ill patients and to compare the results with different routine glucose management protocols of three intensive care units (ICUs) across Europe (Graz, Prague, and London).RESEARCH DESIGN AND METHODS -Sixty patients undergoing cardiac surgery (age 67 Ϯ 9 years, BMI 27.7 Ϯ 4.9 kg/m 2 , 17 women) with postsurgery blood glucose levels Ͼ120 mg/dl (6.7 mmol/l) were investigated in three different ICUs (20 per center). Patients were randomized to either blood glucose management (target range 80 -110 mg/dl [4.4 -6.1 mmol/l]) by the fully automated model predictive control (MPC) algorithm (n ϭ 30, 10 per center) or implemented routine glucose management protocols (n ϭ 30, 10 per center). In all patients, arterial glucose was measured hourly to describe the glucose profile until the end of the ICU stay but for a maximum period of 48 h. CONCLUSIONS -The data suggest that the MPC algorithm is safe and effective in controlling glycemia in critically ill postsurgery patients. RESULTS Diabetes Care 29:271-276, 2006E pidemiological studies have revealed a significant relationship between impaired glycemic control and poor outcome in patients with acute cardiovascular events (1-3), postoperative wound infections (4,5), and trauma (6). Patients with diabetes are affected, but patients with stress hyperglycemia with no previous diagnosis of diabetes also have a poor prognosis (1,2,7,8). Critical illness and trauma induce counterregulatory hormone release and alterations in carbohydrate metabolism such as enhanced hepatic gluconeogenesis, insulin resistance, and relative insulin deficiency (9,10).A growing body of evidence indicates that treatment of hyperglycemia improves clinical outcome (11). In a prospective randomized trial in Leuven, postoperative patients were treated with an intensive insulin protocol (12). Strict glycemic control (80 -110 mg/dl) resulted in a reduction of in-hospital mortality and a decrease in organ system dysfunction compared with moderate hyperglycemia (180 -200 mg/dl). In another study performed on a mixed medical-surgical population, the implementation of an intensive glucose management protocol led to decreased mortality, morbidity, and length of intensive care unit (ICU) stay of critically ill adult patients (13).Based on this clinical evidence, efforts have to be made to maintain strict glycemic control in critically ill patients. To achieve this goal, the implementation of complex intensive insulin infusion protocols based on frequent bedside glucose monitoring is required. Numerous guidelines have been developed and tested to implement tight glycemic control in ICUs (13-18). However, most of these guidelines still require user interventions or intuitive decisions of ICU staff.The development of a closed-loop control system that automatically regulates the dose of insulin based on glucose measurements could permit tight glycemic control without increasing the work-

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“…A near-significant trend toward decreasing mortality was seen in patients with acute myocardial infarction who did not receive reperfusion therapy. The authors concluded that insulin therapy initiated in the hospital in critically ill patients has a beneficial effect on short-term mortality in different clinical settings [31].…”

Section: The Importance Of Glycemic Controlmentioning

confidence: 99%