Key Point

Intensive insulin therapy has a number of benefits in the critically ill, including reduced ICU and hospital mortality.

SALT LAKE CITY—Intensive insulin administration to limit or prevent the development of hyperglycemia during the ICU stay has yielded promising results, according to data reported at CHEST 2006. This therapy has been linked to a variety of benefits such as better survival, a decreased incidence of bloodstream infection, and a shorter length of hospital stay, pointed out Stephen M. Pastores, MD, Associate Professor of Anesthesiology and Medicine and Director of the Medicine Fellowship Program at the Memorial Sloan-Kettering Cancer Center in New York City.¹

A number of trials support intensive insulin therapy in the ICU, Dr. Pastores said. In 2001, for example, van den Berghe and colleagues reported that among 1,548 surgical ICU patients, intensive insulin therapy reduced the following variables, compared with conventional insulin treatment:

• Overall in-hospital mortality by 34%
• Bloodstream infections by 46%
• Acute renal failure requiring dialysis or hemofiltration by 41%
• The median number of red-cell transfusions by 50%
• Critical-illness polyneuropathy by 44%.

Intensive therapy also reduced the need for prolonged mechanical ventilation and intensive care. History of diabetes or hyperglycemia at the time of admission did not affect the results.²

In this trial, intensive insulin therapy was intended to maintain blood glucose at a level between 80 and 110 mg/dL at all times. By contrast, conventional therapy called for insulin administration only when the blood glucose level exceeded 215 mg/dL, with the goal of maintaining glucose levels of between 180 and 200 mg/dL. Hypoglycemia, defined as blood glucose level of 40 mg/dL or less, occurred in 39 patients in the intensive-treatment group, compared with six patients in the conventional-treatment group.

Reporting in an article published in 2006, the van den Berghe group again compared intensive to conventional insulin therapy in a trial involving 1,200 medical ICU patients.3 Although intensive insulin therapy was not associated with reduced overall in-hospital mortality in this trial, it did help to prevent newly acquired kidney injury, accelerate weaning from mechanical ventilation, and speed ICU and hospital discharge.

In the subgroup of 767 patients who stayed in the ICU for more than three days, in-hospital mortality was 52.5% for those who received conventional insulin therapy versus only 43% for those given intensive treatment. Intensive treatment resulted in greater in-hospital mortality when the ICU stay was shorter than three days.

—Timothy Begany

Reference
1. Pastores SM, Marik PE, Landry D, Sprung CL. Endocrine issues in the critically ill. Presented at: annual meeting of the American College of Chest Physicians; October 24, 2006; Salt Lake City, Utah.
2. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med. 2001;345:1359-1367.
3. van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med. 2006; 354:449-461.

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