Best evidence in critical care medicine: treatment for hyperglycemia in the intensive care unit: a 'bittersweet' message.

摘要

Background: Hyperglycemia and insulin resistance are common in severe illness and are associated with a worse outcome. In 2001, a randomized, single-centre, prospective unblinded trial of surgical patients compared intensive-glycemic control (serum glucose 4.4-6.1 mmol centre L~(-1)) with more liberal glucose management (serum glucose 10-12 mmol centre L~(-1)). Significant decreases in mortality and morbidity were observed in the intensively treated group. In addition, a pronounced mortality benefit was demonstrated for patients who required intensive care unit (ICU) therapy for three or more days. It was unresolved as to whether or not these benefits may apply to medical ICU patients. This study was undertaken to address these issues.Question: Does intensive insulin treatment decrease mortality amongst medical ICU patients?Design: Single centre, prospective, non-blinded, randomized controlled trial comparing conventional insulin therapy to intensive insulin therapy in medical ICU patients expected to stay in ICU for three or more days. The study was conducted between 2002 and 2005.Patients: One thousand two-hundred patients admitted to a medical ICU in Leuven, Belgium and, for whom the anticipated length was > three days, were enrolled. Postoperative surgical patients and those with do-not-resuscitate orders were excluded. Of patients enrolled, 767 remained in ICU for at least three days. The investigation was powered to detect a difference of 7% in outcome (based upon the investigators' previous results in surgical ICU patients). The two groups were similar in all respects, apart from their baseline Therapeutic Intervention Scoring System-28 (TISS-28) scores, which were higher in the treatment group.