Efficacy and Safety of an Insulin Infusion Protocol in a Surgical ICU (original) (raw)
Critical Care, 2008
Introduction Critically ill patients can develop hyperglycaemia even if they do not have diabetes. Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit (ICU) and decreases morbidity in patients in a medical ICU. The effect of this therapy on patients in a mixed medical/surgical ICU is unknown. Our goal was to assess whether the effect of intensive insulin therapy, compared with standard therapy, decreases morbidity and mortality in patients hospitalised in a mixed ICU. Methods This is a prospective, randomised, non-blinded, single-centre clinical trial in a medical/surgical ICU. Patients were randomly assigned to receive either intensive insulin therapy to maintain glucose levels between 80 and 110 mg/dl (4.4 to 6.1 mmol/l) or standard insulin therapy to maintain glucose levels between 180 and 200 mg/dl (10 and 11.1 mmol/l). The primary end point was mortality at 28 days. Results Over a period of 30 months, 504 patients were enrolled. The 28-day mortality rate was 32.4% (81 of 250) in the standard insulin therapy group and 36.6% (93 of 254) in the intensive insulin therapy group (Relative Risk [RR]: 1.1; 95% confidence interval [CI]: 0.85 to 1.42). The ICU mortality in the standard insulin therapy group was 31.2% (78 of 250) and 33.1% (84 of 254) in the intensive insulin therapy group (RR: 1.06; 95%CI: 0.82 to 1.36). There was no statistically significant reduction in the rate of ICU-acquired infections: 33.2% in the standard insulin therapy group compared with 27.17% in the intensive insulin therapy group (RR: 0.82; 95%CI: 0.63 to 1.07). The rate of hypoglycaemia (≤ 40 mg/dl) was 1.7% in the standard insulin therapy group and 8.5% in the intensive insulin therapy group (RR: 5.04; 95% CI: 1.20 to 21.12). Conclusions IIT used to maintain glucose levels within normal limits did not reduce morbidity or mortality of patients admitted to a mixed medical/surgical ICU. Furthermore, this therapy increased the risk of hypoglycaemia. Trial Registration clinicaltrials.gov Identifiers: 4374-04-13031; 094-2 in 000966421
European Scientific Journal, ESJ
Introduction: Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes, and the risk of mortality or significant morbidity is high among those who are treated in the intensive care unit (ICU) for more than 5 days. Objective: To assess the effect of glucose management protocol on mortality and morbidity in a heterogeneous population of critically ill adult patients. Design: A randomized controlled trial. Setting: A 24-bed medical-surgical intensive care unit (ICU) for adult patients at King Hussein Medical Center, the Royal Medical Services. Methods: A total of 50 patients who were considered to need intensive care for at least three days, were randomly assigned into two groups. The intervention group subjects were to undergo a glucose control protocol with insulin infusion titrated to maintain blood glucose level in a target range of 120-160 mg/dL; except septic patients, in whom the target was higher, 160- 180 mg/dL. ...
Critical Care, 2008
Introduction Critically ill patients can develop hyperglycaemia even if they do not have diabetes. Intensive insulin therapy decreases morbidity and mortality rates in patients in a surgical intensive care unit (ICU) and decreases morbidity in patients in a medical ICU. The effect of this therapy on patients in a mixed medical/surgical ICU is unknown. Our goal was to assess whether the effect of intensive insulin therapy, compared with standard therapy, decreases morbidity and mortality in patients hospitalised in a mixed ICU.
Glucose Control by Insulin for Critically Ill Surgical Patients
The Journal of Trauma: Injury, Infection, and Critical Care, 2004
H yperglycemia associated with insulin resistance is common among critically ill patients, even those who do not have diabetes. 1-3 It is a known factor for poor prognosis in hospitalized patients, 4-7 especially after myocardial infarction, 8-10 congestive heart failure, 9 cerebral vascular accident, 11 cardiopulmonary bypass, 12,13 burns, and major surgery. 14,15 Several conditions are related to acute hyperglycemia including diuresis, dehydration, ketonemia, electrolyte imbalance, and change in mental status. Several other pathologies have been documented in critically ill patients, such as an impaired immune response to injury or infection, 16 a higher rate of serious infection, 17 impaired gastrointestinal motility, 18,19 high cardiovascular tonus, 20 impaired wound healing, 21,22 and a higher mortality rate. 23 Acute or new hyperglycemia could be undiagnosed diabetes or stress-induced hyperglycemia. 24 Stress-induced hyperglycemia, described in 5% to 30% of critically ill patients, is believed to be secondary to increased levels of stress hormones. It also can be reproduced after the administration of endotoxin or injection of several stress hormones to healthy volunteers. 25 Umpierrez et al. 6 showed that hyperglycemia in hospitalized patients is a factor for poor outcome and an independent marker of in-hospital mortality, mainly among patients with undiagnosed diabetes (65% of their study patients). Moreover, patients with new hyperglycemia had a higher rate of admission to the intensive care unit (ICU), longer hospitalization, and a higher rate of in-hospital mortality. 6 The clinical significance of new hyperglycemia is unclear. This article presents a review of the literature describing the effect of hyperglycemia on several major systems and recommends treatment management based on a consensus of the data. The major effects of insulin on major body systems are summarized in Table 1.
Benefits and methods of achieving strict glycemic control in the ICU
Critical care nursing clinics of North America, 2004
Hyperglycemia, a frequent complication in critically ill patients, has been shown to have a negative influence on morbidity and mortality. Many factors contribute to hyperglycemia, including the stress response, diabetes, obesity, advanced age, corticosteroids, sepsis, pancreatitis, and the use of nutrition support. Application of intensive insulin therapy, when compared with conventional glycemic control measures, seems to improve outcomes in the critically ill patient. Therefore, effective insulin therapy along with appropriate nutrition support prescriptions provide a means for the critical care nurse and other health care team members to lower complications and enhance recovery in the ICU setting.
Effect of Glycemic State on Hospital Mortality in Critically Ill Surgical Patients
The American Surgeon, 2011
Intensive insulin therapy can reduce mortality. Hypoglycemia related to intensive therapy may worsen outcomes. This study compared risk adjusted mortality for different glycemic states. A retrospective review of patients admitted to a surgical intensive care unit over 4 years was performed. Patients were divided into glycemic groups: HYPER (≥1 episode > 180 mg/dL, any <60), HYPO (≥1 episode < 60 mg/dL, any >180), BOTH (≥1 episode < 60 and ≥1 episode > 180 mg/dL), NORMO (all episodes 60-180 mg/dL), HYPER-Only (≥1 episode > 180, none <60 mg/dL), and HYPO-Only (≥1 episode < 60, none >180 mg/dL). Observed to expected Acute Physiology and Chronic Health Evaluation (APACHE) III mortality ratios (O/E) were studied. Number of adverse glycemic events was compared with mortality. Hypoglycemia and hyperglycemia occurred in 18 per cent and 50 per cent of patients. Mortality was 12.4 per cent (O/E = 0.88). BOTH had the highest O/E ratio (1.43) with HYPO the second h...