[show abstract][hide abstract] ABSTRACT: Intensive insulin therapy reduces morbidity and mortality in patients in surgical intensive care units (ICUs), but its role in patients in medical ICUs is unknown.
In a prospective, randomized, controlled study of adult patients admitted to our medical ICU, we studied patients who were considered to need intensive care for at least three days. On admission, patients were randomly assigned to strict normalization of blood glucose levels (80 to 110 mg per deciliter [4.4 to 6.1 mmol per liter]) with the use of insulin infusion or to conventional therapy (insulin administered when the blood glucose level exceeded 215 mg per deciliter [12 mmol per liter], with the infusion tapered when the level fell below 180 mg per deciliter [10 mmol per liter]). There was a history of diabetes in 16.9 percent of the patients.
In the intention-to-treat analysis of 1200 patients, intensive insulin therapy reduced blood glucose levels but did not significantly reduce in-hospital mortality (40.0 percent in the conventional-treatment group vs. 37.3 percent in the intensive-treatment group, P=0.33). However, morbidity was significantly reduced by the prevention of newly acquired kidney injury, accelerated weaning from mechanical ventilation, and accelerated discharge from the ICU and the hospital. Although length of stay in the ICU could not be predicted on admission, among 433 patients who stayed in the ICU for less than three days, mortality was greater among those receiving intensive insulin therapy. In contrast, among 767 patients who stayed in the ICU for three or more days, in-hospital mortality in the 386 who received intensive insulin therapy was reduced from 52.5 to 43.0 percent (P=0.009) and morbidity was also reduced.
Intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. Although the risk of subsequent death and disease was reduced in patients treated for three or more days, these patients could not be identified before therapy. Further studies are needed to confirm these preliminary data. (ClinicalTrials.gov number, NCT00115479.)
New England Journal of Medicine 03/2006; 354(5):449-61. · 51.66 Impact Factor
[show abstract][hide abstract] ABSTRACT: We studied the effects of total parenteral nutrition (TPN)-associated hyperglycemia on the clinical outcome in premature septic infants in the neonatal intensive care unit.
The charts of all premature infants weighing less than 1500 g upon admission to the neonatal intensive care unit between January 1, 2002, and December 31, 2002, with sepsis, ventilator dependence, and feeding intolerance were studied. Maximum serum glucose concentrations were compared with duration of TPN, mechanical ventilation, hospital length of stay, and survival using Pearson regression analysis and Student's t test.
Thirty-seven patients met the search criteria. The average caloric intake for all infants at the time of blood culture-proven sepsis was 83 +/- 19 kcal/kg per day. The maximum serum glucose concentration (milligrams per deciliter) after having positive blood cultures (sepsis) was positively correlated with the duration of TPN (r = 0.45, P = .005), length of dependence on mechanical ventilation (r = 0.45, P = .006), and hospital length of stay (r = 0.36, P = .03). The average maximum serum glucose level was significantly higher in the nonsurviving infants (241 +/- 46 vs 141 +/- 48, P < .0001).
Hyperglycemia correlated with prolonged ventilator dependency and increased hospital length of stay in premature septic infants. Avoidance of excessive nutrient delivery and tight glycemic control during periods of acute metabolic stress may improve outcome in this patient population.
Journal of Pediatric Surgery 02/2006; 41(1):239-44; discussion 239-44. · 1.38 Impact Factor
[show abstract][hide abstract] ABSTRACT: Technological limitations have impeded accurate energy expenditure assessment in critically ill infants and young children. Instead, a predicted energy expenditure (PEE) is derived based on weight, heat loss, activity, growth requirements, and degree of stress. This study compared actual measured energy expenditure (MEE) with conventional predicted values in 20 critically ill infants and children using a validated metabolic cart designed for use in this age group. All patients were studied either within 4 days of major surgery or during an acute disease process necessitating intensive care. All were severely stressed clinically and were studied while mechanically ventilated in a temperature-controlled environment. The study interval ranged from 1 to 12 hr and averaged 4 hr after a stabilization period of 30 min. The mean MEE was significantly lower than the mean PEE (52.2 +/- 16 kcal/kg/day vs 101.8 +/- 17 kcal/kg/day, P less than 0.001) with a mean MEE/PEE of 52.6 +/- 17% (range 26 to 92%). In a subgroup of 7 paralyzed patients, the mean MEE was significantly lower than in the 13 nonparalyzed patients when compared with PEE and predicted basal metabolic rate (PBMR). The coefficient of variance, conventionally recognized to be approximately 15% for PEE, averaged 6.35% for MEE in this study. These data indicate that if PEE is used as the sole guide for caloric repletion in the stressed infant or child, these patients will be substantially overfed.
Journal of Surgical Research 06/1988; 44(5):467-72. · 2.02 Impact Factor
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