Tight blood glucose control with insulin in the ICU: facts and controversies.
ABSTRACT Recently, the concept that stress hyperglycemia in critically ill patients is an adaptive, beneficial response has been challenged. Two large randomized studies demonstrated that maintenance of normoglycemia with intensive insulin therapy substantially prevents morbidity and reduces mortality in these patients. Since then, questions have been raised about the efficacy in general and in specific subgroups, and about the safety of this therapy with regard to potential harm of brief hypoglycemic episodes and of high-dose insulin administration. These issues are systematically addressed in relation to the available evidence. Intensive insulin therapy during intensive care is effective in reducing the mortality and morbidity of critical illness. The available randomized studies show that an absolute reduction in risk of hospital death of 3 to 4% is to be expected from this therapy in an intention-to-treat analysis. In order to confirm this survival benefit and assign it as statistically significant, future studies should be adequately powered, and hence sample size should be at least 5,000. The absolute reduction in the risk of death increases to approximately 8% when patients are treated with intensive insulin for at least 3 days. Data available thus far indicate that blood glucose control to strict normoglycemia is required to obtain the most clinical benefit. The risk of hypoglycemia increases with this therapy, but it remains unclear whether this is truly harmful in the setting of critical care.
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ABSTRACT: Objective. Bloodstream infection (BSI) secondary to nosocomial urinary tract infection is associated with substantial morbidity, mortality, and additional financial costs. Our objective was to identify predictors of nosocomial urinary tract-related BSI. Design. Matched case-control study. Setting. Midwestern tertiary care hospital. Patients. Cases ([Formula: see text]) were patients with a positive urine culture obtained more than 48 hours after admission and a blood culture obtained within 14 days of the urine culture that grew the same organism. Controls ([Formula: see text]), selected by incidence density sampling, included patients with a positive urine culture who were at risk for BSI but did not develop one. Methods. Conditional logistic regression and classification and regression tree analyses. Results. The most frequently isolated microorganisms that spread from the urinary tract to the bloodstream were Enterococcus species. Independent risk factors included neutropenia (odds ratio [OR], 10.99; 95% confidence interval [CI], 5.78-20.88), renal disease (OR, 2.96; 95% CI, 1.98-4.41), and male sex (OR, 2.18; 95% CI, 1.52-3.12). The probability of developing a urinary tract-related BSI among neutropenic patients was 70%. Receipt of immunosuppressants (OR, 1.53; 95% CI, 1.04-2.25), insulin (OR, 4.82; 95% CI, 2.52-9.21), and antibacterials (OR, 0.66; 95% CI, 0.44-0.97) also significantly altered risk. Conclusions. The heightened risk of urinary tract-related BSI associated with several comorbid conditions suggests that the management of nosocomial bacteriuria may benefit from tailoring to certain patient subgroups. Consideration of time-dependent risk factors, such as medications, may also help guide clinical decisions in reducing BSI.Infection Control and Hospital Epidemiology 10/2012; 33(10):1001-7. · 4.02 Impact Factor
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ABSTRACT: What is known and Objective: Hyperglycaemia in trauma patients admitted to the intensive care unit (ICU) is associated with increased morbidity and mortality. Our pilot study is a prospective randomized controlled trial comparing the impact of two glucose control regimens on outcomes in non-diabetic trauma patients admitted with hyperglycaemia to the ICU. Methods: Trauma patients with blood glucose levels (BGLs) ≥7·8 mm within the first 48 h of the hospital admission were randomized to receive intermittent SQ or continuous IV insulin to maintain BGLs between 4·4 and 6·1 mm. We excluded diabetics on the basis of history, or a glycosylated haemoglobin ≥6% on admission. We compared the effect of SQ vs. IV insulin therapy on the ICU length of stay (ILOS). Results and Discussion: A total of 58 patients were included in the study. The SQ and IV groups were comparable in terms of age, gender, injury severity, revised trauma, Glasgow coma scores and type of trauma (blunt vs. penetrating). There was no significant difference between the two treatment groups in the ILOS (3 vs. 2 days, P = 0·084), hospital length of stay (8 vs. 6, P = 0·09), ventilator support days (6 vs. 3, P = 0·98), requirement for blood transfusion (P = 0·66), rates of infections (P = 0·70), acute kidney injury (P = 0·99) and mortality (P = 0·61). What is new and Conclusion: There was no difference between SQ and IV insulin therapy in the ILOS in non-diabetic trauma patients.Journal of Clinical Pharmacy and Therapeutics 10/2012; · 2.10 Impact Factor
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ABSTRACT: A significant proportion of patients with burn injury have diabetes. Although hyperglycemia during critical illness has been associated with poor outcomes, patients with chronic hyperglycemia based on elevated hemoglobin A1c (HbA1c) measurements at admission have been shown to tolerate higher glucose levels during hospitalization. This relationship has not been evaluated in the burn population. The objective of this study was to examine the impact of chronic glucose control on outcomes in the acute period after burn. This is a retrospective analysis comparing outcomes in patients with chronic hyperglycemia (HbA1c ≥6.5%) and euglycemia (HbA1c <6.5%). Patients aged 18 to 89 years, admitted for initial burn care between January 1, 2009, and June 30, 2010, with an HbA1c measurement at admission were included. The primary endpoint was unplanned readmissions, with secondary endpoints of length of stay and mortality. We included 258 patients (32 with chronic hyperglycemia and 226 with euglycemia). Burn severity was similar between the groups. Patients with chronic hyperglycemia were significantly older and were more likely to have diabetes, respiratory disease, and hypertension. Chronic hyperglycemia was associated with significantly higher time-weighted glucose and glucose variability. Survival rates were similar, but the chronic hyperglycemia group had a significantly longer length of stay (13 vs 9 days; P = .038) and a higher rate of unplanned readmission (18.8 vs 3.6%; P = .001). Chronic hyperglycemia before burn injury is associated with altered glycemic response after burn injury and worse outcomes. Further research is needed to identify whether chronic hyperglycemia necessitates a modified approach to burn care or glycemic management.Journal of burn care & research: official publication of the American Burn Association 01/2013; 34(1):109-14. · 1.54 Impact Factor