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.
- SourceAvailable from: Marc Torjman[Show abstract] [Hide abstract]
ABSTRACT: Availability of a highly accurate in-hospital automated blood glucose (BG) monitor could facilitate implementation of intensive insulin therapy protocols through effective titration of insulin therapy, improved BG control, and avoidance of hypoglycemia. We evaluated a functional prototype BG monitor designed to perform frequent automated blood sampling for glucose monitoring. Sixteen healthy adult volunteer subjects had intravenous catheter insertions in a forearm or hand vein and were studied for 8 hours. The prototype monitor consisted of an autosampling unit with a precise computer-controlled reversible syringe pump and a glucose analytical section. BG was referenced against a Yellow Springs Instrument (YSI) laboratory analyzer. Sampling errors for automated blood draws were assessed by calculating the percent of failed draws, and BG data were analyzed using the Bland and Altman technique. Out of 498 total sample draws, unsuccessful draws were categorized as follow: 11 (2.2%) were due to autosampler technical problems, 21 (4.2%) were due to catheter-related failures, and 37 (7.4%) were BG meter errors confirmed by a glucometer-generated error code. Blood draw difficulties or failures related to the catheter site (e.g., catheter occlusion or vein collapse) occurred in 6/15 (40%) subjects. Mean BG bias versus YSI was 0.20 +/- 12.6 mg/dl, and mean absolute relative difference was 10.4%. Automated phlebotomy can be performed in healthy subjects using this prototype BG monitor. The BG measurement technology had suboptimal accuracy based on a YSI reference. A more accurate BG point-of-care testing meter and strip technology have been incorporated into the future version of this monitor. Development of such a monitor could alleviate the burden of frequent BG testing and reduce the risk of hypoglycemia in patients on insulin therapy.Journal of diabetes science and technology 01/2009; 3(6):1233-41.
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ABSTRACT: Insulin resistance and hyperglycaemia are common in severe sepsis. Mitochondrial uncoupling protein 2 (UCP2) plays a role in insulin release and sensitivity. To determine if a common, functional polymorphism in the UCP2 gene promoter region (the -866 G/A polymorphism) contributes to the risk of hyperglycaemia in severe sepsis. In the prospective group 120 non-diabetic patients who were carriers of the G allele had significantly higher maximum blood glucose recordings than non-carriers (mean (SD) AA 8.5 (2.2) mmol/l; GA 8.5 (2.4) mmol/l; GG 10.1 (3.1) mmol/l; p = 0.0042) and required significantly more insulin to maintain target blood glucose (p = 0.0007). In the retrospective study 103 non-diabetic patients showed a similar relationship between maximum glucose and UCP genotype (AA 6.8 (2.3) mmol/l; GA 7.8 (2.2) mmol/l; GG 9.2 (2.9) mmol/l; p = 0.0078). A common, functional polymorphism in the promoter region of the UCP2 gene is associated with hyperglycaemia and insulin resistance in severe sepsis. This has implications for our understanding of the genetic pathophysiology of sepsis and is of use in the stratification of patients for more intensive management.Journal of Medical Genetics 07/2009; 46(11):773-5. · 5.70 Impact Factor
- Revista Espa de Cardiologia 12/2009; 62(12):1467. · 3.20 Impact Factor