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Van den Berghe, 2001
GIST, Stroke, 1999
DIGAMI, BMJ, 1997

 

                Tight Glycaemic Control in ICU 

 

Principal investigator: Dr Kevin Rooney

 

Currently investigating the evidence into tight glycaemic control in critical care medicine 

 

Current state:            Complete

 EBM Reviews Van den Berghe, 2001 GIST, Stroke, 1999 DIGAMI, BMJ,1997

 

 

Tight Glycaemic Control in ICU 

 

 

1 Kevin Rooney 

 

1Consultant, Intensive Care Unit, Royal Alexandra Hospital, Corsebar Road, Paisley, PA2 9PN 

 

Correspondence: kd.rooney@virgin.net

 

SICS EBMG web site. July 2003             printer friendly format

 

Background

Hyperglycaemia is a relatively common condition among critically ill patients, even in those who have not previously had diabetes mellitus. The causes of this stress-induced hyperglycaemia are multifactorial, however, they are mainly related to insulin resistance, insulin deficiency and overfeeding. For years now, insulin therapy has been used to control this stress-induced hyperglycaemia. However, there remains some confusion over what target of blood glucose should we aim for & in what conditions is this beneficial. I have reviewed the current literature, & presented my findings and conclusions below.

Search Strategy:

Blood glucose, insulin, critical care medicine, mortality, myocardial infarction 

 

Selection Criteria:

RCTs and meta-analysis after 1991 

 

Data Collection and analysis:

PubMed search, hand search of relevant papers. Data analysed using CATmaker™ software.

 

Main Results:

Glucose, Potassium & Insulin (GKI) infusion in mild to moderate hyperglycaemia following acute stroke is provides no better blood sugar control than standard therapy alone.   There is no impact on important patient orientated end-points, but a small increase in biochemical, but not symptomatic, hypoglycaemia.Treating 9 MI patients who have a blood glucose > 11 mmol/L with insulin-glucose infusion followed by qid subcutaneous insulin for at least 3 months will prevent one additional death at 3.5 years. Benefit greatest in low risk patients (<70 years old, no prior MI, no CHF, no digoxin therapy) not previously on insulin. Both treated and control groups showed a reduction in HbA1C in follow up (evidence of glycaemic control).  A greater fall was found in those patients treated with multidose insulin.

In an Intensive Care Unit, tight glycaemic control to between 4.4 and 6.1 mmol/L with intensive insulin therapy reduces mortality, the incidence of septicaemia, the incidence of prolonged ventilation and the need for renal replacement therapy.  Benefit appears attributable to reduction in mortality in those patients in the ICU for > 5 days.   The largest reduction in deaths was the reduction in mortality due to multiple organ failure as a consequence of a proven septic focus.

 

Reviewers conclusions (Grade of Recommendation)

  1. Intensive insulin therapy appears safe.   Insulin infusions increase biochemical but not symptomatic hypoglycaemia (B).
  2. Intensive insulin therapy should only be used in patients who are hyperglycaemic following acute myocardial infarction and in critically ill (ICU) patients (A).
  3.  Until further studies are available, we should aim for a blood glucose of between 4 and 6.1 mmol/L in a general ICU (B).

Areas of further research

  1. A repeat RCT of tight glycaemic control (a la Van den Berghe) in a general ICU. (Currently underway in 2 centres)
  2. A larger RCT (GIST II) of tight glycaemic control in stroke patients. (Currently underway)
  3. A RCT into tight glycaemic control among traumatic brain injury patients.

 

References

  1. Van den Berghe G. et al. Intensive Insulin Therapy in Critically Ill Patients. NEJM 2001; 345 (19): 1359-1367 CAT

  2. Scott JF, et al. Glucose Potassium Insulin Infusions in the Treatment of Acute Stroke Patients With Mild to Moderate Hyperglycaemia: The Glucose Insulin in Stroke Trial (GIST) Stroke 1999 30 (4); 793-9 CAT

  3. DIGAMI study group. Prospective randomised study of intensive insulin treatment on long term survival after acute MI in patients with diabetes mellitus. BMJ 1997; 314(7093):1512-1515. CAT

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