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Tight glycaemic control improves ICU survival.

 

For every 29 patients given intensive insulin therapy, to keep glucose 4.4-6.1 mmol.l-1, compared to standard therapy, one less patient dies in ICU. (95% CI 17 to 101)

Level of Evidence 1+

 

Citation:   Intensive Insulin Therapy in Critically Ill Patients. NEJM 2001; 345 (19): 1359-1367.


Lead author's name and fax: Prof Greet Van den Berghe, Department of Intensive Care, University Hospital Gasthuisberg, University of Leuven. greta.vandenberghe@med.kuleuven.ac.be

 

Three-part Clinical Question: Among critically ill ICU patients, does intensive insulin therapy to maintain relative normoglycaemia, (compared to usual therapy) reduce morbidity and mortality?


Search Terms: 1. critical care2. insulin3. RCT filter

 

The Study: Single-blinded randomised controlled trial with intention-to-treat.


The Study Patients: All patients requiring mechanical ventilation, admitted to a predominantly surgical ICU in Belgium. 62% had cardiac surgery. 13% had diabetes. Median APACHE II=9. Median TISS=43. Randomised at ICU admission. All patients fed continuously.


Control group (N = 783; 783 analysed): Insulin infusion commenced if blood glucose > 11.9 mmol/L and maintained between 10.0 - 11.1 mmol/L. BM checked 1-4 hrly. Dose adjusted according to algorithm and advice of study physician not involved in patient care.


Experimental group (N = 765; 765 analysed): Insulin infusion commenced if blood glucose >6.1 mmol/L and maintained between 4.4 - 6.1 mmol/L. BM checked 1-4 hrly. Dose adjusted according to algorithm and advice of study physician not involved in patient care.

 

The Evidence:

Outcome

Time to Outcome

CER

EER

RRR

ARR

NNT

Death

In ICU

0.080

0.046

43%

0.034

29

95% Confidence Intervals:

12% to 73%

0.010 to 0.058

17 to 101

Death

In Hospital

0.109

0.072

34%

0.037

27

95% Confidence Intervals:

8% to 60%

0.009 to 0.065

15 to 118

Comments:

1. 62% post-cardiac surgery. Although differences in survival apparent in patients with long rather than short ICU stays.  

2. This study is being repeated in a general ICU.

3. GKI infusions reduce morbidity and mortality after MI and CABG.

4. Lower mean blood glucose reduced mortality rate.   In contrast, higher daily insulin dose increased mortality rate.   See Critical Care Medicine 2003; 31:359-366.

5. Insulin is a cheap drug compared to rhAPC.

6. Mortality in this mixed surgical medical ICU was lower than we experience.   The case mix was different, look at the APACHE scores.    However, sepsis is common in our practice, and death due to sepsis is a more common event per 100 patients in our practice, we may need to treat fewer patients to save a life.

Appraised by: Kevin Rooney Department of Anaesthesia & Intensive Care Medicine, Royal Alexandra Hospital, Paisley; 07 October 2002    Email: kd.rooney@virgin.net     Kill or Update By: October 2006

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