ABSTRACT
Miriam
M Treggiari, Veena Karir, N David Yanez, Noel S Weiss, Stephen Daniel and
Steven A Deem
Introduction Intensive insulin therapy (IIT) with tight glycemic
control may reduce mortality and morbidity in critically ill patients and has
been widely adopted in practice throughout the world. However, there is only
one randomized controlled trial showing unequivocal benefit to this approach
and that study population was dominated by post-cardiac surgery patients. We
aimed to determine the association between IIT and mortality in a mixed population
of critically ill patients.
Methods We
conducted a cohort study comparing three consecutive time periods before and
after IIT protocol implementation in a Level 1 trauma center: period I (no
protocol); period II, target glucose 80 to 130
mg/dL; and period III, target glucose 80 to 110 mg/dL. Subjects were 10,456 patients
admitted to intensive care units (ICUs) between 1 March 2001 and 28 February
2005. The main study endpoints
were ICU and hospital mortality, Sequential Organ
Failure Assessment score, and occurrence of hypoglycemia. Multivariable
regression analysis was used to evaluate mortality and organ dysfunction during
periods II and III relative to period I.
Results Insulin
administration increased over time (9% period I, 25% period II, and 42% period
III). Nonetheless, patients in period III had a tendency toward higher adjusted
hospital mortality (odds ratio [OR] 1.15, 95% confidence interval [CI] 0.98,
1.35) than patients in period I. Excess hospital mortality in period III was
present primarily in patients with an ICU length of stay of 3 days or less (OR
1.47, 95% CI 1.11, 1.93 There was an approximately fourfold increase in the
incidence of hypoglycemia from periods I to III.
Conclusion A
policy of IIT in a group of ICUs from a single institution was not associated
with a decrease in hospital mortality. These results, combined with the
findings from several recent randomized trials, suggest that further study is
needed
prior to widespread implementation of IIT in
critically ill patients.
Critical Care 2008, 12:R29 (doi:10.1186/cc6807)
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