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document
Lowering of glucose in critical care : a randomized pilot trial . BACKGROUND Similar to cardiac surgery patients , medical-surgical critically ill patients may benefit from intensive insulin therapy . The objectives of this pilot trial were to evaluate the feasibility of a randomized trial of intensive insulin therapy with respect to ( a ) achieving target glucose values in the 2 ranges of 5 to 7 and 8 to 10 mmol/L and ( b ) uncovering problems with the protocol in anticipation of a larger trial . SETTING The trial was conducted in a 15-bed medical-surgical university-affiliated intensive care unit ( ICU ) . METHODS We included patients older than 18 years , expected to be in ICU for more than 72 hours , with a glucose value of more than 10 mmol/L within 48 hours of ICU admission . Exclusion criteria were diabetic ketoacidosis , severe hepatic failure or hepatic resection , pancreatitis , glucose of less than 2.2 mmol/L on admission to hospital , insulin infusion on admission to ICU , planned withdrawal of life support , and inability to obtain informed consent . Patients underwent concealed random allocation to a target glucose range of 5 to 7 or 8 to 10 mmol/L using pretested algorithms of insulin infusions . Dedicated glucometer measurement of arterial glucose values was calibrated daily to values measured in the laboratory . RESULTS We enrolled 20 patients with a mean ( SD ) Acute Physiology and Chronic Health Evaluation ( APACHE ) II score of 32 ( 10.2 ) ; 14 were insulin-dependent pre-ICU , and all were medical admissions . Mean glucose values were different in the 2 groups ( 7.1 +/- 2.6 vs 9.4 +/- 2.1 mmol/L , P < .001 ) . Although the intensive insulin therapy group had more glucose measurements performed than the control group , a similar proportion of values were within the target range ( 682 [ 42.4 % ] of 1607 values in the 5- to 7-mmol/L range ; 250 [ 38.7 % ] of 660 values in the 8- to 10-mmol/L range , P = .35 ) . Glucose values of less than 2.5 mmol/L developed 7 times in 5 patients , 4 of whom were in the intensive insulin therapy group ; however , no adverse consequences were documented . As expected , there were no differences in clinically important outcomes . CONCLUSIONS In this pilot trial of ICU patients with high illness severity , glucose values were in the 2 target ranges only 40 % of the time , using well-accepted initiation and maintenance insulin infusion algorithms . A large randomized trial of glycemic control is feasible in this population to examine clinically important outcomes , but will require refined insulin algorithms and more comprehensive behavior change strategies to achieve target values .
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Intervention_Pharmacological
intensive insulin therapy
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Intervention_Pharmacological
intensive insulin therapy
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Intervention_Physical
concealed random allocation to a target glucose range of 5 to 7 or 8 to 10 mmol/L using pretested algorithms of
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Intervention_Pharmacological
insulin infusions
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Intervention_Pharmacological
intensive insulin therapy
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Intervention_Pharmacological
insulin
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Intervention_Pharmacological
insulin
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Outcome_Physical
Acute Physiology and Chronic Health Evaluation ( APACHE ) II score
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Outcome_Physical
Mean glucose values
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Outcome_Physical
glucose measurements
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Outcome_Physical
Glucose values
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Outcome_Physical
glucose values
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Participant_Condition
medical-surgical critically ill patients
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Participant_Age
older than 18 years
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Participant_Condition
expected to be in ICU for more than 72 hours
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Participant_Condition
hepatic failure or hepatic resection , pancreatitis , glucose
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Participant_Sample-size
20
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Participant_Condition
high illness severity