Treatment
One of the most sweeping changes in intensive care unit (ICU) and post-surgical care in recent years is the trend toward more aggressive treatment of stress-induced hyperglycemia. The 2008 guidelines from the Surviving Sepsis Campaign recommend insulin therapy in critically ill patients.
A number of research studies have demonstrated that even mildly elevated blood glucose levels (110 mg/dL or 6.1 mmol/L) in a hospital intensive care unit (ICU) can measurably increase the morbidity and mortality of such patients. According to a randomized control trial (RCT) of over 1500 surgical ICU patients, controlling patients’ blood glucose below 110 mg/dL or 6.1 mmol/L significantly decreased mortality from 8% with conventional treatment to 4.6%, and also decreased morbidity from bloodstream infections by 46%, acute renal failure requiring dialysis or hemofiltration and critical illness polyneuropathy (Van den Berghe, 2001). A subsequent RCT of 1200 medical ICU patients found that intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. On the other hand, several studies failed to show benefit or demonstrated harmful effects (mainly from hypoglycemia) of intensive insulin therapy in critically ill patients. A meta-analysis of studies on this topic could not demonstrate an advantage of tight glycemic control, while there was an increase in hypoglycemia. This questions the validity of current guidelines.
Most recently, the largest RCT to date (with 6104 enrolled patients) comparing the effects of intensive glucose control vs. conventional glucose control in ICU patients found that tight glucose control significantly increased mortality at 90 days after admission to the ICU as compared to conventional glucose control (2.6% increase in the absolute risk of death). In this trial (the NICE-SUGAR Study), patients randomised to the intensive glucose control group had a target blood sugar range of 4.5 to 6.0 mmol/L while those placed in the conventional glucose control group had a blood glucose target range of 8.0 to 10.0 mmol/L (as compared to 10.0 to 11.1 mmol/L in Van den Berghe, 2001). Patients were enrolled from mixed ICU wards (as compared to a surgical ICU in Van den Berghe, 2001). The NICE-SUGAR trial may very well change our approach to the management of stress-induced hyperglycemia in the ICU.
Read more about this topic: Stress Hyperglycemia
Famous quotes containing the word treatment:
“Narcissist: psychoanalytic term for the person who loves himself more than his analyst; considered to be the manifestation of a dire mental disease whose successful treatment depends on the patient learning to love the analyst more and himself less.”
—Thomas Szasz (b. 1920)
“Our treatment of both older people and children reflects the value we place on independence and autonomy. We do our best to make our children independent from birth. We leave them all alone in rooms with the lights out and tell them, “Go to sleep by yourselves.” And the old people we respect most are the ones who will fight for their independence, who would sooner starve to death than ask for help.”
—Margaret Mead (1901–1978)
“Ambivalence reaches the level of schizophrenia in our treatment of violence among the young. Parents do not encourage violence, but neither do they take up arms against the industries which encourage it. Parents hide their eyes from the books and comics, slasher films, videos and lyrics which form the texture of an adolescent culture. While all successful societies have inhibited instinct, ours encourages it. Or at least we profess ourselves powerless to interfere with it.”
—C. John Sommerville (20th century)