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:
“I will use treatment to help the sick according to my ability and judgment, but never with a view to injury and wrongdoing. Neither will I administer a poison to anybody when asked to do so, nor will I suggest such a course. Similarly, I will not give to a woman a pessary to cause abortion. I will keep pure and holy both my life and my art.”
—Hippocrates (c. 460–c. 370 B.C.)
“A regular council was held with the Indians, who had come in on their ponies, and speeches were made on both sides through an interpreter, quite in the described mode,—the Indians, as usual, having the advantage in point of truth and earnestness, and therefore of eloquence. The most prominent chief was named Little Crow. They were quite dissatisfied with the white man’s treatment of them, and probably have reason to be so.”
—Henry David Thoreau (1817–1862)
“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)