Van den Berghe G et al. (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354: 449–461

Previous studies have demonstrated that strict control of blood glucose levels, using insulin therapy, substantially reduces in-hospital mortality in a surgical intensive care unit (ICU), with a more distinct benefit in patients who stayed in the ICU for more than 3 days. In this randomized controlled study, Van den Berghe et al. investigated whether this would also be the case in a medical ICU.

On admission to a medical ICU, adult patients were randomly assigned to either an intensive treatment group, whose blood glucose levels were maintained between 4.4 and 6.1 mmol/l, or a conventional therapy group in whom insulin was started only when blood glucose levels exceeded 12 mmol/l and was tapered when blood glucose levels fell below 10 mmol/l. Among the 1,200 patients enrolled in the study, in-hospital mortality was not substantially reduced by intensive insulin therapy. Morbidity was reduced in the intensive therapy group, however, as shown by a reduction in newly acquired kidney injury, accelerated weaning from mechanical ventilation, and accelerated discharge both from ICU and from the hospital, compared with the conventional treatment group. Patients who received intensive insulin therapy and stayed in the ICU for >3 days (n = 386) had reduced mortality and morbidity compared with those receiving conventional therapy (n = 381).

The authors conclude that intensive insulin therapy reduces morbidity in all patients in the medical ICU. Patients who received intensive insulin therapy and who stayed in the ICU longer than 3 days experienced a reduced mortality as well as morbidity, but these patients could not be identified upon admission.