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CRITICAL CARE

Intensive Insulin Therapy for Critically Ill Patients

at time of writing, Associate Professor of Anesthesiology, Division of Critical Care, Rush Presbyterian St. Luke's Medical Center, Chicago, IL; now, Medical Science Liaison, Actelion Pharmaceuticals US, Inc.

Sandra L Kane-Gill, PharmD MSc

Assistant Professor, School of Pharmacy, University of Pittsburgh, Center for Pharmacoinformatics and Outcomes Research, Pittsburgh, PA

Mary Beth Bobek, PharmD

Director, Cardiovascular Pharmacotherapy, Department of Cardiac Services, New Hanover Regional Medical Center, Wilmington, NC

Joseph F Dasta, MSc FCCM

Professor of Pharmacy, College of Pharmacy, The Ohio State University, Columbus, OH

Reprints: Sandra L Kane-Gill PharmD MSc, School of Pharmacy, University of Pittsburgh, Center for Pharmacoinformatics and Outcomes Research, 904 Salk Hall, 3501 Terrace St., Pittsburgh, PA 15261-0001, fax 412/624-1850, kanesl{at}msx.upmc.edu

OBJECTIVE: To evaluate the clinical outcomes of glycemic control of intensive insulin therapy and recommend its place in the management of critically ill patients.

DATA SOURCES: Searches of MEDLINE (1966–March 2004) and Cochrane Library, as well as an extensive manual review of abstracts were performed using the key search terms hyperglycemia, insulin, intensive care unit, critically ill, outcomes, and guidelines and algorithms.

STUDY SELECTION AND DATA EXTRACTION: All articles identified from the data sources were evaluated and deemed relevant if they included and assessed clinical outcomes.

DATA SYNTHESIS: Mortality among patients with prolonged critical illness exceeds 20%, and most deaths are attributable to sepsis and multisystem organ failure. Hyperglycemia is common in critically ill patients, even in those with no history of diabetes mellitus. Maintaining normoglycemia with insulin in critically ill patients has been shown to improve neurologic, cardiovascular, and infectious outcomes. Most importantly, morbidity and mortality are reduced with aggressive insulin therapy. This information can be implemented into protocols to maintain strict control of glucose.

CONCLUSIONS: Use of insulin protocols in critically ill patients improves blood glucose control and reduces morbidity and mortality in critically ill populations. Glucose levels in critically ill patients should be controlled through implementation of insulin protocols with the goal to achieve normoglycemia, regardless of a history of diabetes. Frequent monitoring is imperative to avoid hypoglycemia.

Key Words: hyperglycemia, insulin infusions, intensive care unit

Published Online, June 8, 2004. www.theannals.com, DOI 10.1345/aph.1D211

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