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Tight Glycemic Control in the ICU


Helen Londe, M.D.
Contributing Editor

The outcome of many illnesses for which patients are treated in intensive care units (ICUs) has not improved dramatically over the past decades, despite the development of high-tech monitors and sophisticated mechanical and pharmacological support of vital organ systems. Indeed, critically ill patients requiring intensive care for more than five days have a 20 percent risk of death and substantial morbidity. Recently, however, evidence from a few randomized controlled clinical studies has shown a reduction in mortality and morbidity in the ICU, simply by rethinking and fine-tuning some of the basic interventions utilized by intensive care medicine, such as mechanical ventilation, fluid administration, inotropic support, and metabolic control.

Results published in 2001 of a prospective randomized trial that evaluated tight glycemic control (TGC) in a surgical ICU has been extremely influential in changing standard of care in ICUs, and as well as generating new studies evaluating TGC in other hospital populations. In that 2001 study, where only 13 percent of patients had a history of diabetes, maintenance of normoglycemia with insulin infusions reduced mortality in patients remaining in the ICU for more than 5 days by 48 percent. It also greatly decreased the incidence of acute renal failure, septicemia, and critical illness polyneuropathy.

While there is ongoing debate and research on what level of blood glucose is optimal, and whether the benefits to patients result solely from lower blood glucose, or from the broad physiological effects of insulin, or from both, glycemic control protocols are being instituted in hospital ICUs. Concerns that arise during protocol implementation include worry about hypoglycemia, accuracy of glucose meters, and increased nursing work-load. Clinicians in units with TGC report that with close monitoring symptomatic hypoglycemia is rare, and recommend choosing a glucome
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