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Intensive Insulin Treatment Associated with Better Outcomes in Surgical ICU Patients

Researchers look at the incidence of surgical site infection (SSI) in patients undergoing hepato-biliary-pancreatic surgery with perioperative intermediate vs. intensive insulin therapy…. 

Hyperglycemia occurs commonly in patients who are acutely ill and those treated in intensive care units. There is conflicting evidence on how to treat hyperglycemia in these patients, especially because of the threat of hypoglycemia when tight glucose control is used. Recent meta-analyses do not support intensive insulin therapy (IT) in critically ill patients, though it may be beneficial for patients in a surgical ICU. Because perioperative hyperglycemia increases the risk of SSI, effective control of blood glucose can reduce the risk of SSI and subsequently enhance recovery and reduce length of hospitalization. One hurdle to this concept is that the optimal perioperative blood glucose range to improve outcomes after surgery is still unclear. Okabayashi, T et al. conducted a study to determine which perioperative glycemic control range was better for reducing SSI, intermediate (target blood glucose range 7.7-10.0 mmol/L) or intensive (target blood glucose 4.4-6.1 mmol/L).

This randomized controlled trial included adult surgical patients who were admitted to the ICU in Kochi, Japan for surgery for hepato-biliary-pancreatic diseases. Patient clinical history was evaluated for details of glucose metabolism, and included FBG level, medications used for the treatment of diabetes, and HbA1c. Diabetes mellitus status was also checked by an in-house diabetologist, and all DM cases were type 2. Patients were admitted overnight before the surgery and remained in the hospital until post-op day 1 following hepatic and/or pancreatic resection. Participants were randomized before the operation to either the intermediate IT group or the intensive IT group and blood glucose was controlled until post-op day 1 using a closed-loop glycemic control system. The primary endpoint for this study was the incidence of SSI.

A total of 225 patients were randomized to the intermediate IT group and 222 patients were randomized to the intensive IT group. None of the patients in either group became hypoglycemic during their stay in the ICU, with hypoglycemia defined as a blood glucose range of <4.4 mmol/L. The rate of SSI after hepato-biliary-pancreatic surgery was 6.7%, with patients in the intensive IT group having fewer post-op SSIs than those in the intermediate IT group (9.8% vs. 4.1%). Patients in the intensive IT group also had a lower incidence of postoperative fistula following pancreatic resection. Because of these two findings, patients in the intensive IT group required a significantly shorter length of hospital stay than those in the intermediate IT group.

The results of this study showed those undergoing intensive IT to have a decreased incidence of SSI following hepato-biliary-pancreatic surgery, showing a target blood glucose range of 4.4-6.1 mmol/L to be more beneficial in these patients than a target of 7.7-10.0 mmol/L. The use of a closed-loop glycemic control system allowed for the maintenance of stable glycemic control, with no hypoglycemia or hyperglycemia occurring in any of the patients and less variability of blood glucose concentration. This is an important finding as intensive IT is often not used due to fear of hypoglycemia and patients often receive insufficient nutritional support due to fear of hyperglycemia. The results of the study support the conclusions of previous observational studies that intensive IT improves outcomes for critically ill patients, especially those in the ICU. Future research is still needed to determine the optimal blood glucose range to improve morbidity and mortality in surgical patients, as well as to clarify how long blood glucose levels should be controlled post-operatively. The conductors of this study also suggest that the prospective large randomized control trials reevaluate the effect of tight glucose control for patients in the surgical and medical ICU regarding hypoglycemia with intensive IT, as they have shown closed-loop glycemic control systems to be effective at controlling blood glucose levels and allowing intensive IT without occurrence of hypoglycemia.

Practice Pearls:
  • Using a closed-loop glycemic control system, perioperative intensive insulin therapy was significantly better at reducing SSI and morbidity and shortening post-operative hospitalization than intermediate insulin therapy.
  • The closed-loop glycemic control system was effective at controlling blood glucose levels and performing insulin treatment in the ICU without the occurrence of hypoglycemia in either the intermediate or the intensive IT group. 

Okabayashi, T et al. "Intensive Versus Intermediate Glucose Control in Surgical Intensive-Care Unit Patients" Diabetes Care. 2014; 37: 9p.