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Issue 178 Item 6 Hyperglycemia, Not Hypoinsulinemia, Affects Outcomes

Blood glucose control, rather than amount of insulin administered, accounts for the mortality benefit conferred by intensive therapy in critically ill patients, study findings suggest.

Maintenance of blood glucose at optimal levels using intensive insulin treatment reduces mortality of patients in intensive care, However, the mechanisms of this benefit and the most appropriate target level for blood glucose are not known.

Therefore, Dr. Evans and associates at Royal Brompton Hospital in London prospectively followed 523 consecutive patients, median age 64, admitted to their institution’s ICU in 2002. Most patients were admitted as a result of cardiothoracic surgery. Target blood glucose levels were between 90 and 145 mg/dL. The authors note that mortality rates and length of hospital stay were not affected by diabetes diagnosis or body mass index.

Of more then 20,000 blood glucose measurements, increased insulin administration was associated with a small but statistically significant increased risk of death, "indicating that glucose control rather than administration of exogenous insulin was the dominant factoring improving mortality," the investigators write.

There was a nonsignificant trend for lower mortality rates among subjects kept at blood glucose levels of 145 to 180 mg/dL versus those with higher glucose levels. Moreover, patients who spent the least amount of time at insulin levels of 181 mg/dL or above had a reduced mortality risk compared with those who spent the most time there.

The investigators suggest a target blood glucose level of less than 145 mg/dL, which would be associated with less risk of hypoglycemia than more stringent glucose control. JAMA 2003;290:2041-2047.

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