Clinical potential of insulin therapy in critically ill patients

被引:41
作者
Mesotten, D [1 ]
Van den Berghe, G [1 ]
机构
[1] Catholic Univ Louvain, Dept Intens Care Med, Univ Hosp Gasthuisberg, B-3000 Louvain, Belgium
关键词
D O I
10.2165/00003495-200363070-00001
中图分类号
R9 [药学];
学科分类号
1007 ;
摘要
Stress of critical illness is often accompanied by hyperglycaemia, whether or not the patient has a history of diabetes mellitus. This has been considered to be part of the adaptive metabolic response to stress. The level of hyperglycaemia in patients with acute myocardial infarction (MI) or stroke upon admission to the hospital has been related to the risk of adverse outcome. However, until recently, there was no evidence of a causal relationship and thus stress-induced hyperglycaemia was only treated with exogenous insulin when it exceeded 12 mmol/L (220 mg/dL). In patients with known diabetes, even higher levels were often tolerated. Recently, new data became available in support of another approach. In this review, we focus on the new evidence and the clinical aspects of managing hyperglycaemia with insulin in critically ill patients, drawing a parallel with diabetes management. Particularly, the 'Diabetes and Insulin-Glucose infusion in Acute Myocardial Infarction (DIGAMI) study' and the 'insulin in intensive care study' have provided novel insights. The DIGAMI study showed that in patients with diabetes, controlling blood glucose levels below 12 mmol/L for 3 months after acute MI improves long-term outcome. In the recent study of predominantly surgical intensive care patients, the majority of whom did not previously have diabetes, it was shown that an even tighter control of blood glucose with exogenous insulin, aiming for normoglycaemia, dramatically improved outcome. Indeed, in this large prospective, randomised, controlled study, 1548 intensive care patients had been randomly allocated to either the conventional, approach, with insulin infusion started only when blood glucose levels exceeded 12 mmol/L, or intensive insulin therapy, with insulin infused to maintain blood glucose at a level of 4.5-6.1 mmol/L (80-110 mg/dL). Intensive insulin therapy reduced intensive care mortality by more than 40% and also decreased a number of morbidity factors including acute renal failure, polyneuropathy, ventilator-dependency and septicaemia. Future studies will be needed to further unravel the mechanisms that explain the beneficial effects of this simple and cost-saving intervention. Although available evidence supports implementation of intensive insulin therapy in surgical intensive care, the benefit for other patient populations, such as patients on medical intensive care units or hospitalised patients who do not require intensive care but who do present with stress-induced hyperglycaemia, remains to be investigated.
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收藏
页码:625 / 636
页数:12
相关论文
共 86 条
[21]  
Diabet Control Complications DCCT Res Grp, 1995, KIDNEY INT, V47, P1703
[22]   Glucose-insulin-potassium therapy for treatment of acute myocardial infarction - An overview of randomized placebo-controlled [J].
FathOrdoubadi, F ;
Beatt, KJ .
CIRCULATION, 1997, 96 (04) :1152-1156
[23]   EFFECT OF INTERLEUKIN-1 AND TUMOR-NECROSIS-FACTOR CACHECTIN ON GLUCOSE-TURNOVER IN THE RAT [J].
FLORES, EA ;
ISTFAN, N ;
POMPOSELLI, JJ ;
BLACKBURN, GL ;
BISTRIAN, BR .
METABOLISM-CLINICAL AND EXPERIMENTAL, 1990, 39 (07) :738-743
[24]   Metabolic and nutritional considerations in nonalcoholic fatty liver [J].
Fong, DG ;
Nehra, V ;
Lindor, KD ;
Buchman, AL .
HEPATOLOGY, 2000, 32 (01) :3-10
[25]   CHANGES IN FIBRINOLYSIS IN THE INTENSIVE-CARE PATIENT [J].
FRADE, LJG ;
LANDIN, L ;
AVELLO, AG ;
YERRO, JM ;
NAVARRO, JL ;
CREIGHTON, LJ ;
GAFFNEY, PJ .
THROMBOSIS RESEARCH, 1987, 47 (05) :593-599
[26]  
FRADE LJG, 1987, THROMB RES, V47, P533
[27]   REVERSAL OF THE TOXIC EFFECTS OF CACHECTIN BY CONCURRENT INSULIN ADMINISTRATION [J].
FRAKER, DL ;
MERINO, MJ ;
NORTON, JA .
AMERICAN JOURNAL OF PHYSIOLOGY, 1989, 256 (06) :E725-E731
[28]   Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures [J].
Furnary, AP ;
Zerr, KJ ;
Grunkemeier, GL ;
Starr, A .
ANNALS OF THORACIC SURGERY, 1999, 67 (02) :352-360
[29]   Pathophysiologic correlates of hypocholesterolemia in critically ill surgical patients [J].
Giovannini, I ;
Boldrini, G ;
Chiarla, C ;
Giuliante, F ;
Vellone, M ;
Nuzzo, G .
INTENSIVE CARE MEDICINE, 1999, 25 (07) :748-751
[30]   Low lipid concentrations in critical illness: Implications for preventing and treating endotoxemia [J].
Gordon, BR ;
Parker, TS ;
Levine, DM ;
Saal, SD ;
Wang, JCL ;
Sloan, BJ ;
Barie, PS ;
Rubin, AL .
CRITICAL CARE MEDICINE, 1996, 24 (04) :584-589