Hyperglycemia in acutely ill emergency patients--cause or effect?

To clarify the benefits, risks and timing of glucose control and intensive insulin therapy in several groups, specifically the neurologic, cardiac and septic populations of patients, commonly seen in the emergency department.

Electronic search of MEDLINE (1966-2005; once with PubMed and once with Ovid) and Embase (1980-2005) using the terms insulin and glucose combined with emergency medicine, intensive care, cardiology and emergency department.

There is considerable controversy in the literature surrounding the use of strict glucose control in cardiac, neurologic and septic patients. Much of this literature is non-randomized, and the timing of therapy is poorly investigated.

Hyperglycemia is associated with adverse outcomes in acutely ill neurologic, cardiac and septic patients, but it remains unclear whether this is a causative association. Glucose control and intensive insulin therapy may be useful in some patient subgroups; however, controlled trials of aggressive glycemic control have provided insufficient evidence to justify subjecting patients to the real risks of iatrogenic hypoglycemia. We recommend a cautious approach to the control of glucose levels in acutely ill emergency department patients, with a target glucose of below 8 to 9 mmol/L.