Insulin treatment in intensive care patients

Hyperglycemia is a major risk factor for increased morbidity and mortality in the intensive care unit. In two large randomized controlled single-center studies, the maintenance of strict normoglycemia with intensive insulin therapy has been shown to reduce morbidity and mortality. The benefits were more pronounced with at least a few days of treatment. Several implementation studies confirmed that blood glucose control with intensive insulin therapy is beneficial for critically ill patients. Two studies planned as large randomized controlled trials evaluating the effect of glycemic control in adults were stopped prematurely because of protocol violation and/or increased risk of hypoglycemia. The only multicenter trial designed with sufficient statistical power to assess the impact of strict blood glucose control with intensive insulin therapy on survival of a heterogeneous adult critically ill patient population is still ongoing. While awaiting these results, the current evidence favors strict control of blood glucose levels to normoglycemia below 110 mg/dl. Avoiding glucose toxicity appears crucial to obtain the clinical benefits of this therapy, although direct insulin effects may contribute as well.