Understanding glycemic control in the critically ill: three domains are better than one

Excerpt

Intensive insulin therapy targeting euglycemia burst into prominence 9 years ago with the publication of the single-center study from Leuven, Belgium, involving a cohort of 1,548 mechanically ventilated postoperative patients [1]. The prodigious influence of this landmark study is reflected by the Google Scholar website: 5,421 published manuscripts have cited this work in the 9 years since its publication [2]! Nevertheless, the early promise of this intervention, while corroborated in a large before and after study at my institution [3], and included in treatment guidelines by major organizations [4, 5], was not borne out in subsequent investigations. Two large multicenter studies [6, 7] were terminated prematurely by their safety boards for safety reasons—high rates of severe hypoglycemia—and protocol violations, and the Leuven group’s trial in a medical population demonstrated only modest benefit [8]. Finally, the largest multicenter trial of all—NICE-SUGAR—resulted in a small signal of harm in the intensively treated arm [9]. …