TY - JOUR
T1 - Inpatient glycemic control
T2 - An evolving paradigm
AU - Yalla, Naga M.
AU - Reynolds, L. Raymond
PY - 2009/5
Y1 - 2009/5
N2 - In 2001, Van den Berghe et al published a landmark study of intensive insulin therapy in the setting of a surgical intensive care unit (ICU). Increased attention was also focused on the observational evidence indicating that hyperglycemia is associated with increased morbidity and mortality among diverse patient populations. Because of the dramatic reduction in mortality with normalization of glucose levels in the single center, the Van den Berghe study led to widespread adoption of this practice in ICUs worldwide. Hospitals also began to implement rational subcutaneous insulin protocols based on the American Diabetes Association technical review, replacing the ineffective practice of sliding-scale insulin. Logistical challenges have included coordination of multiple hospital departments and achieving multidisciplinary consensus on goals and methods. Subsequent to the initial Van den Berghe study, other multicenter trials have been fraught with an increased frequency of hypoglycemia and have failed to consistently demonstrate improved outcomes with intensive insulin therapy. Hospitals and expert panels are in the process of examining the combined evidence and considering modifying treatment goals. We recommend continued focus on avoiding hyperglycemia with less aggressive glycemic targets in the critically ill and rational subcutaneous insulin in the noncritically ill, avoiding a return to the obsolescence of sliding-scale insulin.
AB - In 2001, Van den Berghe et al published a landmark study of intensive insulin therapy in the setting of a surgical intensive care unit (ICU). Increased attention was also focused on the observational evidence indicating that hyperglycemia is associated with increased morbidity and mortality among diverse patient populations. Because of the dramatic reduction in mortality with normalization of glucose levels in the single center, the Van den Berghe study led to widespread adoption of this practice in ICUs worldwide. Hospitals also began to implement rational subcutaneous insulin protocols based on the American Diabetes Association technical review, replacing the ineffective practice of sliding-scale insulin. Logistical challenges have included coordination of multiple hospital departments and achieving multidisciplinary consensus on goals and methods. Subsequent to the initial Van den Berghe study, other multicenter trials have been fraught with an increased frequency of hypoglycemia and have failed to consistently demonstrate improved outcomes with intensive insulin therapy. Hospitals and expert panels are in the process of examining the combined evidence and considering modifying treatment goals. We recommend continued focus on avoiding hyperglycemia with less aggressive glycemic targets in the critically ill and rational subcutaneous insulin in the noncritically ill, avoiding a return to the obsolescence of sliding-scale insulin.
KW - Critically ill
KW - Diabetes
KW - Hyperglycemia
KW - Hypoglycemia
KW - Insulin
KW - Intensive care units
UR - http://www.scopus.com/inward/record.url?scp=67549101336&partnerID=8YFLogxK
U2 - 10.3810/pgm.2009.05.1999
DO - 10.3810/pgm.2009.05.1999
M3 - Review article
C2 - 19491537
AN - SCOPUS:67549101336
SN - 0032-5481
VL - 121
SP - 26
EP - 32
JO - Postgraduate medicine
JF - Postgraduate medicine
IS - 3
ER -