The Long and Winding Road Toward Personalized Glycemic Control in the Critically Ill.

Hyperglycemia is very common in critically ill patients and interventional studies of intensive insulin therapy with the goal of returning ICU glycemia to normal levels have demonstrated mixed results. A large body of literature has demonstrated that diabetes, per se, is not independently associated with increased risk of mortality in this population and that the relationship of glucose metrics to mortality is different for patients with and without diabetes. Moreover, these relationships are confounded by preadmission glycemia; in this regard, patients with diabetes and good preadmission glucose control, as reflected by HbA1c levels obtained at the time of ICU admission, are similar to patients without diabetes.

Glycemic control in the critically ill: What have we learned since NICE-SUGAR?

Since publication of the Normoglycemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation trial in 2009, demonstrating increased 90-day mortality in a large cohort of critically ill patients treated with the intensive, rather than moderate blood glucose (BG) target, enthusiasm has dampened for 'tight glucose control' in intensive care units. Nevertheless, a burgeoning literature has clarified limitations of the interventional trials of intensive insulin therapy in the critically ill and explored key clinical aspects of glycemic control in this population. This review provides an overview of the last 6 years of research in this field.

Glycemic variability and mortality in critically ill patients: the impact of diabetes.

Background: Glycemic variability (GV) has recently been associated with mortality in critically ill patients. The impact of diabetes or its absence on GV as a risk factor for mortality is unknown.

Methods: A total of 4084 adult intensive care unit (ICU) patients admitted between October 15, 1999, and June 30, 2009, with at least three central laboratory measurements of venous glucose samples during ICU stay were studied retrospectively.

Cost analysis of intensive glycemic control in critically ill adult patients.

Study Objectives: To assess the effect of an intensive glycemia management protocol on the cost of care of a heterogeneous population of critically ill adult patients.

Design: Economic analysis of a 1,600-patient "before-and-after" study of intensive glycemia management.

Setting: Fourteen-bed mixed medical-surgical adult ICU of a university-affiliated community teaching hospital.

Effect of an intensive glucose management protocol on the mortality of critically ill adult patients.

Objective: To assess the effect of an intensive glucose management protocol in a heterogeneous population of critically ill adult patients.

Patients And Methods: This study consisted of 800 consecutive patients admitted after institution of the protocol (treatment group, between February 1, 2003, and January 10, 2004) and 800 patients admitted immediately preceding institution of the protocol (baseline group, between February 23, 2002, and January 31, 2003). The setting was a 14-bed medical-surgical intensive care unit (ICU) in a university-affiliated community teaching hospital.

Test-ordering strategy in the intensive care unit.

The objective of this study was to assess the effect of an intervention designed to reduce utilization of portable chest x-rays (CXRs) in the intensive care unit (ICU). In this prospective observational study, patients representing 2734 consecutive admissions over a 35-month period were studied. Data collected from the comprehensive ICU database included patient days, ventilator days, number of admissions to the unit, number of CXRs ordered, costs for CXR, Acute Physiology and Chronic Health Evaluation II (Apache II) scores, ICU length of stay (LOS), length of mechanical ventilation, inadvertent extubations from mechanical ventilation, and reintubation within 48 hours of planned extubation.

Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients.

Objective: To investigate the relationship between hyperglycemia and hospital mortality in a heterogeneous group of critically ill patients.

Patients And Methods: Retrospective data were reviewed for 1826 consecutive patients whose glucose values were obtained during their intensive care unit stay at The Stamford Hospital in Stamford, Conn, between October 1, 1999, and April 4, 2002.

Results: Mean and maximum glucose values were significantly higher among nonsurvivors than among survivors for the entire group (P < .