Over a decade ago, the New England Journal of Medicine published a study identifying tight glycemic control in the intensive care unit as a critical step to improving patient outcomes. Today, a small pack of companies is trying to finally deliver on the promise.
Tight Glycemic Control: Critical Care’s Balancing Act
Article preview from Medtech Insight - October, 2012
Late night talk host David Letterman might have made the Top 10 List famous, but the New England Journal of Medicine publishes a noteworthy top 10 list of its own that identifies the most frequently cited articles in the journal’s history. At number five sits a 2001 article entitled “Intensive Insulin Therapy in Critically Ill Patients,” which makes a compelling case for adding the management of blood glucose levels in critical care patients to the list of mandatory care.
Lead author Greet Van den Berghe, MD, PhD, (then head of the department of intensive care medicine at the hospital of the Catholic University of Leuven, Belgium) and her team studied hyperglycemia and insulin resistance in critically ill patients. Diabetes is a common phenomenon in patients in the intensive care unit (ICU), even in those who have not previously had diabetes, due to stress-induced changes in glucose tolerance. Critically ill patients often develop what is known as stress hyperglycemia, in which the tissues in the body that normally absorb glucose become resistant to the effects of insulin, setting off a biofeedback loop that can result in massive glucose overload. This phenomenon has been linked to a number of serious problems for these patients that can aggravate their underlying disease, including the up-regulation of inflammatory pathways and deleterious changes in the immune system, and it is associated with prolonged hospital stay and higher treatment costs as well as an increased risk of in-hospital mortality and morbidity.
In Van den Berghe’s study of 1,548 patients in the surgical ICU, the administration of intensive insulin therapy to normalize blood glucose levels had dramatic effects. Mortality dropped by 34% in the tight glycemic control (TGC) group. TGC patients experienced a 41% reduction in acute renal failure, and a 50% reduction in the need for blood transfusion. Sepsis dropped by 46% in the study, potentially reducing one of the more expensive complications for US hospitals, especially since the Centers for Medicare and Medicaid Services (CMS) has shifted the burden of some hospital-acquired infections to hospitals.
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