Strict glucose control reduces morbidity and costs
In their editorial (BMJ 15th April 2006) Watkinson and colleagues
commented on Van den Berghe’s study of tight insulin control in the
medical intensive care unit (ICU)[1]. Highlighted was the failure to
reproduce the impressive reduction of mortality in surgical ICU, which was
largely attributable to multi-organ failure with a proven septic focus[2].
The authors suggested that this might be because sepsis often triggers ICU
admission in medical patients. However, it is conceivable that in the five
years between studies, results may have been influenced by additional
variables. There has been a rapid increase in the prescription of statins
across Europe, a class of drug which may modulate sepsis[3], increasing by
an average rate of 31% per year between 1997 and 2002[4]. It is not
implausible that had the study in surgical patients[2] been performed at
the same time as the medical study[1] there would be no difference in
mortality from multi-organ failure due to a septic focus.
Watkinson and colleagues focussed on the effect of tight glycaemic
control on mortality in the medical and surgical ICU, but common to both
studies[1,2] were important reductions in morbidity. Tight glycaemic
control was associated with a shorter period of mechanical ventilation and
length of stay in the ICU. Van den Berghe and colleagues have reported
that lower morbidity results in considerable cost savings, an observation
also reported in a mixed medical-surgical ICU which amounted to $1,580 per
patient[5].
Two large multi-centre studies (NICE-SUGAR (5000 patients) and
GLUControl trial (3500 patients)) aim to examine the effect of tight
glycaemic control on morbidity and mortality in a mixed population of
medical and surgical critically ill patients and results should be
available in 2007. We would argue that until this additional data is
published tight glycaemic control remains an appropriate treatment in a
mixed ICU population.
1. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin
therapy in the medical ICU. N Engl J Med 2006;354:449-61.
2. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin
therapy in critically ill patients. N Engl J Med 2001;345:1359-67.
3. Kruger P, Fitzsimmons K, Cook D, Jones M, Nimmo G. Statin therapy
is associated with fewer deaths in patients with bacteraemia. Intensive
Care Med 2006;32:75-9.
4. Walley T, Folino-Gallo P, Schwabe U, Van Ganse E on behalf of the
EuroMedStat group. Variations and increase in use of statins across
Europe: data from administrative databases. BMJ 2004;328:385-6
5. Krinsley JS and Jones RL. Cost analysis of intensive glycemic
control in critically ill adult patients. Chest 2006;129:644-50.
Rapid Response:
Strict glucose control reduces morbidity and costs
In their editorial (BMJ 15th April 2006) Watkinson and colleagues
commented on Van den Berghe’s study of tight insulin control in the
medical intensive care unit (ICU)[1]. Highlighted was the failure to
reproduce the impressive reduction of mortality in surgical ICU, which was
largely attributable to multi-organ failure with a proven septic focus[2].
The authors suggested that this might be because sepsis often triggers ICU
admission in medical patients. However, it is conceivable that in the five
years between studies, results may have been influenced by additional
variables. There has been a rapid increase in the prescription of statins
across Europe, a class of drug which may modulate sepsis[3], increasing by
an average rate of 31% per year between 1997 and 2002[4]. It is not
implausible that had the study in surgical patients[2] been performed at
the same time as the medical study[1] there would be no difference in
mortality from multi-organ failure due to a septic focus.
Watkinson and colleagues focussed on the effect of tight glycaemic
control on mortality in the medical and surgical ICU, but common to both
studies[1,2] were important reductions in morbidity. Tight glycaemic
control was associated with a shorter period of mechanical ventilation and
length of stay in the ICU. Van den Berghe and colleagues have reported
that lower morbidity results in considerable cost savings, an observation
also reported in a mixed medical-surgical ICU which amounted to $1,580 per
patient[5].
Two large multi-centre studies (NICE-SUGAR (5000 patients) and
GLUControl trial (3500 patients)) aim to examine the effect of tight
glycaemic control on morbidity and mortality in a mixed population of
medical and surgical critically ill patients and results should be
available in 2007. We would argue that until this additional data is
published tight glycaemic control remains an appropriate treatment in a
mixed ICU population.
1. Van den Berghe G, Wilmer A, Hermans G, et al. Intensive insulin
therapy in the medical ICU. N Engl J Med 2006;354:449-61.
2. Van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin
therapy in critically ill patients. N Engl J Med 2001;345:1359-67.
3. Kruger P, Fitzsimmons K, Cook D, Jones M, Nimmo G. Statin therapy
is associated with fewer deaths in patients with bacteraemia. Intensive
Care Med 2006;32:75-9.
4. Walley T, Folino-Gallo P, Schwabe U, Van Ganse E on behalf of the
EuroMedStat group. Variations and increase in use of statins across
Europe: data from administrative databases. BMJ 2004;328:385-6
5. Krinsley JS and Jones RL. Cost analysis of intensive glycemic
control in critically ill adult patients. Chest 2006;129:644-50.
Competing interests:
None declared
Competing interests: No competing interests