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Glucose Variance in ICU Patients Receiving Insulin Infusions FREE TO VIEW

Stephen M. Smith, FRACP, FJFICM, PhD; Daniel S. Hagg, MD
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Oregon Health and Science University, Portland, OR

Correspondence to: Stephen M. Smith, FRACP, FJFICM, PhD, Division of Pulmonary and Critical Care Medicine, Biomedical Research Building (UHN-67), 3181 SW Sam Jackson Park Rd, Oregon Health and Science University, Portland OR 97239-3098; e-mail: smisteph@ohsu.edu



Chest. 2008;133(5):1288. doi:10.1378/chest.07-2518
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Published online

To the Editor:

Vanhorebeek and colleagues1recently addressed the controversies surrounding insulin treatment of hyperglycemia in the ICU. The authors reviewed single-center studies23 that demonstrated benefits of tight glucose control, and a multicenter study4 that showed no improvement with insulin use. Failure to achieve glucose targets was proposed to explain the negative multicenter findings.1 This plausible hypothesis begs the question: how did the single-center and multicenter studies compare in achieving target glucose? Vanhoorebeek and colleagues1stated that 70% of treated patients in the Leuven studies23 had mean daily blood glucose levels < 110 mg/dL, compared with a median glucose level of 118 mg/dL in the Glucontrol study.1The Leuven studies23 reported 6:00 am mean glucose levels, but if the mean daily blood glucose level was calculated from these values alone, meaningful comparison of glucose control in the different studies requires the assumptions that glucose does not vary with time of day and is distributed normally. We recently determined that these two assumptions are incorrect; in our ICU, glucose levels varied in an ultradian pattern, peaking twice every 24 h, and had a positively skewed distribution.,5 These new findings complicate the comparison of the reported data undermining the conclusion that failure to achieve target glucose levels underlies the failure of the multicenter study.1

For clinicians and investigators attempting to replicate the impressive results of the Leuven studies, it is essential to know what proportion of all glucose measurements were in range for patients receiving insulin in those studies because 6:00 am values are not representative of mean daily glucose levels.5 We agree with Vanhorbeek et al1 that achieving the glucose target range is crucial when investigating the efficacy of insulin infusion protocols, but the objective comparison of these studies requires that the glucose values achieved be clearly reported and include multiple time points.

The authors have no conflicts of interest to disclose.

Vanhorebeek, I, Langouche, L, Van den Berghe, G (2007) Tight blood glucose control with insulin in the ICU: facts and controversies.Chest132,268-278. [PubMed] [CrossRef]
 
Van den Berghe, G, Wouters, P, Weekers, F, et al Intensive insulin therapy in the critically ill patients.N Engl J Med2001;345,1359-1367. [PubMed]
 
Van den Berghe, G, Wilmer, A, Hermans, G, et al Intensive insulin therapy in the medical ICU.N Engl J Med2006;354,449-461. [PubMed]
 
Brunkhorst, FM, Kuhnt, E, Engel, C, et al Intensive insulin therapy in patient with severe sepsis and septic shock is associated with an increased rate of hypoglycemia: results from a randomized multicenter study (VISEP).Infection2005;33,19-20
 
Smith, SM, Oveson, KE, Strauss, W, et al Ultradian variation of blood glucose in intensive care unit patients receiving insulin infusions.Diabetes Care2007;30,2503-2505. [PubMed]
 

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References

Vanhorebeek, I, Langouche, L, Van den Berghe, G (2007) Tight blood glucose control with insulin in the ICU: facts and controversies.Chest132,268-278. [PubMed] [CrossRef]
 
Van den Berghe, G, Wouters, P, Weekers, F, et al Intensive insulin therapy in the critically ill patients.N Engl J Med2001;345,1359-1367. [PubMed]
 
Van den Berghe, G, Wilmer, A, Hermans, G, et al Intensive insulin therapy in the medical ICU.N Engl J Med2006;354,449-461. [PubMed]
 
Brunkhorst, FM, Kuhnt, E, Engel, C, et al Intensive insulin therapy in patient with severe sepsis and septic shock is associated with an increased rate of hypoglycemia: results from a randomized multicenter study (VISEP).Infection2005;33,19-20
 
Smith, SM, Oveson, KE, Strauss, W, et al Ultradian variation of blood glucose in intensive care unit patients receiving insulin infusions.Diabetes Care2007;30,2503-2505. [PubMed]
 
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