Update in Critical Care

Update in Critical Care

Molly Osborne, MD, PhD*

From Oregon Health & Science University, Portland, Oregon.

2007 Series: Update Sessions from Internal Medicine 2007

The current Update in Critical Care reviews the past year's most important articles relevant to those practicing critical care. Critical care medicine continues to advance rapidly, particularly with results from large multicenter trials. Results from studies by the Acute Respiratory Distress Syndrome Clinical Trials Network have substantial implications for use of such diagnostic devices as the pulmonary artery catheter and for decisions about fluid therapy in sepsis. This update also reviews a follow-up study addressing use of intensive insulin therapy; several articles addressing such important aspects of infectious disease as timing of antibiotic therapy, role of daptomycin, and a comparison of diagnostic techniques for ventilator-associated pneumonia; and a recent study identifying important barriers to optimal end-of-life care. The Table shows changes to clinical practice that should emerge from these articles.

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Table. Changes to Clinical Practice Emerging from Articles Important to Intensivists in 2006

Insulin Therapy

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. [PMID: 16452557]

Question: Does intensive insulin therapy improve the prognosis of patients in a medical intensive care unit (ICU)?

Study Design: Unblinded, randomized trial.

Patients: 1200 adult patients admitted to the medical ICU who were assumed to require 3 or more days of intensive care. Surgical ICU patients and medical patients able to receive oral nutrition were excluded because such patients usually need fewer than 3 days of intensive care; patients with do-not-resuscitate orders on admission were also excluded.

Setting: 2 university hospitals in Leuven, Belgium.

Intervention: Intensive insulin treatment (595 patients) or conventional insulin treatment (605 patients). Intensive treatment was insulin infusion for blood glucose level greater than 6.1 mmol/L (>110 mg/dL) to maintain normoglycemia (glucose level, 4.4 to 6.1 mmol/L [80 to 110 mg/dL]). Conventional insulin treatment was continuous insulin infusion by pump for blood glucose levels greater than 12 mmol/L (>215 mg/dL) to maintain a blood glucose level between 10 and 11 mmol/L (180 and 200 mg/dL).

Outcomes: The primary outcome …

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