Greet Van den Berghe

Intensive insulin therapy for the critically ill patient

More and more evidence argues against the concept that the characteristic dysregulation of glucose homeostasis in critical illness or “diabetes of injury” is an adaptive, benefical response in the modern intensive care era. Stress hyperglycemia has been linked to poor outcome of the patients in several studies. Proof of a causal relationship has been provided by a large, prospective, randomized, controlled study where strict blood glucose control to normoglycemia with intensive insulin therapy strongly reduced mortality and morbidity of surgical intensive care patients. These results were recently confirmed in a medical intensive care patient population. Most of the clinical benefits of intensive insulin therapy appear to be related to the blood glucose control, but also non-glycemic metabolic and non-metabolic actions of insulin contribute. Although substantial progress has been made in the understanding of the pathways involved, more studies are needed to improve our knowledge on their relative importance and that of those yet to be unravelled.