Published ahead of print on October 20, 2005, doi:10.1164/rccm.200506-961OC Am. J. Respir. Crit. Care Med., Volume 173, Number 4, February 2006, 407-413 A more recent version of this article appeared on February 15, 2006
Submitted on June 22, 2005 Intensive Insulin Therapy in Postoperative ICU Patients: A Decision AnalysisMoritoki Egi1,1 Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia, 2 Department of Intensive Care, Westmead Hospital, Westmead, New South Wales, Australia, 3 Department of Intensive Care, Western Hospital, Footscray, Victoria, Australia, 4 Department of Intensive Care, Geelong Hospital, Geelong, Victoria, Australia * To whom correspondence should be addressed. E-mail: rinaldo.bellomo{at}austin.org.au.
Rationale: Intensive insulin therapy (IIT) may reduce mortality in mechanically ventilated post-operative patients Objectives: To assess the risks and benefits of IIT in different institutions Design: Retrospective, blinded-to-outcome selection of patient cohorts from four hospitals. Methods: Selection of a cohort of patients with clinical features similar to those reported in a recent study of IIT and of all mechanically ventilated post-operative patients from each hospital. Retrieval of information on glucose control. Assessment of risks and benefits and final outcomes. Measurements and Main Results: We selected 783 consecutive patients with similar clinical and demographic features to the IIT trial control group and four general cohorts for a total of 4,150 consecutive mechanically ventilated post-operative patients. In these patients, glucose levels were measured 212,663 times for a mean value of 8.22 ± 2.7 mmol/l (148 ± 49mg/dl). ICU mortality varied from 2.2 to 13.6%. The incidence of hypoglycemia (defined as <2.2 mmol/L) varied from 1.4 to 2.7%. Assuming a beneficial effect of IIT as reported, the number needed to treat (NNT) to save one life varied from 38 in one ICU to 125 in another, while the rate of hypoglycemia (number needed to harm - NNH) varied from 7 to 13. Conclusions: The NNT to prevent an ICU death and the associated risk of hypoglycemia (NNH) with IIT vary widely according to baseline mortality, case mix and case selection. Rational decision analysis in individual intensive care units should take these factors into account. Key words: Critical illness; Critical care; Glucose; Insulin; number needed to treat (NNT), mortality
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