Insulin therapy protects the central and peripheral nervous system of intensive care patients.
OBJECTIVE
To investigate the effectiveness of maintaining blood glucose levels below 6.1 mmol/L with insulin as prevention of secondary injury to the central and peripheral nervous systems of intensive care patients.


METHODS
The authors studied the effect of intensive insulin therapy on critical illness polyneuropathy (CIPNP), assessed by weekly EMG screening, and its impact on mechanical ventilation dependency, as a prospectively planned subanalysis of a large randomized, controlled trial of 1,548 intensive care patients. In the 63 patients admitted with isolated brain injury, the authors studied the impact of insulin therapy on intracranial pressure, diabetes insipidus, seizures, and long-term rehabilitation at 6 and 12 months follow-up.


RESULTS
Intensive insulin therapy reduced ventilation dependency (p = 0.0007; Mantel-Cox log rank test) and the risk of CIPNP (p < 0.0001). The risk of CIPNP among the 405 long-stay (> or =7 days in intensive care unit) patients was lowered by 49% (p < 0.0001). Of all metabolic and clinical effects of insulin therapy, and corrected for known risk factors, the level of glycemic control independently explained this benefit (OR for CIPNP 1.26 [1.09 to 1.46] per mmol blood glucose, p = 0.002). In turn, prevention of CIPNP explained the ability of intensive insulin therapy to reduce the risk of prolonged mechanical ventilation (OR 3.75 [1.49 to 9.39], p = 0.005). In isolated brain injury patients, intensive insulin therapy reduced mean (p = 0.003) and maximal (p < 0.0001) intracranial pressure while identical cerebral perfusion pressures were obtained with eightfold less vasopressors (p = 0.01). Seizures (p < 0.0001) and diabetes insipidus (p = 0.06) occurred less frequently. At 12 months follow-up, more brain-injured survivors in the intensive insulin group were able to care for most of their own needs (p = 0.05).


CONCLUSIONS
Preventing even moderate hyperglycemia with insulin during intensive care protected the central and peripheral nervous systems, with clinical consequences such as shortening of intensive care dependency and possibly better long-term rehabilitation.
Van den Berghe
G
G
Department of Intensive Care Medicine, Catholic University of Leuven, B-3000 Leuven, Belgium. greta.vandenberghe@med.kuleuven.ac.be
Schoonheydt
K
K
Becx
P
P
Bruyninckx
F
F
Wouters
P J
PJ
D000328:Adult; D000368:Aged; D001921:Brain / Q000187:drug effects / Q000378:metabolism / Q000503:physiopathology; D001925:Brain Damage, Chronic / Q000150:complications* / Q000378:metabolism / Q000503:physiopathology; D001928:Brain Diseases, Metabolic / Q000378:metabolism / Q000503:physiopathology / Q000628:therapy; D002545:Brain Ischemia / Q000150:complications; D016638:Critical Illness; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000150:complications* / Q000188:drug therapy / Q000517:prevention & control; D007004:Hypoglycemic Agents / Q000494:pharmacology / Q000627:therapeutic use; D007328:Insulin / Q000494:pharmacology / Q000627:therapeutic use*; D007362:Intensive Care Units / Q000592:standards; D020300:Intracranial Hemorrhages / Q000150:complications; D019586:Intracranial Hypertension / Q000188:drug therapy / Q000378:metabolism / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D010525:Peripheral Nerves / Q000187:drug effects / Q000378:metabolism / Q000503:physiopathology; D011115:Polyneuropathies / Q000188:drug therapy* / Q000378:metabolism / Q000503:physiopathology; D011446:Prospective Studies; D020521:Stroke / Q000150:complications; D016896:Treatment Outcome
D007004:Hypoglycemic Agents; D007328:Insulin