Intensive insulin therapy in postoperative intensive care unit patients: a decision analysis.
BACKGROUND
Intensive insulin therapy (IIT) may reduce mortality in mechanically ventilated postoperative patients.


OBJECTIVE
To assess the risks and benefits of IIT in different institutions.


METHODS
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 postoperative patients from each hospital. Retrieval of information on glucose control. Assessment of risks and benefits and final outcomes.


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 postoperative patients. In these patients, glucose levels were measured 212,663 times for a mean value of 8.22 +/- 2.7 mmol/L (148 +/- 49 mg/dl). Intensive care unit (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 to save one life varied from 38 in one ICU to 125 in another, whereas the rate of hypoglycemia (number needed to harm) varied from 7 to 13.


CONCLUSIONS
The number needed to treat to prevent an ICU death and the associated risk of hypoglycemia (number needed to harm) with IIT vary widely according to baseline mortality, case mix, and case selection. Rational decision analysis in individual ICUs should take these factors into account.
Egi
Moritoki
M
Department of Intensive Care, Austin and Repatriation Medical Centre, Heidelberg 3084, Victoria, Australia.
Bellomo
Rinaldo
R
Stachowski
Edward
E
French
Craig J
CJ
Hart
Graeme
G
Stow
Peter
P
Li
Weiqui
W
Bates
Samantha
S
D003422:Critical Care; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007328:Insulin / Q000008:administration & dosage*; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D012121:Respiration, Artificial; D012189:Retrospective Studies
D007328:Insulin