title: Early glycemic control in critically ill emergency department patients: pilot trial.
abstract: OBJECTIVE
  Glycemic control in the critically ill intensive care unit (ICU) patient has been shown to improve morbidity and mortality. We sought to investigate the effect of early glycemic control in critically ill emergency department (ED) patients in a small pilot trial.
  
  
  METHODS
  Adult non-trauma, non-pregnant ED patients presenting to a university tertiary referral center and identified as critically ill were eligible for enrollment on a convenience basis. Critical illness was determined upon assignment for ICU admission. Patients were randomized to either ED standard care or glycemic control. Glycemic control involved use of an insulin drip to maintain blood glucose levels between 80-140 mg/dL. Glycemic control continued until ED discharge. Standard patients were managed at ED attending physician discretion. We assessed severity of illness by calculation of APACHE II score. The primary endpoint was in-hospital mortality. Secondary endpoints included vasopressor requirement, hospital length of stay, and mechanical ventilation requirement.
  
  
  RESULTS
  Fifty patients were randomized, 24 to the glycemic group and 26 to the standard care cohort. Four of the 24 patients (17%) in the treatment arm did not receive insulin despite protocol requirements. While receiving insulin, three of 24 patients (13%) had an episode of hypoglycemia. By chance, the patients in the treatment group had a trend toward higher acuity by APACHE II scores. Patient mortality and morbidity were similar despite the acuity difference.
  
  
  CONCLUSIONS
  There was no difference in morbidity and mortality between the two groups. The benefit of glycemic control may be subject to source of illness and to degree of glycemic control, or have no effect. Such questions bear future investigation.
authors.affiliation: University of Massachusetts Medical School, Department of Emergency Medicine, Worcester, MA.
authors.forename: Jason
authors.initials: J
authors.lastname: Cohen
authors.forename: Eric
authors.initials: E
authors.lastname: Goedecke
authors.forename: Jennifer E
authors.initials: JE
authors.lastname: Cyrkler
authors.forename: Virginia B
authors.initials: VB
authors.lastname: Mangolds
authors.forename: Jane
authors.initials: J
authors.lastname: Bateman
authors.forename: Karin
authors.initials: K
authors.lastname: Przyklenk
authors.forename: Marie T
authors.initials: MT
authors.lastname: Mullen
references.citation: N Engl J Med. 2001 Nov 8;345(19):1368-77
references.pmid: 11794169
references.citation: N Engl J Med. 2008 Jan 10;358(2):125-39
references.pmid: 18184958
references.citation: N Engl J Med. 2001 Nov 8;345(19):1359-67
references.pmid: 11794168
references.citation: N Engl J Med. 2006 Feb 2;354(5):449-61
references.pmid: 16452557
references.citation: Crit Care Clin. 2005 Jan;21(1):81-9, viii-ix
references.pmid: 15579354
references.citation: Crit Care Med. 2008 Jan;36(1):296-327
references.pmid: 18158437
references.citation: Curr Opin Crit Care. 2002 Dec;8(6):600-6
references.pmid: 12454549
references.citation: Front Neuroendocrinol. 2002 Oct;23(4):370-91
references.pmid: 12381331
references.citation: N Engl J Med. 2009 Mar 26;360(13):1283-97
references.pmid: 19318384
references.citation: Crit Care Med. 2006 Jun;34(6):1589-96
references.pmid: 16625125