Does intensive insulin therapy really reduce mortality in critically ill surgical patients? A reanalysis of meta-analytic data.
Two recent systematic reviews evaluating intensive insulin therapy (IIT) in critically ill patients grouped randomized controlled trials (RCTs) by type of intensive care unit (ICU). The more recent review found that IIT reduced mortality in patients admitted to a surgical ICU, but not in those admitted to medical ICUs or mixed medical-surgical ICUs, or in all patients combined. Our objective was to determine whether IIT saves lives in critically ill surgical patients regardless of the type of ICU. Pooling mortality data from surgical and medical subgroups in mixed-ICU RCTs (16 trials) with RCTs conducted exclusively in surgical ICUs (five trials) and in medical ICUs (five trials), respectively, showed no effect of IIT in the subgroups of surgical patients (risk ratio = 0.85, 95% confidence interval (CI) = 0.69 to 1.04, P = 0.11; I2 = 51%, 95% CI = 1 to 75%) or of medical patients (risk ratio = 1.02, 95% CI = 0.95 to 1.09, P = 0.61; I2 = 0%, 95% CI = 0 to 41%). There was no differential effect between subgroups (interaction P = 0.10). There was statistical heterogeneity in the surgical subgroup, with some trials demonstrating significant benefit and others demonstrating significant harm, but no surgical subgroup consistently benefited from IIT. Such a reanalysis suggests that IIT does not reduce mortality in critically ill surgical patients or medical patients. Further insights may come from individual patient data meta-analyses or from future large multicenter RCTs in more narrowly defined subgroups of surgical patients.
Interdepartmental Division of Critical Care and Department of Medicine, University of Toronto, R, Fraser Elliot Building, 3rd Floor, South Wing, 3S-805, 190 Elizabeth Street, Toronto, Ontario, Canada. j.friedrich@utoronto.ca
Jan O
JO
Friedrich
Clarence
C
Chant
Neill K J
NK
Adhikari
D003422:Critical Care / Q000592:standards*; D016638:Critical Illness; D006801:Humans; D007328:Insulin / Q000008:administration & dosage*; D015201:Meta-Analysis as Topic; D016032:Randomized Controlled Trials as Topic / Q000592:standards; D013514:Surgical Procedures, Operative / Q000592:standards*
D007328:Insulin