Intensive versus conventional insulin therapy: a randomized controlled trial in medical and surgical critically ill patients.

OBJECTIVE: The role of intensive insulin therapy in medical surgical intensive care patients remains unclear. The objective of this study was to examine the effect of intensive insulin therapy on mortality in medical surgical intensive care unit patients. DESIGN: Randomized controlled trial. SETTINGS: Tertiary care intensive care unit. PATIENTS: Medical surgical intensive care unit patients with admission blood glucose of > 6.1 mmol/L or 110 mg/dL. INTERVENTION: A total of 523 patients were randomly assigned to receive intensive insulin therapy (target blood glucose 4.4-6.1 mmol/L or 80-110 mg/dL) or conventional insulin therapy (target blood glucose 10-11.1 mmol/L or 180-200 mg/dL). MEASUREMENTS AND MAIN OUTCOMES: The primary end point was intensive care unit mortality. Secondary end points included hospital mortality, intensive care unit and hospital length of stay, mechanical ventilation duration, the need for renal replacement therapy and packed red blood cells transfusion, and the rates of intensive care unit acquired infections as well as the rate of hypoglycemia (defined as blood glucose < or = 2.2 mmol/L or 40 mg/dL). There was no significant difference in intensive care unit mortality between the intensive insulin therapy and conventional insulin therapy groups (13.5% vs. 17.1%, p = 0.30). After adjustment for baseline characteristics, intensive insulin therapy was not associated with mortality difference (adjusted hazard ratio 1.09, 95% confidence interval 0.70-1.72). Hypoglycemia occurred more frequently with intensive insulin therapy (28.6% vs. 3.1% of patients; p < 0.0001 or 6.8/100 treatment days vs. 0.4/100 treatment days; p < 0.0001). There was no difference between the intensive insulin therapy and conventional insulin therapy in any of the other secondary end points. CONCLUSIONS: Intensive insulin therapy was not associated with improved survival among medical surgical intensive care unit patients and was associated with increased occurrence of hypoglycemia. Based on these results, we do not advocate universal application of intensive insulin therapy in intensive care unit patients. TRIAL REGISTRATION: Current Controlled Trials registry (ISRCTN07413772) http://www.controlled-trials.com/ISRCTN07413772/07413772; 2005.

Magnesium supplementation and the potential association with mortality rates among critically ill non-cardiac patients.

OBJECTIVE: Recent literature showed that development of hypomagnesemia is associated with higher mortality. The objective of this study is to evaluate the impact of magnesium supplementation on mortality rates of critically ill patients. METHODS: All patients admitted to the Intensive Care Unit (ICU) of King Abdul-Aziz Medical City, Riyadh, Saudi Arabia since September 2003 were included. We recorded the demographics data, APACHE score, daily magnesium levels and magnesium supplementation. We collected the data for 30 days or until discharge from ICU. Statistical analysis was performed using the student t-test for continuous data and the Fischers exact test for categorical data. Nothing was carried out to influence the behavior of intensivists in replacing magnesium. RESULTS: During the study period, 71 patients (45 males and 26 females) were admitted to the ICU, the mean age was 54 +/- 18 years for males and 56 +/- 19.2 years for females. The mean magnesium level on admission was 0.78 +/- 0.2 mmol/L and the majority of the patients were medical admissions. Approximately 39.4% had hypomagnesemia on admission and the overall mortality rate was 31%. In able to standardize the supplementation of magnesium among groups, the daily magnesium supplementation index (DMSI = total magnesium supplement in grams/length of stay in days) was calculated. The mortality rates for DMSI with <1 grm/day (low groups) was statistically significant higher than that of DMSI with >or=1 grm/day (high group) (43.5% versus 17%, p=0.035). There was no statistically significant differences between magnesium levels of both groups of DMSI except at admission where DMSI group had higher magnesium levels (<1 grm/day). CONCLUSION: Daily magnesium supplementation index higher than 1 grm/day is associated with lower mortality rates for critically ill patients. This effect was not found to be independent and may be related to severity of illness. Given that magnesium levels were similar between the 2 groups of DMSI at almost all points of the study, magnesium supplementation per se may be beneficial in lowering mortality rates. The exact cause of this effect is unknown. An aggressive magnesium supplementation protocol may be warranted. A larger scale randomized study is necessary to evaluate this effect.