Benefits of Intensive Insulin Therapy in Critical Illness
Benefits of Intensive Insulin Therapy in Critical Illness
Tight blood glucose control with insulin reduces morbidity and mortality of critically ill patients. However, the relative impact of maintaining normoglycemia and of glycemia-independent actions of insulin remains unknown. We therefore independently manipulated blood glucose and plasma insulin levels in burn-injured, parentally fed rabbits over 7 days to obtain four study groups: two normoglycemic groups with either normal or elevated insulin levels and two hyperglycemic groups with either normal or elevated insulin levels. We studied the relative impact of glycemia and glycemia-independent effects of insulin on survival; myocardial contractility in an open chest preparation; endothelial function in isolated aortic rings; and liver, kidney, and leukocyte function in a rabbit model of critical illness. Mortality was significantly lower in the two normoglycemic groups independent of insulin levels. Maintaining normoglycemia, independent of insulin levels, prevented endothelial dysfunction as well as liver and kidney injury. To increase myocardial systolic function, elevated insulin levels and prevention of hyperglycemia were required concomitantly. Leukocyte dysfunction was present in the two hyperglycemic groups, which could in part be rescued by insulin. The results suggest that the observed benefits of intensive insulin therapy required mainly maintenance of normoglycemia; whereas glycemia-independent actions of insulin exerted only minor, organ-specific impact.
Hyperglycemia in critically ill patients is brought about by hepatic and peripheral insulin resistance and by concomitant relative insulin deficiency due to limited compensatory ability of pancreatic β-cells, largely independent of the underlying disease. Hyperglycemia during critical illness has long been considered essential to provide fuel for vital organ systems and hence was interpreted as a beneficial adaptation. Evidence is now growing against this notion as hyperglycemia is identified as an independent risk factor for adverse outcome of numerous surgical and medical conditions, and avoiding hyperglycemia with intensive insulin therapy has been shown to improve outcome. The risks of hyperglycemia comprise increased vulnerability to infectious complications, impaired recovery of organ failure, myocardial dysfunction, and neuromuscular weakness. The cardiovascular and immune systems thus emerge as two important target systems of glycemic control in the critically ill.
It remains unclear, however, to what extent maintaining normoglycemia and glycemia-independent actions of insulin account for the different clinical benefits of intensive insulin therapy in the critically ill. A post hoc analysis of the randomized controlled study of intensive insulin therapy in surgical intensive care patients suggested that blood glucose control best explains the clinical benefits of the intervention. In contrast, insulin-induced promotion of glycolysis in cardiomyocytes and a diversion of fatty acids to adipocytes is thought to reduce oxygen consumption in the heart, which is proposed as the mechanism behind a cardioprotective effect of insulin infused together with glucose and potassium (GIK). Clinical studies investigating outcome-effects of GIK, however, revealed controversial results. This could be due to either different doses of insulin and glucose or to the varying levels of blood glucose achieved with the different protocols.
In the current study, we aimed at defining the extent to which blood glucose control and glycemia-independent actions of insulin contribute to the major benefits of intensive insulin therapy in an animal model of prolonged critical illness. End point measures were mortality, liver and kidney function, hemodynamic function, endothelial function, and day-3 leukocyte function.
Abstract and Introduction
Abstract
Tight blood glucose control with insulin reduces morbidity and mortality of critically ill patients. However, the relative impact of maintaining normoglycemia and of glycemia-independent actions of insulin remains unknown. We therefore independently manipulated blood glucose and plasma insulin levels in burn-injured, parentally fed rabbits over 7 days to obtain four study groups: two normoglycemic groups with either normal or elevated insulin levels and two hyperglycemic groups with either normal or elevated insulin levels. We studied the relative impact of glycemia and glycemia-independent effects of insulin on survival; myocardial contractility in an open chest preparation; endothelial function in isolated aortic rings; and liver, kidney, and leukocyte function in a rabbit model of critical illness. Mortality was significantly lower in the two normoglycemic groups independent of insulin levels. Maintaining normoglycemia, independent of insulin levels, prevented endothelial dysfunction as well as liver and kidney injury. To increase myocardial systolic function, elevated insulin levels and prevention of hyperglycemia were required concomitantly. Leukocyte dysfunction was present in the two hyperglycemic groups, which could in part be rescued by insulin. The results suggest that the observed benefits of intensive insulin therapy required mainly maintenance of normoglycemia; whereas glycemia-independent actions of insulin exerted only minor, organ-specific impact.
Introduction
Hyperglycemia in critically ill patients is brought about by hepatic and peripheral insulin resistance and by concomitant relative insulin deficiency due to limited compensatory ability of pancreatic β-cells, largely independent of the underlying disease. Hyperglycemia during critical illness has long been considered essential to provide fuel for vital organ systems and hence was interpreted as a beneficial adaptation. Evidence is now growing against this notion as hyperglycemia is identified as an independent risk factor for adverse outcome of numerous surgical and medical conditions, and avoiding hyperglycemia with intensive insulin therapy has been shown to improve outcome. The risks of hyperglycemia comprise increased vulnerability to infectious complications, impaired recovery of organ failure, myocardial dysfunction, and neuromuscular weakness. The cardiovascular and immune systems thus emerge as two important target systems of glycemic control in the critically ill.
It remains unclear, however, to what extent maintaining normoglycemia and glycemia-independent actions of insulin account for the different clinical benefits of intensive insulin therapy in the critically ill. A post hoc analysis of the randomized controlled study of intensive insulin therapy in surgical intensive care patients suggested that blood glucose control best explains the clinical benefits of the intervention. In contrast, insulin-induced promotion of glycolysis in cardiomyocytes and a diversion of fatty acids to adipocytes is thought to reduce oxygen consumption in the heart, which is proposed as the mechanism behind a cardioprotective effect of insulin infused together with glucose and potassium (GIK). Clinical studies investigating outcome-effects of GIK, however, revealed controversial results. This could be due to either different doses of insulin and glucose or to the varying levels of blood glucose achieved with the different protocols.
In the current study, we aimed at defining the extent to which blood glucose control and glycemia-independent actions of insulin contribute to the major benefits of intensive insulin therapy in an animal model of prolonged critical illness. End point measures were mortality, liver and kidney function, hemodynamic function, endothelial function, and day-3 leukocyte function.
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