We're unable to sign you in at this time. Please try again in a few minutes.
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Correspondence |

Glucose Control in Critically Ill Patients With Severe Sepsis—Reply

Bruce R. Bistrian, MD, PhD; George L. Blackburn, MD, PhD
Arch Surg. 2010;145(12):1213-1214. doi:10.1001/archsurg.2010.260.
Text Size: A A A
Published online


In reply

As we stated in our review of nutrition support, it was also our recommendation based on current data that for critically ill patients receiving principally enteral nutrition, which is generally inadequate in the first 72 hours, a target goal of modest hyperglycemia of a glucose level less than 150 mg/dL (to convert to millimoles per liter, multiply by 0.0555) is appropriate for intensive insulin therapy.1 This reflects the findings of the NICE-SUGAR study, which compared tight glucose control of 81 to 108 mg/dL with an intermediate level of less than 180 mg/dL and found a significantly higher risk of hypoglycemia in the intensive insulin therapy group but also an increased mortality.2 In their initial landmark study, van den Berghe et al3 found that tight glucose control, treatment to true normoglycemia (glucose level 80-110 mg/dL), and early and aggressive feeding decreased hospital mortality by one-third in surgical intensive care unit patients, especially those with sepsis and multisystem organ failure and longer intensive care unit stays. There were a number of methodological differences between the original van den Berghe et al study3 and the NICE-SUGAR study including different target ranges for blood glucose level, different accuracies of glucometers, and varying levels of expertise of the participating institutions.4 Most importantly, as far as we can determine, all subsequent randomized trials after the initial van den Berghe et al study used enteral nutrition primarily. Furthermore, subsequent trials also had much tighter glucose regulation in the control group than in the original van den Berghe study in which the control group received insulin only when their blood glucose level exceeded 200 mg/dL, which was the standard therapy at the time. Thus, recent trials have been comparisons of very tight control with a high and sometimes unacceptable risk of hypoglycemia to less severe but still tight control to about the 150-mg/dL level with much less risk of hypoglycemia but still substantially better glucose control than in the pre–van den Berghe et al years. A second important consideration is that enteral nutrition may be an important factor in the development of hypoglycemia, first because intestinal absorption is often impaired in critically ill patients and second because tube feeding is often discontinued while insulin continues to be administered during intensive insulin therapy. Total parenteral nutrition is also associated with much higher insulin levels for the same amount of nutrient intake,5 implying insulin resistance, which may be partially protective to the development of insulin-induced hypoglycemia. Thus, for the much smaller group of critically ill patients, that is, those receiving principally total parenteral nutrition as both early and adequate feeding, a lower goal level of glucose may be warranted based on findings of the initial and unique van den Berghe study where tight control led to an improved outcome compared with both moderate control as well as loose control.2 However, it would be a reasonable alternative to accept the less intense target value of less than 150 mg/dL for these individuals as well. Ultimately, the optimal target for blood glucose level in critically ill patients receiving total parenteral nutrition will need to be determined by additional study.

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

First Page Preview

View Large
First page PDF preview





Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.


Some tools below are only available to our subscribers or users with an online account.

0 Citations

Sign in

Purchase Options

• Buy this article
• Subscribe to the journal
• Rent this article ?

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles

Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed
Matching Content and Context: Evidence-Based Teaching Scripts

Users' Guides to the Medical Literature: A Manual for Evidence-Based Clinical Practice, 3rd ed
Verbal Synopses