Impact of Intensive Insulin Therapy on Neuromuscular Complications and Ventilator Dependency in the Medical Intensive Care Unit Greet Hermans, Alexander Wilmer, Wouter Meersseman, Ilse Milants, Pieter J. Wouters, Herman Bobbaers, Frans Bruyninckx, and Greet Van den Berghe Am J Respir Crit Care Med Vol 175. pp 480–489, 2007 R2 이동영

Critical illness polyneuropathy (CIP) primary axonal motor & sensory neural disease in critically ill patients sepsis and multiple organ failure: 70 ~ 82 % limb weakness, weaning difficulties hospital stay, mortality rates: 7 times critical illness myopathy(CIM) coexistent primary muscle disease

Risk factors use of corticosteroids, neuromuscular blocker, vasopressors, or aminoglycosides organ failure & parenteral nutrition renal replacement therapy Strict glycemic control in a surgical ICU ↓ incidence of CIP in pt for at least 7 days ↓ incidence of prolonged mechanical ventilation They examine the effect of the same therapeutic intervention in a medical ICU population

METHODS Intensive insulin therapy (IIT) 80 ~ 110 mg/dl Conventional insulin therapy (CIT) 180~215 mg/dl Diagnosis of CIP electroneuromyography (ENMG)

Figure 1. CONSORT diagram

Figure 2. Incidence of CIP/CIM and of prolonged MV Figure 3. Cumulative hazard plots for time to weaning from MV and time to first ENMG positive for CIP/CIM

DISCUSSION

CIP/CIM Comparable incidence of CIP/CIM in different risk factor suggests that these risk factors might be less important than metabolic disturbances, which can be at least partially prevented by IIT Effects of chronic hyperglycemia on the PNS in diabetes hypothesized PNS : increased risk for the accelerated development of damage by hyperglycemia due to passive uptake of glucose increased generation and/or deficient scavenging system for reactive oxygen species

Hypothesized... avoiding hyperglycemia Protect neural mitochondrial structure and function ↓ organ damage by endothelial protection through a diminished release of nitric oxide insulin therapy endothelial protection ↓ inflammation improvement of dyslipidemia

Effect of Corticosteroids on the occurrence of CIP/CIM they found protective effect of corticosteroids ↑ in CIM / CIP when treated with a combination of corticosteroids and NMBA Most reports steroids alone did not find such a correlation two reports, corticosteroids: important risk factor for the development of neuromuscular disorders their results Corticosteroids, may not exert deleterious effects on CIP/CIM when blood glucose levels are kept normal with insulin, and might even be protective d/t antiinflammatory properties of glucocorticoids

Prolonged Mechanical Ventilation IIT itself significantly and independently ↓ the risk for prolonged MV effect of IIT reducing the incidence of prolonged MV daily insulin dose anabolic effect of insulin on the skeletal muscle days of treatment with glucocorticoids ↑ the risk for prolonged MV catabolic effects of glucocorticoids on the skeletal muscle

Other risk factors for prolonged MV days of treatment with norepinephrine and bacteremia TPN paradoxically protective for prolonged MV

Limitations Not perform an analysis on the total intention-to-treat population at least 7 days No study between the enteral or parenteral feeding Hypoglycemia

Conclusions IIT is the only therapy that has been proven to actually decrease the incidence of CIP/CIM, and the incidence of prolonged MV: not only in a surgical population but also in a medical ICU population, in which the incidence of other known risk factors for CIP/CIM is much higher