In critical care medicine, it is unlikely that any single study has had the influence to match that of the study by van den Berghe et al1 of intensive insulin therapy in surgical intensive care patients. Published in 2001, the study reported that targeting normoglycemia in ventilated patients in a surgical intensive care unit (ICU) reduced the risk of in-hospital death by one-third. Although the size of the treatment effect seemed improbable, the underlying concept had face validity as improved glycemic control had been proven beneficial in other patients with severe acute illness.2 As a result, tight glycemic control in critically ill adults is now recommended by numerous organizations including the American Diabetes Association3 and the Institute for Healthcare Improvement.4 In this issue of JAMA, Wiener and colleagues5 report a meta-analysis of studies examining tight glycemic control in critically ill adults; their conclusions, that tight glycemic control does not significantly reduce in-hospital mortality, may surprise many clinicians.
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