SymposiumThe level of glycemic control needed to improve outcomes without increasing the risk of hypoglycemia in hospitalized patients with critical illness is controversial. Achieving reasonable control of blood glucose without causing an excess risk of hypoglycemia is especially challenging in patients with ESRD, a condition commonly encountered in the critically ill.In 2001, Van den Berghe and colleague's landmark study in a surgical intensive care unit (ICU) suggested that strict blood glucose (BG) control (mean 103 mg/dL) was associated with a mortality and morbidity benefit in comparison to standard therapy (mean 153 mg/dL).1 A subsequent study of patients in the medical ICU however failed to show similar benefits and hypoglycemia was a frequent complication.2 Meta-analysis of multiple studies shows an inconsistent mortality benefit with intensive glycemic control and highlights the increased risk of hypoglycemia.3 More recently, the NICE-SUGAR study compared all-cause and cause-specific mortality and morbidity (new organ failure, bacteremia, redcell transfusion, and volume resuscitation) in over 6100 surgical and medical ICU patients treated either with an intensive insulin regimen (target BG 81-108 mg/dL) or a standard insulin regimen (target BG less than 180 mg/dL). 4 This trial concluded that intensive BG control was associated with a significant increase in the incidence of both moderate hypoglycemia (BG 41-70 mg/dL), and severe hypoglycemia (BG ≤ 40 mg/dL). Both degrees of hypoglycemia were associated with increased all-cause mortality, and particularly cardiovascular mortality. 5The cumulative effect of repeated hypoglycemia-related stress responses increases the risk of cardiac arrhythmias, neurological impairment, seizures, and death. [5][6] In light of AbstractComputerized insulin infusion protocols have facilitated more effective blood glucose (BG) control in intensive care units (ICUs). This is particularly important in light of the risks associated with hypoglycemia. End stage renal disease (ESRD) increases the risk of insulin-induced hypoglycemia. We evaluated BG control in 210 patients in 2 medical ICUs and in 2 surgical ICUs who were treated with a computerized insulin infusion program (CIIP). Our CIIP was programmed for a BG target of 140-180 mg/dL for medical ICU patients or 120-160 mg/dL for surgical ICU patients. In addition, we focused on BG control in the 11% of our patients with ESRD. Mean BG was 147 ± 20 mg/dL for surgical ICU patients and 171 ± 26 mg/ dL for medical ICU patients. Of both surgical and medical ICU patients, 17% had 1 or more BG 60-79 mg/dL, while 3% of surgical ICU and 8% of medical ICU patients had 1 or more BG < 60 mg/dL. Mean BG in ESRD patients was 147 ± 16 mg/dL similar to 152 ± 23 mg/dL in patients without ESRD. Of ESRD patients, 41% had 1 or more BG < 79 mg/dL as compared with 17.8% of non-ESRD patients (P < .01). A higher BG target for medical ICU patients as compared with surgical ICU patients yielded comparably low rates of moderate or severe hypoglycemia....

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