Patient de 33 ans. Polytoxicomane avec FE à 25%. Intox ³récréative² à la cocaine la veille. Retrouvé ³bleu² par conjointe.
Réanimé par ambulanciers, combitube. Arrive au CH avec une TA à 100/60 et un pouls à 140. Convulsion focale du visage et hémicorps gauche. Livedo pancorporel. Tolère le tube endotrachéal sans sédation. Gluco à 82.5 (confirmé deux fois...). Je lui ai donné de l¹insuline IV en bolus et perfusion à double concentration (entre autre). Ct-Scan cérébral normal. Il est mort quand même quelques heures plus tard aux soins intensifs. Ma plus haute glycémie à date. Claude Ceci dit, pour les chocs septiques, pas d¹insuline IV d¹emblée. Mais un contrôle glycémique tendant vers une glycémie normale (4-6) est associé avec une Diminution de mortalité variant de 4 à 15% selon les études: Arch Intern Med. 2004 Oct 11;164(18):2005-11. Links Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Pittas AG, Siegel RD, Lau J. Divisions of Endocrinology, Diabetes and Metabolism, Tufts-New England Medical Center, Boston, Mass, USA. [EMAIL PROTECTED] BACKGROUND: Hyperglycemia is common in critically ill hospitalized patients, and it is associated with adverse outcomes, including increased mortality. The objective of this meta-analysis was to determine the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. METHODS: An electronic search in the English-language articles of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles were performed. Randomized controlled trials that reported mortality data on critically ill hospitalized adult patients who were treated with insulin were selected. Data on patient demographics, hospital setting, intervention (formulation and dosage of insulin, delivery method, and duration of therapy), mortality outcomes, adverse events, and methodological quality were extracted. RESULTS: Thirty-five trials met the inclusion criteria. Combining data from all trials using a random-effects model showed that insulin therapy decreases short-term mortality by 15% (relative risk [RR], 0.85; 95% confidence interval [CI], 0.75-0.97). In subgroup analyses, insulin therapy decreased mortality in the surgical intensive care unit (RR, 0.58; 95% CI, 0.22-0.62), when the aim of therapy was glucose control (RR, 0.71; 95% CI, 0.54-0.93), and in patients with diabetes mellitus (RR, 0.73; 95% CI, 0.58-0.90). A near-significant trend toward decreasing mortality was seen in patients with acute myocardial infarction who did not receive reperfusion therapy (RR, 0.84; 95% CI, 0.71-1.00). No randomized trials of insulin in the medical intensive care unit were identified. CONCLUSION: Insulin therapy initiated in the hospital in critically ill patients has a beneficial effect on short-term mortality in different clinical settings. PMID: 15477435 [PubMed - indexed for MEDLINE] N Engl J Med. 2001 Nov 8;345(19):1359-67. Links Comment in: Intensive insulin therapy in the critically ill patients. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R. Department of Intensive Care Medicine, Catholic University of Leuven, Belgium. [EMAIL PROTECTED] BACKGROUND: Hyperglycemia and insulin resistance are common in critically ill patients, even if they have not previously had diabetes. Whether the normalization of blood glucose levels with insulin therapy improves the prognosis for such patients is not known. METHODS: We performed a prospective, randomized, controlled study involving adults admitted to our surgical intensive care unit who were receiving mechanical ventilation. On admission, patients were randomly assigned to receive intensive insulin therapy (maintenance of blood glucose at a level between 80 and 110 mg per deciliter [4.4 and 6.1 mmol per liter]) or conventional treatment (infusion of insulin only if the blood glucose level exceeded 215 mg per deciliter [11.9 mmol per liter] and maintenance of glucose at a level between 180 and 200 mg per deciliter [10.0 and 11.1 mmol per liter]). RESULTS: At 12 months, with a total of 1548 patients enrolled, intensive insulin therapy reduced mortality during intensive care from 8.0 percent with conventional treatment to 4.6 percent (P<0.04, with adjustment for sequential analyses). The benefit of intensive insulin therapy was attributable to its effect on mortality among patients who remained in the intensive care unit for more than five days (20.2 percent with conventional treatment, as compared with 10.6 percent with intensive insulin therapy, P=0.005). The greatest reduction in mortality involved deaths due to multiple-organ failure with a proven septic focus. Intensive insulin therapy also reduced overall in-hospital mortality by 34 percent, bloodstream infections by 46 percent, acute renal failure requiring dialysis or hemofiltration by 41 percent, the median number of red-cell transfusions by 50 percent, and critical-illness polyneuropathy by 44 percent, and patients receiving intensive therapy were less likely to require prolonged mechanical ventilation and intensive care. CONCLUSIONS: Intensive insulin therapy to maintain blood glucose at or below 110 mg per deciliter reduces morbidity and mortality among critically ill patients in the surgical intensive care unit. PMID: 11794168 [PubMed - indexed for MEDLINE] Le 30/09/07 14:50, « Catherine Bich » <[EMAIL PROTECTED]> a écrit : > Vous arrive-t-il de débuter,à l¹urgence ,de l¹insuline à hautes doses pour les > cas de choc septique ?Voire même de septicémie sans choc trop trop évident ? > > Parlant sucre,donnez-vous encore un bolus d¹insuline lors de l¹initiation de > l¹insulinoTx dans les cas d¹acido-cétose ? > > C. >
