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Insulin Therapy in Septic Shock

In a study of 509 patients with septic shock and multiple-organ-dysfunction syndrome, researchers investigated whether intensive insulin therapy decreased mortality in those who received corticosteroid treatment. Patients with septic shock commonly are treated with corticosteroids, which may induce hyperglycemia. The study also tested the benefit of fludrocortisone treatment.
Patients were randomly assigned to one of four treatments:

Intensive insulin therapy (continuous I.V. insulin infusion) plus hydrocortisone

Intensive insulin infusion plus hydrocortisone and fludrocortisone

Conventional insulin therapy plus hydrocortisone

Conventional insulin therapy plus hydrocortisone and fludrocortisones

   Hydrocortisone was given as a 50-mg bolus every 6 hours for 7 days. Fludrocortisone was given orally in 50-mcg tablets once daily for 7 days.
   Of the patients who received conventional insulin therapy, 43% died. Of those who received intensive insulin therapy, 46% died. Those in the intensive therapy group had many more episodes of severe hypoglycemia (less than 40 mg/dl) than those in the conventional therapy group.
   Of the patients who received fludrocortisone, 43% died. Of those who didn't, 46% died.
   The researchers concluded that intensive insulin therapy to reduce the risk of hyperglycemia failed to improve in-hospital mortality in patients given hydrocortisone for septic shock. Further, they found that adding fludrocortisone made no significant improvement. (JAMA, 303[4]:341-348)

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