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Copyright ©2009 The WJG Press and Baishideng. All rights reserved.
World J Gastroenterol. Sep 7, 2009; 15(33): 4132-4136
Published online Sep 7, 2009. doi: 10.3748/wjg.15.4132
Blood glucose control in patients with severe sepsis and septic shock
Hiroyuki Hirasawa, Shigeto Oda, Masataka Nakamura
Hiroyuki Hirasawa, Shigeto Oda, Masataka Nakamura, Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba 260-8677, Japan
Author contributions: Hirasawa H wrote the manuscript; Oda S performed the literature searches, data collection and analysis; Nakamura M performed the clinical study on the relationship between cytokine blood levels and glucose control in septic patients.
Correspondence to: Hiroyuki Hirasawa, MD, PhD, Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, 1-8-1 Inohana, Chuo, Chiba 260-8677, Japan. hhirasawa@faculty.chiba-u.jp
Telephone: +81-43-2262341 Fax: +81-43-2262173
Received: May 7, 2009
Revised: June 6, 2009
Accepted: June 13, 2009
Published online: September 7, 2009
Abstract

The main pathophysiological feature of sepsis is the uncontrollable activation of both pro- and anti-inflammatory responses arising from the overwhelming production of mediators such as pro- and anti-inflammatory cytokines. Such an uncontrollable inflammatory response would cause many kinds of metabolic derangements. One such metabolic derangement is hyperglycemia. Accordingly, control of hyperglycemia in sepsis is considered to be a very effective therapeutic approach. However, despite the initial enthusiasm, recent studies reported that tight glycemic control with intensive insulin therapy failed to show a beneficial effect on mortality of patients with severe sepsis and septic shock. One of the main reasons for this disappointing result is the incidence of harmful hypoglycemia during intensive insulin therapy. Therefore, avoidance of hypoglycemia during intensive insulin therapy may be a key issue in effective tight glycemic control. It is generally accepted that glycemic control aimed at a blood glucose level of 80-100 mg/dL, as initially proposed by van den Berghe, seems to be too tight and that such a level of tight glycemic control puts septic patients at increased risk of hypoglycemia. Therefore, now many researchers suggest less strict glycemic control with a target blood glucose level of 140-180 mg/dL. Also specific targeting of glycemic control in diabetic patients should be considered. Since there is a significant correlation between success rate of glycemic control and the degree of hypercytokinemia in septic patients, some countermeasures to hypercytokinemia may be an important aspect of successful glycemic control. Thus, in future, use of an artificial pancreas to avoid hypoglycemia during insulin therapy, special consideration of septic diabetic patients, and control of hypercytokinemia should be considered for more effective glycemic control in patients with severe sepsis and septic shock.

Keywords: Blood glucose; Diabetes mellitus; Insulin; Hypercytokinemia; Inflammation mediators