Recently published papers: Asking the unanswerable – measuring the immeasurable and decontaminating the infected

JF KennedyAddress at Vanderbilt University Nashville, Tennessee, May 18 1963As 2003 marches on one is left reflecting on yet another year in which the intensive care literature has continued to challenge the accepted tenets, and as always one continues to be surprised by the results. The study conducted by Finney and coworkers [1] illustrates well how our increasing knowledge leads to more questions. Since the study by van den Berghe and coworkers [2] was reported, much attention has been given to rigorous control of blood glucose levels in patients, although as Finney and coworkers [1] pointed out the mechanisms underlying the perceived benefits are unclear. In particular, the observed mortality reduction might have been due to avoidance of hyperglycaemia or to the dose of exogenous insulin, or perhaps a combination of the two.That observational study of 531 intensive care unit (ICU) patients (523 studied) examined blood glucose levels and quantity of insulin administered; a secondary question was to determine whether there was a threshold glucose concentration associated with increased mortality [1]. Glycaemic control was split into six bands that were determined prospectively. The patients were predominantly male, over 60 years old and overweight. Cardiac surgery was the reason for admission in 85% of individuals, and interestingly only 17 of the patients were judged to be underweight. The relationship between ICU outcomes, glucose control and insulin dose was modelled using multivariable logistic regression. In all cases increased insulin administration was associated with a significantly increased risk for death. Despite the fact that over 16% of patients had diabetes, this was not an independent risk factor. The conclusions drawn were that it is the control of blood glucose levels that account for any observed mortality benefit, rather than intensive insulin therapy. The data also implied that patients whose glucose levels remained predominantly below 10 mmol/