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Welcome to World Shared Practices forum. Today we're going to be discussing tight glycemic control. With us today is Dr. Michael Agus, who is the Chief of the Medicine Critical Care Program at Boston Children's Hospital and Associate Professor at Harvard Medical School. Dr. Agus is the principal investigator and first author on a recent report in the New England Journal examining the role of tight glycemic control in the Pediatric Cardiac Intensive Care Unit environment. Dr. Agus, welcome.

Thank you, nice to be here.

I wonder if I could begin by asking a question of our colleagues in the audience. Could you leave a comment and tell us which city your pediatric intensive care unit is in, and could you tell us if, any time in the last decade, your PICU had a formal or an informal guideline on tight glycemic control in the care of a critically ill child, whether it's a child with sepsis or a child after cardiac surgery. Later in the program, we'll be asking what your current practice is, but I wonder now if you could leave a comment, as I said, if, in the last 10 years, your program had a protocol for tight glycemic control at some point.

We're back. Dr. Agus, I wonder if we could begin by, if you could explain the biologic rationale for tight glycemic control. Obviously, the audience is well aware of the long history of glucose insulin potassium infusions in critical illness, and the studies that have been going on for 50 years in that realm. But could you take us through the biologic rationale. Is it the avoidance of hyperglycemia? Or is it the introduction of insulin? Could we hear about that and what motivated you for this study?

You're right to say that glucose-insulin-potassium infusion, or GIK infusion has been around for a long time. In fact, starting in the 1960s, the medical cardiology population began to treat their post-myocardial infarction patients with a GIK infusion to try to determine if there were improved recovery times, improved function, after that event. By the 1970s, the practice had shifted to cardiac surgery, and had been published multiple times in lots of different studies. But the interesting thing about the field is that each study was a little bit different in terms of how they defined their population, what dose they used, how they performed the protocol.

And really, going into the '80s and '90s, there was no clear decision that all clinicians in the field had come to about whether this practice was worthwhile. In the late '90s, there was a single review that looked like there was a benefit, and a couple years later, there was an equally prominent review, or meta-analysis of the literature that suggested that it had no benefits at all. That really, I think, laid the backdrop of the use of insulin in a sick population.

Now, the benefits that the groups were able to see, when there were benefits, were published in again, various different formats, but they certainly included membrane stabilization, anti-arrhythmic effects, improved myocardial glycogen content, post-operative insulin resistance, when they moved in the cardiac surgical field, reduction of circulating free fatty acid levels, which are known to have some degree of toxicity to the cardiac myocyte, improved glucose utilization, and then there were other benefits that seemed to be present in terms of improved cardiac index, improved immune function.