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Critically ill patients who require prolonged intensive care support are at high risk of developing multiple organ failure and death. Hyperglycaemia and resistance to insulin are closely associated with major illness or major surgery. This is true irrespective of whether patients are diabetic or not. It has been shown that tight glycaemic control using exogenous intensive insulin therapy improves outcome in critically ill patients. We review the pathophysiology of hyperglycaemia and examine the clinical and economic benefits of such therapy.