Intensive versus Conventional Glucose Control in Critically Ill Patients

Abstract

Background The optimal target range for blood glucose in critically ill patients remains unclear. Methods Within 24 hours after admission to an intensive care unit(ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter(4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter(10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization. Results Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients(27.5%) in the intensive-control group and 751(24.9%) in the conventional-control group died(odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative(surgical) patients and nonoperative(medical) patients(odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P = 0.10). Severe hypoglycemia(blood glucose level, <40 mg per deciliter>[2.2 mmol per liter]) was reported in 206 of 3016 patients(6.8%) in the intensive-control group and 15 of 3014(0.5%) in the conventional-control group(P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU(P = 0.84) or hospital(P = 0.86) or the median number of days of mechanical ventilation(P = 0.56) or renal-replacement therapy(P=0.39). Conclusions In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter.(ClinicalTrials.gov number, NCT00220987.)

Acute Kidney Injury in Diabetic Patients With Acute Myocardial Infarction: Role of Acute and Chronic Glycemia

“…The detrimental effects of glycemic disorder are not limited to stress hyperglycemia; they also include fluctuations of glycemic values, with acute glucose changes in both directions 35. Accordingly, it has been shown that intensive lowering of glycemia may have a detrimental effect in patients with high glycemic values at admission but without stress hyperglycemia 36, 37. In view of the close association between stress hyperglycemia and AKI risk, future studies should investigate whether tight control of hyperglycemia, based on the combined evaluation of acute and chronic glycemia, will prevent AKI and improve overall prognosis in AMI.…”

Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 1: pathophysiological considerations

“…Normoglycaemia and whole body protein stores can be preserved by insulin therapy suggesting that insulin sensitivity rather than insulin responsiveness is reduced during and after surgery 54. Although the safety and efficacy of glucose control in the ICU has been debated, trials have consistently shown that in post‐operative patients55 and in trauma patients56 improved glucose control with insulin in the intensive care situation has proven beneficial by avoiding complications as long as the deleterious effects of hypoglycaemia are avoided. In the ward situation, intensive insulin treatment is more dubious and hard to control and, therefore, measures should be taken to minimise the insulin resistance and thereby avoiding the need of insulin 53…”

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

“…A post‐hoc analysis of the NICE‐SUGAR study database20 showed that very strict control leads to moderate and severe hypoglycemia, both of which are associated with an increased risk of death, whereas high incidence of hypoglycemia possibly leads to increased mortality in patients assigned to a group under very strict control.…”

“…This recommendation has been challenged by recent studies suggesting that an even lower target BG is required to prevent SSI 12, 13, 14, 15, 16, 17, 18. The intensive insulin administration protocol (intensive protocol), however, leads to an increased risk of hypoglycemia, which, in turn, is associated with increased morbidity and mortality 19, 20. It seems that very strict glycemic control has modest benefits, with adverse effects often outweighing these advantages in critically ill patients.…”