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From MedPage Today SCCM 2017 Meeting Coverage | Click here for the complete article


Revisiting Tight Glucose Control in the ICU
Lower mortality risk with lower glucose target

By Charles Bankhead, Senior Associate Editor, MedPage Today January 23, 2017

 

Action Points
  • Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
  • More stringent glucose control in critically ill patients (80 to 110 mg/dL) led to a lower mortality without a significant increase in severe hypoglycemia, possibly reopening a discussion that many experts considered over.
  • Note that the study involved three medical centers that have adopted an automated "e-protocol" for blood glucose management in ICU patients in which clinicians can choose between two blood glucose targets: 80 to 110 mg/dL or 90 to 140 mg/dL.

HONOLULU -- More stringent glucose control in critically ill patients led to a lower mortality without a significant increase in severe hypoglycemia, possibly reopening

a discussion that many experts considered over, it was reported here.
 

Patients treated to a glucose target of 80 to 110 mg/dL had a 36% lower 30-day mortality compared with patients treated to a target of 90 to 140 mg/dL. The lower target was achieved with less than 1% incidence of severe hypoglycemia.

The survival benefit associated with a lower glucose level held up in an analysis that took into account patients' illness severity and comorbidities, Andrew Hersh, MD, of Intermountain Medical Center and the University of Utah in Salt Lake City, reported at the Society of Critical Care Medicine (SCCM) conference.
 

"We concluded that we are able to target a low blood glucose level with very low rates of severe hypoglycemia -- very low compared with other studies," said Hersh. "After controlling for confounders, a lower blood glucose target was associated with a 36% relative decrease in 30-day mortality across the surgical ICU, cardiac ICU, and cardiothoracic ICU population.
 

"There has never been a randomized controlled trial of 'intensive' versus 'conservative' glucose management that has not been severely confounded by high rates of hypoglycemia," he said. "Perhaps it's time?"


A landmark study published 15 years ago showed significant improvement in survival out to 6 months for surgical ICU (SICU) patients managed by intensive insulin therapy (IIT) to maintain a blood glucose level <110 mg/dL. However, questions persisted about the results, including their generalizability to other critically ill populations.


Authors of the first guideline from the SCCM Surviving Sepsis Campaign, published in 2004, concluded that a blood glucose target of 150 mg/dL is appropriate for stabilized patients with sepsis, adding that "there is no reason to think that these data are not generalizable to all severely septic patients."


Two years later, another study then failed to replicate the findings with intensive insulin therapy in medical ICU patients. And a 2008 study of intensive IIT and pentastarch resuscitation in septic patients was stopped early because of an excess of severe hypoglycemia and associated adverse events with no improvement in survival.


Yet another study found IIT associated with increased mortality in ICU patients, as well as a 12-fold higher rate of severe hypoglycemia. Authors reported that a glucose target of 180 mg/dL led to better outcomes compared with a target of 81 to 108 mg/dL.

 

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