SCCM 2017 Meeting Coverage |
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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
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
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.
More stringent glucose control in critically ill
patients led to a lower mortality without a
significant increase in severe hypoglycemia,
that many experts considered over, it was
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)
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.
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
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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