Friday, May 29, 2009
Tight glucose control raises ICU mortality
| Intensively controlling blood glucose in critically ill patients increases mortality, researchers have found. The study, published in the New England Journal of Medicine, contradicts prior research which favored tight glucose control in surgical intensive care unit (ICU) patients and has prompted calls for guidelines to be revised. “Far from reducing mortality, the tighter range actually resulted in a 2.6 percent increase in mortality in a broad range of critically ill patients,” said lead author of the NICE-SUGAR* trial, Professor Simon Finfer. “The international guidelines need to be urgently reviewed and critical care practitioners need to consider this evidence and probably not target such tight glucose control in their patients.” The NICE-SUGAR study was a large, randomized controlled trial conducted in 6,104 critically ill patients in 42 hospitals across four countries. Patients were randomly assigned to undergo either intensive control (with a target blood glucose range of 81 to 108 mg/dL or 4.5 to 6 mmol/L) or conventional control (target blood glucose range of 180 mg/dL or 10 mmol/L or less). The primary endpoint was death from any cause within 90 days after randomization. [N Engl J Med 2009; 360(13):1283-97] Intensive blood glucose control resulted in 78 more deaths than the conventional control group (829 versus 751, an absolute increase of 2.6 percent; P=0.02). Severe hypoglycemia was also predictably higher in the intensive control group (206 cases out of 3,016 patients versus 15 cases out of 3,014 patients in the control group; P<0.001). However, there was no significant difference between treatment groups in the median length of hospital or ICU stay, the median number of days of mechanical ventilation or renal replacement therapy. “Intensive therapy often ends up with unacceptably high rates of hypoglycemia [and] that is counter-productive,” said Dr. Richard Chen, who is head of the division of endocrinology and director of the diabetes center at Changi General Hospital, Singapore. “Because of this, most ICUs do not attempt to lower blood glucose to below 6.1 mmol/L, but prefer to keep it just below 10 mmol/L, which the NICE-SUGAR study has shown to be safer.” A joint statement by the American Diabetes Association (ADA) and the American Association of Clinical Endocrinologists (AACE) was issued in response to the NICE-SUGAR study. Although supporting the data, they also advised caution, stating: “The NICE-SUGAR study should not lead to an abandonment of the concept of good glucose management in the hospital setting. Uncontrolled high blood glucose can lead to serious problems for hospitalized patients, such as dehydration and increased propensity to infection.” Finfer and his colleagues are by no means advocating abandoning glucose control entirely, but they emphasize that targeting very low blood glucose may be harmful in critically ill patients. Based on their data, Finfer – who is senior staff specialist in intensive care at the Royal North Shore Hospital of Sydney, Australia – recommends targeting blood glucose to 10 mmol/L. This was the target used in the conventional control arm of the study, which resulted in lower mortality. Although not intensively normalizing blood glucose, it would still be viewed as “good” glucose control, and some two-thirds of conventional control patients required intravenous insulin to achieve it. “Good glycemic control in the critically ill is still necessary, as it lowers risk of concomitant sepsis,” added Chen. “The key is not to be too over-zealous.” Complete recommendations regarding glucose control will be published later this year in Endocrine Practice and Diabetes Care, but for now, the ADA and AACE are aligning themselves with the NICE-SUGAR trial. “Until more information is available, it seems reasonable for clinicians to treat critical care patients with the less intensive – yet good – glucose control strategies used in the conventional arm of the NICE-SUGAR trial,” they conclude. * NICE-SUGAR: Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation. Source : http://www.mims.com/Page.aspx?menuid=RecentHL&RecentHeaderID=92 |
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