Chest
Original ResearchCritical Care MedicineToward Understanding Tight Glycemic Control in the ICU: A Systematic Review and Metaanalysis
Section snippets
Identification of Trials
Our aim was to identify all relevant RCTs that compared the mortality of ICU patients randomized to an IIT protocol aimed to achieve tight glycemic control (glucose of 80-110 mg/dL) with those randomized to a control arm that received less strict glucose control. The primary outcome measure was 28-day (or hospital) mortality. Secondary outcome measures included the need for dialysis, acquired blood stream infections, and the incidence of hypoglycemia (defined as a blood glucose of < 40 mg/dL).
Trials Included
Figure 1 shows details of study identification, inclusion, and exclusion. Our search strategy initially yielded 62 citations. Of these, six unique studies met our inclusion criteria.4, 14, 15, 27, 28, 29 One additional study (published in abstract form) was identified from a review of articles identified by the initial search strategy30; this study has subsequently been published in full.31 In all, seven studies met the inclusion criteria; these included the two Leuven Intensive Insulin Therapy
Discussion
The NICE-SUGAR study, as well as four additional RCTs, were unable to replicate the findings of the two Leuven Intensive Insulin Therapy Trials and, indeed, raised the possibility that tight glycemic control may increase organ failure and death in patients fed according to current guidelines. It seems unlikely that the difference in outcome between these trials was due to a failure to reach the target blood glucose levels, because the mean daily glucose and insulin use was similar among
Conclusions
In conclusion, we believe that the variation in intravenous glucose load may explain the conflicting outcomes between the Leuven Intensive Insulin Therapy studies and the subsequent confirmatory studies. Furthermore, our metaanalysis suggests that there are no data to support the use of IIT in patients who are fed enterally.
Acknowledgments
Author contributions: Dr Marik: was responsible for performing the metaanalysis, interpreting the data, and writing the manuscript.
Dr Preiser: was responsible for performing the metaanalysis, interpreting the data, and writing the manuscript.
Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
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