Blood sugar: how low should we go?

Van den Berghe G, Bouillon R, & Mesotten D. Glucose control in critically ill patients. New England Journal of Medicine 2009; 361: 89

RHH Journal Club. July 11th, 2013. Dr Pavan Battu

Full-text article (if available)

Does normalisation of blood glucose levels with insulin therapy improve the prognosis of critically ill patients?

Study Design

Single centre, prospective, randomised, controlled trial

Methodology

  • Population:

Mechanically ventilated intensive care patients (dedicated primarily but not exclusively to surgical patients)

  • Intervention/Control
    • Conventional group Insulin was started only if glucose level > 215 mg/dL (target 180-200 mg/dL)
    • Intensive group Insulin was started if glucose > 110 mg/dL (target 80-110 mg/dL)
    • Primary outcome
      • Death from any cause during intensive care
      • Secondary Outcome
        • In hospital death, no. of days in ICU, need for prolonged ICU stay (>14 days) or readmission, need for ventilator support, critical illness polyneuropathy, markers of inflammation, infections or use of antibiotics > 10 days, transfusion requirements and hyperbilirubinemia.

Validity

  • Groups had similar prognosis
  • Majority of the patients admitted were following cardiac surgery (>60%)
  • No. of patients involved : Conventional 783, Intensive 765
  • Randomisation by sealed envelope, stratified
  • Blinding (partial)
  • Confounding factors: none noted
  • Follow up: Complete

Results

Primary Outcome:

Patients on intensive Insulin therapy has significantly low death rate

Secondary outcome

Patients requiring > 14 days of intensive care, patients requiring > 14 days of       ventilator support, no. of blood stream infections, EMG evidence of critical-illness     polyneuropathy was lower in intensive group

Take Home Message

There is a definitely a beneficial effect on the mortality and morbidity of intensive strict control of glucose.  Here are my reservations:

1. Majority of the patients included in the study had cardiac surgery; hence applying it to general/medical ICU needs further evaluation

2. Glucose homeostasis is a dynamic process and adjusting insulin based on periodic measurements would risk hypo/hyperglycaemic episodes

3. Glucose targets are arbitrary.

 

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