Literature at a Glance
- Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.
- Intensive glucose-lowering therapy in diabetic patients at high risk for cardiovascular events increased mortality.
- Targeting normal glycated hemoglobin levels with a gliclazide-based regimen does not have an effect on preventing major macrovascular events.
- Non-invasive ventilation has no effect on short-term mortality or rates of tracheal intubation and admission to ICU
- Routine use of a rhythm-control strategy does not reduce the rate of death from cardiovascular causes.
- No clinical benefit exists in employing intensive renal replacement over a conventional approach in critically ill patients.
- Initial UFH bolus and infusion dosing used for NSTE ACS often exceeds recommended weight-adjusted dosing.
- High BNP or NT-pro-BNP levels can differentiate patients who are at a higher risk of complicated hospital course and short-term mortality.
- Use of a silver-coated ET tube reduces the incidence of VAP, as well as delays time to VAP occurrence.
Clinical question: Does tight glucose control for critically ill patients affect mortality?
Background: Intensive glucose control for adult ICU patients has been advocated by numerous professional societies and adopted worldwide as a means to reduce mortality of critically ill patients. Evidence from multiple randomized controlled trials of tight glucose control in the ICU setting, however, shows mixed results.
Study Design: Meta-analysis of randomized controlled trials.
Setting: 29 studies involving 8,432 critically ill patients.
Synopsis: This study evaluated 29 trials involving critically ill adult patients randomized to tight glucose control versus usual care. Comparing these patients, there was no significant difference in short-term mortality (<30 days). Stratification of trials by level of glucose control (very tight <110 mg/dL versus moderately tight <150 mg/dL) and by ICU setting (surgical, medical, or mixed medical-surgical) did not affect mortality.
Tight glucose control was associated with a reduced risk of septicemia, but only in surgical patients. There was no association between tight control and a new need for dialysis, consistent across all ICU settings, as well as with both levels of glucose control. Finally, there was an increased risk of hypoglycemia (<40 mg/dL) with tight control, higher in patients who received very tight control versus those who received moderately tight control.
Limitations of the studies evaluated in this meta-analysis include difficulties with consistently maintaining tight glucose control. Twenty one percent of the trials did not achieve a mean glucose level within 5 mg/dL of the goal. This, along with a lack of standardization in reporting glucose control, makes study comparison problematic.
Bottom Line: Tight glucose control in critically ill patients is not associated with reduction in short-term mortality, but it is associated with an increased risk of hypoglycemia.
Citation: Wiener, RS, Wiener DC, Larson, RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300:933-944.
Clinical Question: Does intensive glucose-lowering therapy reduce cardiac events in high-risk diabetic patients?
Background: Epidemiologic studies have suggested the risk of cardiovascular disease increases with higher levels of glycated hemoglobin in patients with type-2 diabetes. No definitive data from randomized trials exist to test the effect of intensive glucose-lowering therapy on the rate of cardiovascular events in high-risk diabetic patients.
Study Design: Multicenter randomized controlled trial led by the Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group.