Findings Challenge Tight Glucose Control for Critically Ill Patients
TUESDAY Aug. 26, 2008 -- Tight glucose control doesn't significantly reduce the risk of in-hospital death among critically ill patients. But, it is associated with an increased risk of hypoglycemia (abnormally low blood sugar), according to a study that challenges the common practice of tight glucose control for this group of patients.
Currently, many major medical organizations advise tight glucose control for critically ill patients, and these recommendations have been adopted in many intensive care units around the world, according to background information in the review study by U.S. researchers.
They analyzed data from 8,432 patients in 29 previous studies and found no significant difference in hospital death rates for patients on tight glucose control (21.6 percent) and those receiving usual care (23.3 percent).
The researchers also found that tight glucose control was not associated with a significantly decreased risk for new need for dialysis (11.2 percent vs. 12.1 percent), but was associated with a significantly decreased risk (10.9 percent vs. 13.4 percent) of septicemia (generalized illness due to bacteria in the blood).
However, patients on tight glucose control had about a five-fold increased risk of hypoglycemia (13.7 percent vs. 2.5 percent).
"Given the overall findings of this meta-analysis, it seems appropriate that the guidelines recommending tight glucose control in all critically ill patients should be re-evaluated until the results of larger, more definitive clinical trials are available," concluded Dr. Renda Soylemez Wiener, of the Department of Veterans Affairs Medical Center in White River Junction, Vt., and Dartmouth Medical School, in Hanover, N.H., and colleagues.
The study was published in the Aug. 27 issue of the Journal of the American Medical Association.
But, Simon Finfer, of the George Institute for International Health, and Anthony Delaney, of the Royal North Shore Hospital in Sydney, Australia, wrote in an accompanying editorial that it's possible that some of the studies included in the meta-analysis were flawed or that the meta-analysis itself was flawed.
"Possible explanations for the discordant results of the study by van den Berghe et al and the meta-analysis by Wiener et al are that the meta-analysis is flawed, the studies that form the basis of the meta-analysis are flawed or inherently different, or the findings of the study by van den Berghe et al occurred due to random chance or as a result of another unique factor interacting with tight glycemic control."
They added that "those investigating tight glycemic control should take a step back and address the fundamental questions of defining quality standards for tight glycemic control, finding affordable methods of frequent and highly accurate measurement of blood glucose in the ICU, and conduct multicenter efficacy studies to determine if tighter glycemic control can reduce mortality under optimal conditions. If tighter glycemic control can be proven effective in optimal conditions, determining how to make that benefit available to millions of critically ill patients in both developed and resource-poor countries around the world would be a truly worthwhile challenge. There is no simple or clear answer to the complex problem of glycemic control in critically ill adults; at present, targeting tight glycemic control cannot be said to be either right or wrong."
Posted: August 2008