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New findings published in the August 27 issue of JAMA
call into interrogative sentence the tight glucose control that many professional
societies recommend for critically inauspicious adults. Researchers performed a
meta-analysis and found that tight glucose control is not associated
with a significant step-down in risk of end in the hospital, merely it
is linked to an increased risk of hypoglycemia (lour than normal
glucose sugar levels).
A randomised controlled test published in 2001 by van den Berghe et al found a 33% reduction in risk of hospital mortality for critically ill
operative patients world Health Organization practiced soaked glucose control. "Because few
interventions in critically ill adult patients reduce mortality to this
extent, the results of this trial were sky-high received and
rapidly incorporated into guidelines," write Renda Soylemez
Wiener, M.D., M.P.H., (Department of Veterans
Affairs Medical Center, White River Junction, Vt., and Dartmouth
Medical School, Hanover, N.H.) and colleagues.
Further, tight glucose control in all critically ill patients is a
recommendation of highly well-thought-of organization such as the American
Diabetes Association and the American Association of Clinical
Endocrinologists. "These recommendations have light-emitting diode to worldwide adoption
of tight glucose control in a variety of intensive care unit (ICU)
settings," according to Wiener. However, on that point are some trials of tight
glucose control in certain intensive care unit (ICU) settings that have
not resulted in mortality benefit merely have resulted in an increased
risk of infection for hypoglycemia.
In the meta-analysis, Wiener and colleagues studied 29 randomized
controlled trials with 8,432 patients that compared risks and benefits
of usual upkeep in critically ill adults with tight glucose control
(glucose goal of less than 150 mg/dL).
One finding was that 'tween tight glucose control and usual forethought
strategies, thither was no significant conflict in infirmary mortality -
21.6% to 23.3%, severally. The researchers also noted no significant
differences in hospital mortality when separately analyzing surgical,
medical, and medical-surgical ICU settings. While tight glucose control
resulted in a risk of new need for dialysis by 11.2%, the rate for
usual charge was 12.1% - not a significant difference of opinion. However, tight
glucose control condition was associated with a significantly decreased risk of
septicemia, a generalized malady due to bacteria in the blood stream
(10.9% to 13.4%, severally). Additionally, the risk of hypoglycemia
under tight glucose control was about 5 times higher than under usual
care (13.7% to 2.5%).
The authors reason out that, "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 ar available."
Simon Finfer, M.B.B.S., F.J.F.I.C.M. (The George Institute for
International Health) and Anthony Delaney, M.B.B.S., F.J.F.I.C.M.
(Royal North Shore Hospital, Sydney, Australia) write in an
accompanying comment that:
"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 strain the ground of the
meta-analysis ar flawed or inherently different, or the findings of
the study by van den Berghe et al occurred ascribable to random chance or as a
result of another unique factor interacting with tight glycemic
control."
They add: "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
patronize and highly accurate measurement of blood glucose in the ICU,
and conduct multicenter efficacy studies to define if tighter
glycemic restraint can cut back mortality under optimal weather condition. If
tighter glycemic control tin be proved effective in optimal atmospheric condition,
determining how to get that benefit available to millions of
critically inauspicious patients in both developed and resource-poor countries
around the populace would be a unfeignedly worthwhile challenge. There is no
unsubdivided or clear answer to the complex problem of glycemic control in
critically ill adults; at pose, targeting tight glycemic control
cannot be said to be either right or wrong."
Benefits and Risks of Tight Glucose Control in Critically Ill
Adults: A Meta-analysis
Renda Soylemez Wiener; Daniel C. Wiener; Robin J. Larson
JAMA (2008). 300[8]:
pp. 933-944.
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Written by: Peter M Crosta
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Thursday 4 September 2008
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