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Intensive versus conventional glucose control in critically ill patients

Simon Finfer, Dean R Chittock, Steve Yu-Shuo Su, Deborah Blair, Denise Foster, Vinay Dhingra, Rinaldo Bellomo, Deborah Cook, Peter Dodek, William R Henderson, Paul C H├ębert, Stephane Heritier, Daren K Heyland, Colin McArthur, Ellen McDonald, Imogen Mitchell, John A Myburgh, Robyn Norton, Julie Potter, Bruce G Robinson, Juan J Ronco
New England Journal of Medicine 2009 March 26, 360 (13): 1283-97

BACKGROUND: The optimal target range for blood glucose in critically ill patients remains unclear.

METHODS: Within 24 hours after admission to an intensive care unit (ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter (4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter (10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization.

RESULTS: Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative (surgical) patients and nonoperative (medical) patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycemia (blood glucose level, < or = 40 mg per deciliter [2.2 mmol per liter]) was reported in 206 of 3016 patients (6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39).

CONCLUSIONS: In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter. ( number, NCT00220987.)


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Peter Xu wrote:


I think you misunderstood the conclusion. This study found that a more intensive blood glucose control (between 81 and 108) resulted in HIGHER mortality than conventional control under 180. The authors attribute some of the mortality to hypoglycemia resulting from the intense blood glucose control.

Marco Macias wrote:


Exactly. The intensive use of insulin infusions leds yo Higher mortility and usually increase risk of hypoglucemia.

Alexander Pine wrote:


Other than "as used in previous studies," what is the rationale for choosing the lower blood glucose target? Why 81-108, and not say, 144. Would result be any different?

Dr Wadid wrote:


The mention glucose level should be regarded in all diabetic and non diabetic ICU patient , it is FBS or random?

Jason Hine wrote:


Out surviving sepsis guidelines target <180, but do not address the negative effects of overshooting. This article to me validates what makes sense but was not yet confirmed.

Salman Khan wrote:


Other studies have also defined this conclusion in critical care patients.
I think nutrition plays a deep role in healing and glucose is a mean of nutrition for the cell of course not uncontrolled but also not in a strict control

Leon du Toit wrote:


The intervention "tight control" was ineffective in producing target glucose 81-108. Most participants in the intervention arm had glucose levels outside the target range.

sandoval freder wrote:


Considero los recursos de este estudio y los resultados son confiables.

Jay Patel wrote:


Interesting. However, didn't it prove what we already know? Having a treatment plan closer to normal blood glucose levels results in decreased mortality when compared to a group that probably has higher blood glucose?

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