Critique of normoglycemia in intensive care evaluation: survival using glucose algorithm regulation (NICE-SUGAR)--a review of recent literature.

PURPOSE OF REVIEW: The publication of the long awaited results of the Normoglycaemia in Intensive Care Evaluation - Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial generated intense controversy in the area of glycemic control in the critically ill. NICE-SUGAR reported results in direct contrast to the original Leuven study and challenged the legitimacy of a mortality benefit of tight glycemic control in the intensive care unit (ICU). This review of the recent literature critically examines the salient differences between NICE-SUGAR and the original Leuven study.

RECENT FINDINGS: Differences in glycemic targets within the control and intervention groups, variability with patients reaching these set targets, and the disparity in study execution and nutritional strategies are some of the methodological differences explaining the observed differences in mortality and morbidity between the two studies. The Leuven study should be viewed as a 'proof-of-concept' study with future studies aimed at confirming its finding and optimizing clinical algorithms to safely implement it in various 'real world' settings. Discrepancies in implementation and nutrition make direct comparison of NICE-SUGAR and the original Leuven study impracticable.

SUMMARY: Accurate replication of the original Leuven methodology may be the limiting factor for achieving the benefits gained by intensive insulin therapy (IIT). Determination of ICU capability (physicians, nurses, standardization of equipment, etc.) is crucial to implementing tight glycemic targets. If IIT is not achievable due to adverse outcomes such as hypoglycemia, more lax and reachable glucose control should be sought.