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Tight Glycemic Control Without Early Parenteral Nutrition in Critical Care

Length of stay in intensive care units (ICUs) and 90-day mortality were not significantly different with tight glucose control in critically ill patients who were not receiving early parenteral nutrition, a study shows. “Hyperglycemia was less severe than that previously reported in patients receiving parenteral nutrition,” the authors conclude. “Further lowering of blood-glucose levels into the normal fasting range, guided by a computer algorithm, avoided iatrogenic hypoglycemia without affecting the length of time that ICU care was needed or mortality,”

At the time of ICU admission, patients were randomly assigned to liberal glucose control (insulin initiated at blood glucose levels above 215 mg/dL)or to tight glucose control (blood glucose level targeted with the use of the LOGIC-Insulin algorithm at 80–110 mg/dL). For 1 week, neither group received parenteral nutrition. The primary outcomes were the length of time ICU care was needed (efficacy outcome) and 90-day mortality (safety outcome).

“Of 9,230 patients who underwent randomization, 4,622 were assigned to liberal glucose control and 4,608 to tight glucose control,” the authors write. “The median morning blood-glucose level was 140 mg per deciliter (interquartile range, 122 to 161) with liberal glucose control and 107 mg per deciliter (interquartile range, 98 to 117) with tight glucose control. Severe hypoglycemia occurred in 31 patients (0.7%) in the liberal-control group and 47 patients (1.0%) in the tight-control group. The length of time that ICU care was needed was similar in the two groups (hazard ratio for earlier discharge alive with tight glucose control, 1.00; 95% confidence interval, 0.96 to 1.04; P = 0.94). Mortality at 90 days was also similar (10.1% with liberal glucose control and 10.5% with tight glucose control, P = 0.51). Analyses of eight prespecified secondary outcomes suggested that the incidence of new infections, the duration of respiratory and hemodynamic support, the time to discharge alive from the hospital, and mortality in the ICU and hospital were similar in the two groups, whereas severe acute kidney injury and cholestatic liver dysfunction appeared less prevalent with tight glucose control.”

Editorial: “On the basis of evidence from previous randomized, controlled trials, the American Diabetes Association recommends initiation of insulin for the treatment of persistent hyperglycemia (blood-glucose level >180 mg per deciliter), with a targeted glucose range of 140 mg per deciliter (7.8 mmol per liter) to 180 mg per deciliter for most critically ill patients,” writes an editorialist. “More stringent goals, such as a glucose level of 100 to 180 mg per deciliter (5.6 to 10.0 mmol per liter), may be appropriate as long as they can be achieved without clinically significant hypoglycemia.”

Source: New England Journal of Medicine