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Ideas and Opinions |

Glucose Control in the Intensive Care Unit: A Roller Coaster Ride or a Swinging Pendulum?

Richard J. Comi, MD
[+] Article, Author, and Disclosure Information

From Dartmouth Hitchcock Medical Center, Lebanon, New Hampshire.

Potential Financial Conflicts of Interest: None disclosed.

Requests for Single Reprints: Richard J. Comi, MD, Dartmouth Hitchcock Medical Center, Hitchcock Clinic, 1 Medical Center Drive, Lebanon, NH 03756.

Ann Intern Med. 2009;150(11):809-811. doi:10.7326/0003-4819-150-11-200906020-00009
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Many studies of tight control of blood glucose in critically ill patients are associated with poor outcomes. However, randomized studies of tight glucose control in patients admitted to coronary care or surgical intensive care units showed a reduction in mortality rates; supported by recommendations from professional organizations, many intensive care units implemented protocols for tight glucose control. More recent studies in medical intensive care units did not confirm the benefits of tight control, however, and the most recent study suggests that tight control increases mortality rates. Furthermore, tight control significantly increases episodes of hypoglycemia. The sum of the recent literature suggests that a degree of glucose control lies between the extremes of the adverse outcomes related to poor glucose control and those related to overly aggressive glucose control.





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Glycemic Control in the ICU
Posted on June 9, 2009
Cesar Alaniz
University of Michigan Health System
Conflict of Interest: None Declared

We would like to clarify one aspect of Dr. Comi's commentary on glucose control in the intensive care and amplify upon another. First, although the NICE-SUGAR control group was stated to have a target glucose level of less than 180mg/dL, it was actually much less than 180mg/dL as insulin infusions were continued until blood glucose reached 144mg/dL.(1) Indeed, the time-weighted mean blood glucose in the control group was 144mg/dL. Data on the mean glucose levels in patients who received insulin therapy were not provided. Thus, it would appear that the standard for glucose control would be closer to 8mmol/L (144mg/dL) rather than below 10mmol/L (180mg/dL) as suggested by Dr. Comi.

Second, regarding the relationship of hypoglycemia and adverse outcome, we believe it is time for increased scrutiny in this area. Our own MICU data (target glucose < 140mg/dL) show that for every episode of blood glucose < 40mg/dL there are 12 episodes of blood glucose between 40 and 70mg/dL. Evaluation of short-term hypoglycemia (mean nadir for 5 minutes of 52mg/dL) in healthy volunteers was associated with significant blunting of neuroendocrine, autonomic nervous system, and metabolic counterregulatory responses with subsequent episodes of hypoglycemia.(2) Also, hypoglycemic-hyperinsulinemic clamp studies in healthy volunteers showed significant increases in IL-6, ACTH, and cortisol at mean blood glucose levels of 50mg/dL.(3) Thus, deleterious effects of hypoglycemia likely begin at glucose levels higher than 40mg/dL.

1. NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.

2. Davis SN, Mann S, Galassetti P, et al. Effects of differing durations of antecedent hypoglycemia on counterregulatory responses to subsequent hypoglycemia in normal humans. Diabetes 2000;49:189701903.

3. Dotson S, Failing HJ, Freeman R, Adler GK. Hypoglycemia increases serum interleukin-6 levels in healthy men and women. Diabetes Care 2008;31:1232-3.

Conflict of Interest:

None declared

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