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Intensive versus Conventional Glucose Control in Critical Ill PatientsN Engl J Med 2009; 360:1283-1297.
雙和醫院劉慧萍藥師
Introduction
Hyperglycemia Common in acutely ill patients, including ICU patients Increased morbidity and mortality
Randomized, controlled trial of critically ill surgical patients showing that tight glucose control reduced hospital mortality Guidelines recommend tight glucose control in all critically ill
adults Tight glucose control not used frequently
Conflicting results among trials Increased risk of severe hypoglycemia
Goal of this trial To test the hypothesis that intensive glucose control reduces
mortality at 90 days
Methods (I)
Study Design A parallel-group, multi-center, randomized,
controlled trial performed at 42 hospitals, 38 academic tertiary care hospitals, and 4 community hospitals
Follow-up 90 days
Patient Population Patients expected to require treatment in the ICU
on 3 or more consecutive days
Methods (II)
Randomly assigned to 2 groups Intensive glucose control
Glucose target- 81 to 108 mg/dL Conventional control
Glucose target 180 mg/dL≦ Insulin administered if glucose level >180 mg/dL an
d reduced and discontinued insulin if glucose level <144 mg/dL
Control of blood glucose was achieved with the use of an intravenous infusion of insulin in saline
Methods (III)
Time of discontinued intervention Patients started eating Discharged from ICU
Resumed if the patient readmitted to ICU within 90 days
Time of discontinued permanently Death 90 days after randomization
Data Collection
Demographic and clinical characteristics Including APACHE II score
All blood glucose measurements Insulin administration Red-cell administration Blood cultures positive for pathogenic organisms Type and volume of all enteral and parenteral nutrition and additi
onal IV glucose administration Corticosteroid administration Organ failure Use of mechanical ventilation Renal replacement therapy
Outcome MeasurementPrimary outcome
Death from any cause within 90 days after randomization
Examined in subgroups Operative and nonoperative With and without diabetes With and without trauma With and without sepsis Treated and not treated with corticosteroids APACHE II score 25 or more and less
Outcome Measurements
Secondary outcomes Survival time during the first 90 days Cause-specific death Duration of mechanical ventilator and renal-replacement
therapy Stays in the ICU and hospital
Tertiary outcomes Death from any cause within 28 days after randomization Place of death Incidence of new organ failure Positive blood culture Receipt of red-cell transfusion Volume of the transfusion
Definition
Operative admission Admitted to ICU directly from the operating or recovery roo
m Diabetes
Based on medical history Trauma
Admitted to ICU within 48 hours after admission to hospital for trauma
Previous treatment with corticosteroids Systemic corticosteroids for 72 hours or more immediately
before randomization Serious adverse events
Blood glucose 40 mg/dL or less
ResultsStudy Participants
Recruited period December 2004 ~
November 2008
Baseline Characteristics
ResultsInsulin Administration and Treatment Effects Intensive group vs. conventional group
Receiving insulin 2931/3014 (97.2%) vs. 2080/3014 (69.0%) p < 0.001
Mean insulin dose 50.238.1 vs. 16.929.0 units/day p < 0.001
Mean time-weighted blood glucose level 11518 vs. 14423 mg/dL p < 0.001
ResultsNutrition and Concomitant Treatment
Intensive v.s. conventional group Nutrition during the first 14 days
Mean daily amount of nonprotein calories administration 891490 v.s. 872500 kcal; p = 0.14
Enteral nutrition- 624496 vs. 623496 kcal Parenteral nutrition- 173359 vs. 162345 kcal IV glucose- 93.488.8 v.s. 87.293.5 kcal
Corticosteroids 1042/3010 (34.6%) vs. 955/3009 (31.7%); p = 0.02
ResultsOutcome Measurements
829 of 3010 patients (27.5%) in the intensive-control group had died as compared with 751 of 3012 patients (24.9%) in the conventional group
Majority of deaths occurred in the ICU Intensive v.s. conventional group
546/829 (65.9%) v.s. 498/751 (66.3%) The absolute difference in mortality was 2.6 percent
points (95% CI, 0.4 to 4.8) The odds ratio for death with intensive control was 1.
14 (95% CI, 1.02 to 1.28 ; p = 0.02) Adjusted odds ratio, 1.14 (95% CI, 1.01 to 1.29; p =
0.04)
ResultsOutcome Measurements
Deaths from cardiovascular causes were more common in the intensive-control group (41.6%) than in the conventional-control group (35.8%) (absolute difference, 5.8 percentage points; p = 0.02)
Distributions of proximate causes of death were similar (p = 0.12)
The median survival time was lower in the intensive-control group than in the conventional-control group (hazard ratio, 1.11; 95% CI, 1.01 to 1.23; p = 0.03)
ResultsSurvival Time
ResultsOutcomes Measurements
No significant difference between the two groups in the median length of stay in the ICU or hospital.
No significant difference between the two groups in the number of patients developed new organ failures (p = 0.11)
The number of days of mechanical ventilator and renal replacement therapy, or in the rates of positive blood cultures and red-cell transfusion.
ResultsComparison between Subgroups
No significant difference for comparisons of subgroups Operative and nonoperative patients (p = 0.10) With or without diabetes (p = 0.60) With or without severe sepsis (p = 0.93) APACHE II score 25 and < 25 (≧ p = 0.84)
No significant but indicated a possible trend With trauma and without trauma (p = 0.07) Receiving and not receiving corticosteroids (p = 0.
06)
ResultsSerious Adverse Events
Severe hypoglycemia (blood glucose level 40 mg≦/dL) was recorded in 206 of 3016 patients (6.8%) in the intensive-control group, as compared with 15 of 3014 patients (0.5%) in the conventional-control group (odds ratio, 14.7; 95% CI, 9.0 to 25.9; p < 0.001)
The recorded number of episodes of severe hypoglycemia severe hypoglycemia was 272 in the intensive-control group, as compared with 16 in the conventional-control group.
No long-term sequelae of severe hypoglycemia were reported
Clinical Impact
A goal of normoglycemia for glucose control does not necessarily benefit critical ill patients and may be harmful Lower blood glucose target is not recommended in critically
ill adults. The excess deaths in the intensive-control group we
re predominantly from cardiovascular causes. These differences might suggest that reducing blood glucose levels by the administration of insulin has adverse effects on cardiovascular system. Not examined mechanisms in this trial, further research is n
eeded
Strengths
Standardized, complex management of blood glucose through a computerized treatment algorithm accessible on centralized servers
Patients received predominantly enteral nutrition consonant with current evidence-based feeding guidelines
Longer follow-up period
Limitation
Use of a subjective criterion- expected length of stay in the ICU.
Inability to make treating staff and study personnel unaware of the treatment-group assignments.
Achievement of a glucose level modestly above the target range in a substantial proportion of patients in the intensive group.
Not collect specific data to address potential biologic mechanisms of the trial interventions or their costs.
Benefits and Risks of Tight Glucose Control in Critically Ill AdultsA Meta-analysis
JAMA. 2008; 300:933-944.
Data Sources
MEDLINE (1950-June 6, 2008) The Cochrane Library Clinical trial registries Reference lists Abstracts from conferences from both the
American Thoracic Society (2001-2008) and the Society of Critical Care Medicine (2004-2008)
Study Selection
Inclusion criteria Randomized controlled trial
Adult ICU Intervention group received tight glucose control (goal < 150
mg/dL using insulin) Comparison group received usual care Primary or secondary end points included hospital or short-ter
m mortality ( 30-day), septicemia, new need for dialysis, or h≦ypoglycemia
Exclusion criteria Intervention conducted primarily during the intraoperative p
eriod rather than during ICU stay
Outcome Measures
Primary outcome measure Hospital mortality
Death occurring during the hospital stay or within 30 days following admission
Secondary outcome measure Septicemia New need for dialysis hypoglycemia
Subgroup Analyses
Glucose goal in the tight control group Very tight control
≦ 110mg/dL Moderately tight control
111-150 mg/dL According to recommendation for glucose control in critically ill pa
tients American Diabetes Association
Close to 110mg/dL Surviving Sepsis Campaign
<150mg/dL ICU setting
Surgical ICU Medical ICU Mixed medical-surgical ICU
Search Results
ResultsPrimary Outcome No significant difference in hospital mortality
between tight glucose control and usual care strategies (21.6% vs. 23.3%; 95% CI, 0.85-1.03)
Conclusion
Tight glucose control is not associated with significant reduced hospital mortality or new dialysis but is associated with increased risk of hypoglycemia.
Larger, more definitive clinical trials are needed to reevaluated tight glucose control in critically ill patients
Open Discussion
What are the target range of blood glucose levels in ICU among different hospital?
Should patients in surgical ICU need tighter glucose control?
Thank You for Attention