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The Optimal Target for Acute Glycemic Control in Critically Ill Patients: a Network Meta-Analysis
The Optimal Target for Acute Glycemic Control in Critically Ill Patients: a Network Meta-Analysis
Yatabe T, Inoue S, Sakaguchi M, Egi M. Intensive Care Med. 2017;43:16-28.
Study Question: What is the optimal target for acute glycemic control in critically ill patients to minimize risk of mortality, infection, and hypoglycemic events?
Study Description: This network meta-analysis evaluated studies from recent systematic reviews as well as the PubMed and Cochrane Library databases. Randomized controlled trials (RCTs) published in English were included if they compared different glycemic targets in critically ill adults and evaluated an outcome of interest. Patients were categorized into one of four groups (< 110, 110-144, 144-180, and > 180 mg/dL) based on the upper blood glucose target limit utilized in the study. The primary outcome evaluated was hospital mortality.
Results: Thirty-five RCTs (18,098 patients) met inclusion criteria. No statistically significant differences were noted in mortality or risk of infection between groups. When evaluated based on ICU setting (medical or surgical), no difference in mortality or infection was noted between groups. In medical ICUs, a lower blood glucose target (110-144 mg/dL) increased risk of hypoglycemia compared to higher targets (144-180 or > 180 mg/dL).
Conclusions: There was no difference in mortality or infection risk between groups. Lower blood glucose targets (< 110 or 110-144 mg/dL) were associated with increased hypoglycemic events.
Perspective: There is a lack of consensus regarding the optimal blood glucose target in critically ill patients. The Surviving Sepsis Campaign 2016 Guidelines recommend an upper blood glucose limit of ≤ 180 mg/dL rather than ≤ 110 mg/dL, but do not recommend a lower glucose limit due to lack of evidence. Although targets of ≤ 110 mg/dL or > 180 mg/dL are not routinely utilized in clinical practice, there has been a lack of data regarding the optimal blood glucose target within the 110-180 mg/dL range. Based on the lack of a difference in mortality or infection risk between groups and increased hypoglycemic events in the < 110 and 110-144 mg/dL groups, this network meta-analysis provides support for the already existing recommendation of several medical organizations to target blood glucose levels of 140-180 mg/dL in critically ill patients, especially if in the medical ICU.