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Recommendations Summary

CI: Blood Glucose Control 2012

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    CI: Blood Glucose Control

    In critically ill adult patients, the Registered Dietitian (RD) should promote blood glucose control between 140 to 180mg per dL. Tight blood glucose control (80 to 110mg per dL) is not associated with reduced hospital length of stay (LOS), infectious complications, cost of medical care, days on mechanical ventilation or mortality and increases risk of hypoglycemia. Glucose level >180mg per dL is associated with increased mortality.
     

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      • Treatment of hyperglycemia may increase risk for hypoglycemia
      • Insulin clearance is impaired by certain clinical conditions (kidney disease, liver disease) and may increase risk for hypoglycemia.

    • Conditions of Application

      There are no conditions which may limit the application of this recommendation.

    • Potential Costs Associated with Application

      Additional costs may be incurred due to increased medication, equipment, testing supplies for laboratory assays, and staff time required to achieve blood glucose control.

    • Recommendation Narrative

      A total of 17 studies were included in the evidence analysis for this recommendation:

      • Six positive quality randomized controlled trials (RCTs) (Arabi et al, 2008; Brunkhorst et al, 2008; Finfer et al, 2009; and Van den Berghe et al, 2001; 2003; 2006)
      • Five positive quality cohort studies (Krinsley, 2004; Krinsley and Jones, 2006; Oddo et al; 2008; Treggiari et al, 2008; and Zerr et al,  1997)
      • One positive quality retrospective cross-sectional database study (Krinsley, 2003)
      • One positive quality meta-analysis (Wiener et al, 2008)
      • Two neutral quality RCTs (Grey and Perdrizet, 2004; and Mitchell et al, 2006)
      • One neutral quality non-randomized trial (Furnary et al, 1999)
      • One neutral quality cross-sectional correlation study (Golden et al, 1999).

      Impact of Blood Glucose Control on Mortality in Critically Ill Patients

      • Thirteen studies provide inconsistent evidence regarding the effect of tight blood glucose control (between 80mg and 110mg per dL) on mortality. Some found a decrease in mortality, while others show no effect or even increased mortality. When blood glucose is controlled between 180mg per dL and 215mg per dL, mortality appears to be increased. There is limited evidence about the optimal target blood glucose level needed to reduce mortality.
      • Evidence is based on the following studies: Arabi et al, 2008; Brunkhorst et al, 2008; Finfer et al, 2009; Grey and Perdrizet, 2004; Krinsley, 2003; Krinsley, 2004; Mitchell et al, 2006; Oddo et al, 2008; Treggiari et al, 2008; Van den Berghe et al, 2001, 2003, 2006; and Wiener et al, 2008.

      Impact of Blood Glucose Control on Infectious Complications in Critically Ill Patients

      • Eleven studies provide evidence that in surgical (primarily cardiac) patients, tight control of blood glucose reduces the risk of some types of infectious complications. However, this effect has not been consistently demonstrated in other types of intensive are unit (ICU) patients.
      • Evidence is based on the following studies: Arabi et al, 2008; Finfer et al, 2009; Furnary et al, 1999; Golden et al, 1999; Grey and Perdrizet, 2004; Krinsley, 2004; Zerr et al, 1997; Van den Berghe et al, 2001; 2003; 2006; and Wiener et al, 2008.

      Impact of Blood Glucose Control on Hospital Length of Stay (LOS) in Critically Ill Patients

      • Four studies provide inconsistent evidence that tight control (between 80mg and 110mg per dL) or moderate control (below 140mg per dL) in critically ill patients leads to a decrease in ICU LOS.
      • Evidence is based on the following studies: Arabi et al, 2008; Krinsley, 2004; Krinsley and Jones, 2006; and Van den Berghe et al, 2001.

      Impact of Blood Glucose Control on Days on Mechanical Ventilation in Critically Ill Patients

      • Four studies provide inconsistent evidence that tight control of blood glucose (between 80mg and 110mg per dL) or moderate control of blood glucose (below 140mg per dL) in critically ill patients leads to a reduced number of days on mechanical ventilation.
      • Evidence is based on the following studies: Arabi et al, 2008; Krinsley and Jones, 2006; Van den Berghe et al, 2001; and Van den Berghe et al, 2006). 

      Impact of Blood Glucose Control on Cost of Medical Care in Critically Ill Patients

      • One cohort study provides limited evidence that controlling blood glucose values in critically ill patients leads to a decrease in the cost of medical care.  In the 2009 update, there were no new studies meeting the inclusion criteria for this question.
      • Evidence is based on the following study: Krinsley and Jones, 2006.

    • Recommendation Strength Rationale

      • Subjects were primarily middle-aged to older adults (mean ages, 42 to 70). Most studies consisted of primarily male subjects (41% to 73%). The patient population consisted of critically ill adults and trauma patients.
      • Grade II evidence is available for the conclusion statements regarding the impact of blood glucose control in critically ill adult patients on: 
        • Mortality
        • Infectious complications
        • LOS 
        • Days on mechanical ventilation  
      • Grade III evidence is available for the conclusion statement regarding the impact of blood glucose control on cost of medical care in critically ill adult patients. 

    • Minority Opinions

      None.