Critical Illness

CI: Blood Glucose Control (2009)

• Monitoring and Evaluation
  What impact does blood glucose control have on mortality in critically ill patients? (Updated 2009)

  • Conclusion

    Results are inconsistent from several primary research studies investigating 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.

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What impact does blood glucose control have on mortality in critically ill patients?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, Syed SJ, Giridhar HR, Rishu AH, Al-Daker MO, Kahoul SH, Britts RJ, Sakkijha MH. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008 Dec; 36(12): 3,190-3,197.
      • Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K; German Competence Network Sepsis (SepNet). N Engl J Med. 2008 Jan 10; 358(2): 125-139.
      • Finfer S, Chittock DR, et al, for the The Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) Investigators. Intensive versus conventional glucose control in critically ill patients. NEJM. 2009; 360(13): 1,283.
         
      • Grey NJ, Perdrizet GA. Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control. Endocr Pract. 2004 Mar-Apr;10 Suppl 2:46-52.
      • Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients? Mayo Clin Proc. 2003. Dec;78(12):1472-8.
      • Krinsley JS Effect of an intensive glucose management protocol on the mortality of critically ill patients. Mayo Clin Proc Nov 15, 2004. 2004;79(8):992-1000.
      • Mitchell I, Knight E, Gissane J, Tamhane R, Kolli R, Leditschke IA, Bellomo R, Finfer S; Australian and New Zealand Intensive Care Society Clinical Trials Group. A phase II randomised controlled trial of intensive insulin therapy in general intensive care patients. Crit Care Resusc. 2006; 8(4): 289-293.
      • Oddo M, Schmidt M, Carrera E, Badjatia N, Connolly ES, Presciutti M, Ostapkovich ND, Levind J, Le Roux P and Mayer S. Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: A microdialysis study. Crit Care Med. 2008; 36: 3,233.
      • Treggiari MM, Karir V, Yanez ND, Weiss NS, Daniel S, Deem SA. Intensive insulin therapy and mortality in critically ill patients. Crit Care. 2008; 12(1): R29. Epub 2008 Feb 29.
      • Van Den Berghe G, Wouter P. Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359-366.  
      • Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P and Bouillon R. Intensive Insulin Therapy in Critically Ill Patients. NEJM. 2001;345(19):1359-1367.
      • Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Wijngaerden EV, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical icu. N Engl J Med 2006; 354:449-61.  
      • Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: A meta-analysis. JAMA. 2008 Aug 27; 300(8): 933-944.
  • Search Plan and Results: CI: Blood Glucose Control 2009
     
  What impact does blood glucose control have on infectious complications in critically ill patients? (Updated 2009)

  • Conclusion

    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 ICU patients.

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What impact does blood glucose control have on infectious complications in critically ill patients?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, Syed SJ, Giridhar HR, Rishu AH, Al-Daker MO, Kahoul SH, Britts RJ, Sakkijha MH. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008 Dec; 36(12): 3,190-3,197.
      • Finfer S, Chittock DR, et al, for the The Normoglycemia in Intensive Care Evaluation–Survival Using Glucose Algorithm Regulation (NICE-SUGAR) Investigators. Intensive versus conventional glucose control in critically ill patients. NEJM. 2009; 360(13): 1,283.
         
      • Furnary AP, Zerr KJ, Grunkemeier GL, Starr A. Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures, Ann Thorac Surg 1999;67:352-62.
      • Golden SH, Peart-Vigilance C, Kao WH, Brancati FL. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Diabetes Care. 1999;22(9):1408-1414.
      • Grey NJ, Perdrizet GA. Reduction of nosocomial infections in the surgical intensive-care unit by strict glycemic control. Endocr Pract. 2004 Mar-Apr;10 Suppl 2:46-52.
      • Krinsley JS Effect of an intensive glucose management protocol on the mortality of critically ill patients. Mayo Clin Proc Nov 15, 2004. 2004;79(8):992-1000.
      • Van Den Berghe G, Wouter P. Bouillon R, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med. 2003;31(2):359-366.  
      • Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P and Bouillon R. Intensive Insulin Therapy in Critically Ill Patients. NEJM. 2001;345(19):1359-1367.
      • Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Wijngaerden EV, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical icu. N Engl J Med 2006; 354:449-61.  
      • Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: A meta-analysis. JAMA. 2008 Aug 27; 300(8): 933-944.
      • Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, Kanhere V, Starr A. Glucose control lowers the risk of wound infection in diabetics after open heart operations. Ann Thorac Surg 1997;63:356-61.
  • Search Plan and Results: CI: Blood Glucose Control 2009
     
  What impact does blood glucose control have on length of hospital stay in critically ill patients? (Updated 2009)

  • Conclusion

    There is 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.  

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What impact does blood glucose control have on length of hospital stay in critically ill patients?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, Syed SJ, Giridhar HR, Rishu AH, Al-Daker MO, Kahoul SH, Britts RJ, Sakkijha MH. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008 Dec; 36(12): 3,190-3,197.
      • Krinsley JS and Jones RL, Cost analysis of initensive glycemic control in critically ill adult patients. Chest. 2006. 129:644-650.
      • Krinsley JS Effect of an intensive glucose management protocol on the mortality of critically ill patients. Mayo Clin Proc Nov 15, 2004. 2004;79(8):992-1000.
      • Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P and Bouillon R. Intensive Insulin Therapy in Critically Ill Patients. NEJM. 2001;345(19):1359-1367.
  • Search Plan and Results: CI: Blood Glucose Control 2009
     
  What impact does blood glucose control have on days on mechanical ventilation in critically ill patients? (Updated 2009)

  • Conclusion

    There is 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.

  • Grade: II
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What impact does blood glucose control have on days on mechanical ventilation in critically ill patients?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Arabi YM, Dabbagh OC, Tamim HM, Al-Shimemeri AA, Memish ZA, Haddad SH, Syed SJ, Giridhar HR, Rishu AH, Al-Daker MO, Kahoul SH, Britts RJ, Sakkijha MH. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med. 2008 Dec; 36(12): 3,190-3,197.
      • Krinsley JS and Jones RL, Cost analysis of initensive glycemic control in critically ill adult patients. Chest. 2006. 129:644-650.
      • Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P and Bouillon R. Intensive Insulin Therapy in Critically Ill Patients. NEJM. 2001;345(19):1359-1367.
      • Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Wijngaerden EV, Bobbaers H, Bouillon R. Intensive insulin therapy in the medical icu. N Engl J Med 2006; 354:449-61.  
  • Search Plan and Results: CI: Blood Glucose Control 2009
     
  What impact does blood glucose control have on cost of medical care in critically ill patients? (Updated 2009)

  • Conclusion

    In the 2009 update, there were no new studies meeting the inclusion criteria for this question. There is limited evidence that controlling BG values in critically ill patients leads to a decrease in the cost of medical care.

  • Grade: III
    • Grade I means there is Good/Strong evidence supporting the statement;
    • Grade II is Fair;
    • Grade III is Limited/Weak;
    • Grade IV is Expert Opinion Only;
    • Grade V is Not Assignable.
    • High (A) means we are very confident that the true effect lies close to that of the estimate of the effect;
    • Moderate (B) means we are moderately confident in the effect estimate;
    • Low (C) means our confidence in the effect estimate is limited;
    • Very Low (D) means we have very little confidence in the effect estimate.
    • Ungraded means a grade is not assignable.
  • Evidence Summary: What impact does blood glucose control have on cost of medical care in critically ill patients?
    • Detail
    • Quality Rating Summary
      For a summary of the Quality Rating results, click here.
    • Worksheets
      • Krinsley JS and Jones RL, Cost analysis of initensive glycemic control in critically ill adult patients. Chest. 2006. 129:644-650.
  • Search Plan and Results: CI: Blood Glucose Control 2009