Intensive glucose control has been suggested for critically ill patients to improve outcomes. Two recent reports, a systematic review and a new randomized trial, found this treatment was associated with increased hypoglycemia and unclear benefits on mortality. A review of 26 randomized trials compared intensive glucose control with conventional glucose management in 13,567 intensive care unit (ICU) patients. There were no significant differences in overall mortality (24.7% vs. 24.9%). Intensive glucose control was associated with lower mortality in surgical ICU patients (7.4% vs. 11.8%, p < 0.05, NNT 23) in a meta-analysis of 5 trials (level 2 [mid-level] evidence). However, there was no difference in mortality in medical ICU patients (34.9% vs. 36.7%) or mortality in mixed ICU patients (26.7% vs. 25.6%). Hypoglycemia was significantly increased in intensive glucose control groups (10.7% vs. 1.6%, p < 0.05, NNH 10). The prevalence of diabetes was not reported (CMAJ 2009 Apr 14;180(8):821 PDF). In the NICE-SUGAR trial, 6,104 patients (20% with history of diabetes) were randomized within 24 hours of ICU admission to intensive or conventional glucose control. In this trial, intensive control was associated with both higher mortality (27.5% vs. 24.9%, p = 0.02, NNH 38) and a higher rate of severe hypoglycemia (6.8% vs. 0.5% (p < 0.001, NNH 15) (level 2 [mid-level] evidence). In a subgroup analysis, surgical patients had higher mortality with intensive control (odds ratio 1.31, 95% CI 1.07-1.61) (N Engl J Med 2009 Mar 26;360(13):1283). For more information, see the new Intensive glucose control in critical care topic in DynaMed.
