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Benefits and risks of tight glucose control in critically ill adults: a meta-analysis.
JAMA. 2008 Aug 27; 300(8):933-44.JAMA

Abstract

CONTEXT

The American Diabetes Association and Surviving Sepsis Campaign recommend tight glucose control in critically ill patients based largely on 1 trial that shows decreased mortality in a surgical intensive care unit. Because similar studies report conflicting results and tight glucose control can cause dangerous hypoglycemia, the data underlying this recommendation should be critically evaluated.

OBJECTIVE

To evaluate benefits and risks of tight glucose control vs usual care in critically ill adult patients.

DATA SOURCES

MEDLINE (1950-2008), the Cochrane Library, clinical trial registries, reference lists, and abstracts from conferences from both the American Thoracic Society (2001-2008) and the Society of Critical Care Medicine (2004-2008).

STUDY SELECTION

We searched for studies in any language in which adult intensive care patients were randomly assigned to tight vs usual glucose control. Of 1358 identified studies, 34 randomized trials (23 full publications, 9 abstracts, 2 unpublished studies) met inclusion criteria.

DATA EXTRACTION AND ANALYSIS

Two reviewers independently extracted information using a prespecified protocol and evaluated methodological quality with a standardized scale. Study investigators were contacted for missing details. We used both random- and fixed-effects models to estimate relative risks (RRs).

RESULTS

Twenty-nine randomized controlled trials totaling 8432 patients contributed data for this meta-analysis. Hospital mortality did not differ between tight glucose control and usual care overall (21.6% vs 23.3%; RR, 0.93; 95% confidence interval [CI], 0.85-1.03). There was also no significant difference in mortality when stratified by glucose goal ([1] very tight: < or = 110 mg/dL; 23% vs 25.2%; RR, 0.90; 95% CI, 0.77-1.04; or [2] moderately tight: < 150 mg/dL; 17.3% vs 18.0%; RR, 0.99; 95% CI, 0.83-1.18) or intensive care unit setting ([1] surgical: 8.8% vs 10.8%; RR, 0.88; 95% CI, 0.63-1.22; [2] medical: 26.9% vs 29.7%; RR, 0.92; 95% CI, 0.82-1.04; or [3] medical-surgical: 26.1% vs 27.0%; RR, 0.95; 95% CI, 0.80-1.13). Tight glucose control was not associated with significantly decreased risk for new need for dialysis (11.2% vs 12.1%; RR, 0.96; 95% CI, 0.76-1.20), but was associated with significantly decreased risk of septicemia (10.9% vs 13.4%; RR, 0.76; 95% CI, 0.59-0.97), and significantly increased risk of hypoglycemia (glucose < or= 40 mg/dL; 13.7% vs 2.5%; RR, 5.13; 95% CI, 4.09-6.43).

CONCLUSION

In critically ill adult patients, tight glucose control is not associated with significantly reduced hospital mortality but is associated with an increased risk of hypoglycemia.

Authors+Show Affiliations

VA Outcomes Group, 111 B, Department of Veterans Affairs Medical Center, White River Junction, VT 05009, USA. renda.s.wiener@dartmouth.eduNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Research Support, U.S. Gov't, Non-P.H.S.

Language

eng

PubMed ID

18728267

Citation

Wiener, Renda Soylemez, et al. "Benefits and Risks of Tight Glucose Control in Critically Ill Adults: a Meta-analysis." JAMA, vol. 300, no. 8, 2008, pp. 933-44.
Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008;300(8):933-44.
Wiener, R. S., Wiener, D. C., & Larson, R. J. (2008). Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA, 300(8), 933-44. https://doi.org/10.1001/jama.300.8.933
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):933-44. PubMed PMID: 18728267.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. AU - Wiener,Renda Soylemez, AU - Wiener,Daniel C, AU - Larson,Robin J, PY - 2008/8/30/pubmed PY - 2008/9/3/medline PY - 2008/8/30/entrez SP - 933 EP - 44 JF - JAMA JO - JAMA VL - 300 IS - 8 N2 - CONTEXT: The American Diabetes Association and Surviving Sepsis Campaign recommend tight glucose control in critically ill patients based largely on 1 trial that shows decreased mortality in a surgical intensive care unit. Because similar studies report conflicting results and tight glucose control can cause dangerous hypoglycemia, the data underlying this recommendation should be critically evaluated. OBJECTIVE: To evaluate benefits and risks of tight glucose control vs usual care in critically ill adult patients. DATA SOURCES: MEDLINE (1950-2008), the Cochrane Library, clinical trial registries, reference lists, and abstracts from conferences from both the American Thoracic Society (2001-2008) and the Society of Critical Care Medicine (2004-2008). STUDY SELECTION: We searched for studies in any language in which adult intensive care patients were randomly assigned to tight vs usual glucose control. Of 1358 identified studies, 34 randomized trials (23 full publications, 9 abstracts, 2 unpublished studies) met inclusion criteria. DATA EXTRACTION AND ANALYSIS: Two reviewers independently extracted information using a prespecified protocol and evaluated methodological quality with a standardized scale. Study investigators were contacted for missing details. We used both random- and fixed-effects models to estimate relative risks (RRs). RESULTS: Twenty-nine randomized controlled trials totaling 8432 patients contributed data for this meta-analysis. Hospital mortality did not differ between tight glucose control and usual care overall (21.6% vs 23.3%; RR, 0.93; 95% confidence interval [CI], 0.85-1.03). There was also no significant difference in mortality when stratified by glucose goal ([1] very tight: < or = 110 mg/dL; 23% vs 25.2%; RR, 0.90; 95% CI, 0.77-1.04; or [2] moderately tight: < 150 mg/dL; 17.3% vs 18.0%; RR, 0.99; 95% CI, 0.83-1.18) or intensive care unit setting ([1] surgical: 8.8% vs 10.8%; RR, 0.88; 95% CI, 0.63-1.22; [2] medical: 26.9% vs 29.7%; RR, 0.92; 95% CI, 0.82-1.04; or [3] medical-surgical: 26.1% vs 27.0%; RR, 0.95; 95% CI, 0.80-1.13). Tight glucose control was not associated with significantly decreased risk for new need for dialysis (11.2% vs 12.1%; RR, 0.96; 95% CI, 0.76-1.20), but was associated with significantly decreased risk of septicemia (10.9% vs 13.4%; RR, 0.76; 95% CI, 0.59-0.97), and significantly increased risk of hypoglycemia (glucose < or= 40 mg/dL; 13.7% vs 2.5%; RR, 5.13; 95% CI, 4.09-6.43). CONCLUSION: In critically ill adult patients, tight glucose control is not associated with significantly reduced hospital mortality but is associated with an increased risk of hypoglycemia. SN - 1538-3598 UR - https://www.unboundmedicine.com/medline/citation/18728267/Benefits_and_risks_of_tight_glucose_control_in_critically_ill_adults:_a_meta_analysis_ L2 - https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.300.8.933 DB - PRIME DP - Unbound Medicine ER -