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Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis.
Crit Care. 2012 Oct 22; 16(5):R203.CC

Abstract

INTRODUCTION

Hyper- and hypoglycemia are strongly associated with adverse outcomes in critical care. Neurologically injured patients are a unique subgroup, where optimal glycemic targets may differ, such that the findings of clinical trials involving heterogeneous critically ill patients may not apply.

METHODS

We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing intensive insulin therapy with conventional glycemic control among patients with traumatic brain injury, ischemic or hemorrhagic stroke, anoxic encephalopathy, central nervous system infections or spinal cord injury.

RESULTS

Sixteen RCTs, involving 1248 neurocritical care patients, were included. Glycemic targets with intensive insulin ranged from 70-140 mg/dl (3.9-7.8 mmol/L), while conventional protocols aimed to keep glucose levels below 144-300 mg/dl (8.0-16.7 mmol/L). Tight glycemic control had no impact on mortality (RR 0.99; 95% CI 0.83-1.17; p = 0.88), but did result in fewer unfavorable neurological outcomes (RR 0.91; 95% CI 0.84-1.00; p = 0.04). However, improved outcomes were only observed when glucose levels in the conventional glycemic control group were permitted to be relatively high [threshold for insulin administration > 200 mg/dl (> 11.1 mmol/L)], but not with more intermediate glycemic targets [threshold for insulin administration 140-180 mg/dl (7.8-10.0 mmol/L)]. Hypoglycemia was far more common with intensive therapy (RR 3.10; 95% CI 1.54-6.23; p = 0.002), but there was a large degree of heterogeneity in the results of individual trials (Q = 47.9; p<0.0001; I2 = 75%). Mortality was non-significantly higher with intensive insulin in studies where the proportion of patients developing hypoglycemia was large (> 33%) (RR 1.17; 95% CI 0.79-1.75; p = 0.44).

CONCLUSIONS

Intensive insulin therapy significantly increases the risk of hypoglycemia and does not influence mortality among neurocritical care patients. Very loose glucose control is associated with worse neurological recovery and should be avoided. These results suggest that intermediate glycemic goals may be most appropriate.

Authors

No affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Meta-Analysis
Review
Systematic Review

Language

eng

PubMed ID

23082798

Citation

Kramer, Andreas H., et al. "Optimal Glycemic Control in Neurocritical Care Patients: a Systematic Review and Meta-analysis." Critical Care (London, England), vol. 16, no. 5, 2012, pp. R203.
Kramer AH, Roberts DJ, Zygun DA. Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. Crit Care. 2012;16(5):R203.
Kramer, A. H., Roberts, D. J., & Zygun, D. A. (2012). Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. Critical Care (London, England), 16(5), R203. https://doi.org/10.1186/cc11812
Kramer AH, Roberts DJ, Zygun DA. Optimal Glycemic Control in Neurocritical Care Patients: a Systematic Review and Meta-analysis. Crit Care. 2012 Oct 22;16(5):R203. PubMed PMID: 23082798.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. AU - Kramer,Andreas H, AU - Roberts,Derek J, AU - Zygun,David A, Y1 - 2012/10/22/ PY - 2012/06/25/received PY - 2012/08/29/accepted PY - 2012/10/23/entrez PY - 2012/10/23/pubmed PY - 2015/9/16/medline SP - R203 EP - R203 JF - Critical care (London, England) JO - Crit Care VL - 16 IS - 5 N2 - INTRODUCTION: Hyper- and hypoglycemia are strongly associated with adverse outcomes in critical care. Neurologically injured patients are a unique subgroup, where optimal glycemic targets may differ, such that the findings of clinical trials involving heterogeneous critically ill patients may not apply. METHODS: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing intensive insulin therapy with conventional glycemic control among patients with traumatic brain injury, ischemic or hemorrhagic stroke, anoxic encephalopathy, central nervous system infections or spinal cord injury. RESULTS: Sixteen RCTs, involving 1248 neurocritical care patients, were included. Glycemic targets with intensive insulin ranged from 70-140 mg/dl (3.9-7.8 mmol/L), while conventional protocols aimed to keep glucose levels below 144-300 mg/dl (8.0-16.7 mmol/L). Tight glycemic control had no impact on mortality (RR 0.99; 95% CI 0.83-1.17; p = 0.88), but did result in fewer unfavorable neurological outcomes (RR 0.91; 95% CI 0.84-1.00; p = 0.04). However, improved outcomes were only observed when glucose levels in the conventional glycemic control group were permitted to be relatively high [threshold for insulin administration > 200 mg/dl (> 11.1 mmol/L)], but not with more intermediate glycemic targets [threshold for insulin administration 140-180 mg/dl (7.8-10.0 mmol/L)]. Hypoglycemia was far more common with intensive therapy (RR 3.10; 95% CI 1.54-6.23; p = 0.002), but there was a large degree of heterogeneity in the results of individual trials (Q = 47.9; p<0.0001; I2 = 75%). Mortality was non-significantly higher with intensive insulin in studies where the proportion of patients developing hypoglycemia was large (> 33%) (RR 1.17; 95% CI 0.79-1.75; p = 0.44). CONCLUSIONS: Intensive insulin therapy significantly increases the risk of hypoglycemia and does not influence mortality among neurocritical care patients. Very loose glucose control is associated with worse neurological recovery and should be avoided. These results suggest that intermediate glycemic goals may be most appropriate. SN - 1466-609X UR - https://www.unboundmedicine.com/medline/citation/23082798/Optimal_glycemic_control_in_neurocritical_care_patients:_a_systematic_review_and_meta_analysis_ L2 - https://ccforum.biomedcentral.com/articles/10.1186/cc11812 DB - PRIME DP - Unbound Medicine ER -