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Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis.
Crit Care. 2018 01 19; 22(1):11.CC

Abstract

BACKGROUND

Optimal glycaemic targets in traumatic brain injury (TBI) remain unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing intensive with conventional glycaemic control in TBI requiring admission to an intensive care unit (ICU).

METHODS

We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to November 2016. Outcomes of interest included ICU and in-hospital mortality, poor neurological outcome, the incidence of hypoglycaemia and infective complications. Data were analysed by pairwise random effects models with secondary analysis of differing levels of conventional glycaemic control.

RESULTS

Ten RCTs, involving 1066 TBI patients were included. Three studies were conducted exclusively in a TBI population, whereas in seven trials, the TBI population was a sub-cohort of a mixed neurocritical or general ICU population. Glycaemic targets with intensive control ranged from 4.4 to 6.7 mmol/L, while conventional targets aimed to keep glucose levels below thresholds of 8.4-12 mmol/L. Conventional versus intensive control showed no association with ICU or hospital mortality (relative risk (RR) (95% CI) 0.93 (0.68-1.27), P = 0.64 and 1.07 (0.84-1.36), P = 0.62, respectively). The risk of a poor neurological outcome was higher with conventional control (RR (95% CI) = 1.10 (1.001-1.24), P = 0.047). However, severe hypoglycaemia occurred less frequently with conventional control (RR (95% CI) = 0.22 (0.09-0.52), P = 0.001).

CONCLUSIONS

This meta-analysis of intensive glycaemic control shows no association with reduced mortality in TBI. Intensive glucose control showed a borderline significant reduction in the risk of poor neurological outcome, but markedly increased the risk of hypoglycaemia. These contradictory findings should motivate further research.

Authors+Show Affiliations

Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK. J.Hermanides@amc.uva.nl. Department of Anesthesiology, Academic Medical Centre, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands. J.Hermanides@amc.uva.nl.Neurosciences Critical Care Unit, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.Intensive Care Unit, Royal Adelaide Hospital, Adelaide, 5000, Australia.Intensive Care Unit, Royal Melbourne Hospital, Melbourne, 3050, Australia.Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, CB2 0QQ, UK.

Pub Type(s)

Journal Article
Meta-Analysis
Research Support, Non-U.S. Gov't
Review
Systematic Review

Language

eng

PubMed ID

29351760

Citation

Hermanides, Jeroen, et al. "Glycaemic Control Targets After Traumatic Brain Injury: a Systematic Review and Meta-analysis." Critical Care (London, England), vol. 22, no. 1, 2018, p. 11.
Hermanides J, Plummer MP, Finnis M, et al. Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis. Crit Care. 2018;22(1):11.
Hermanides, J., Plummer, M. P., Finnis, M., Deane, A. M., Coles, J. P., & Menon, D. K. (2018). Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis. Critical Care (London, England), 22(1), 11. https://doi.org/10.1186/s13054-017-1883-y
Hermanides J, et al. Glycaemic Control Targets After Traumatic Brain Injury: a Systematic Review and Meta-analysis. Crit Care. 2018 01 19;22(1):11. PubMed PMID: 29351760.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Glycaemic control targets after traumatic brain injury: a systematic review and meta-analysis. AU - Hermanides,Jeroen, AU - Plummer,Mark P, AU - Finnis,Mark, AU - Deane,Adam M, AU - Coles,Jonathan P, AU - Menon,David K, Y1 - 2018/01/19/ PY - 2017/08/12/received PY - 2017/10/31/accepted PY - 2018/1/21/entrez PY - 2018/1/21/pubmed PY - 2018/10/3/medline KW - Glucose control KW - Glycaemia KW - Intensive insulin therapy KW - Systematic review KW - Traumatic brain injury SP - 11 EP - 11 JF - Critical care (London, England) JO - Crit Care VL - 22 IS - 1 N2 - BACKGROUND: Optimal glycaemic targets in traumatic brain injury (TBI) remain unclear. We performed a systematic review and meta-analysis of randomised controlled trials (RCTs) comparing intensive with conventional glycaemic control in TBI requiring admission to an intensive care unit (ICU). METHODS: We systematically searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to November 2016. Outcomes of interest included ICU and in-hospital mortality, poor neurological outcome, the incidence of hypoglycaemia and infective complications. Data were analysed by pairwise random effects models with secondary analysis of differing levels of conventional glycaemic control. RESULTS: Ten RCTs, involving 1066 TBI patients were included. Three studies were conducted exclusively in a TBI population, whereas in seven trials, the TBI population was a sub-cohort of a mixed neurocritical or general ICU population. Glycaemic targets with intensive control ranged from 4.4 to 6.7 mmol/L, while conventional targets aimed to keep glucose levels below thresholds of 8.4-12 mmol/L. Conventional versus intensive control showed no association with ICU or hospital mortality (relative risk (RR) (95% CI) 0.93 (0.68-1.27), P = 0.64 and 1.07 (0.84-1.36), P = 0.62, respectively). The risk of a poor neurological outcome was higher with conventional control (RR (95% CI) = 1.10 (1.001-1.24), P = 0.047). However, severe hypoglycaemia occurred less frequently with conventional control (RR (95% CI) = 0.22 (0.09-0.52), P = 0.001). CONCLUSIONS: This meta-analysis of intensive glycaemic control shows no association with reduced mortality in TBI. Intensive glucose control showed a borderline significant reduction in the risk of poor neurological outcome, but markedly increased the risk of hypoglycaemia. These contradictory findings should motivate further research. SN - 1466-609X UR - https://www.unboundmedicine.com/medline/citation/29351760/Glycaemic_control_targets_after_traumatic_brain_injury:_a_systematic_review_and_meta_analysis_ L2 - https://ccforum.biomedcentral.com/articles/10.1186/s13054-017-1883-y DB - PRIME DP - Unbound Medicine ER -