Cargando…

Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis

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 ap...

Descripción completa

Detalles Bibliográficos
Autores principales: Kramer, Andreas H, Roberts, Derek J, Zygun, David A
Formato: Online Artículo Texto
Lenguaje:English
Publicado: BioMed Central 2012
Materias:
Acceso en línea:https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682305/
https://www.ncbi.nlm.nih.gov/pubmed/23082798
http://dx.doi.org/10.1186/cc11812
_version_ 1782273383754366976
author Kramer, Andreas H
Roberts, Derek J
Zygun, David A
author_facet Kramer, Andreas H
Roberts, Derek J
Zygun, David A
author_sort Kramer, Andreas H
collection PubMed
description 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; I(2 )= 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.
format Online
Article
Text
id pubmed-3682305
institution National Center for Biotechnology Information
language English
publishDate 2012
publisher BioMed Central
record_format MEDLINE/PubMed
spelling pubmed-36823052013-06-25 Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis Kramer, Andreas H Roberts, Derek J Zygun, David A Crit Care Research 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; I(2 )= 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. BioMed Central 2012 2012-10-22 /pmc/articles/PMC3682305/ /pubmed/23082798 http://dx.doi.org/10.1186/cc11812 Text en Copyright ©2012 Kramer et al.; licensee BioMed Central Ltd. http://creativecommons.org/licenses/by/2.0 This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
spellingShingle Research
Kramer, Andreas H
Roberts, Derek J
Zygun, David A
Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
title Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
title_full Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
title_fullStr Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
title_full_unstemmed Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
title_short Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
title_sort optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis
topic Research
url https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3682305/
https://www.ncbi.nlm.nih.gov/pubmed/23082798
http://dx.doi.org/10.1186/cc11812
work_keys_str_mv AT kramerandreash optimalglycemiccontrolinneurocriticalcarepatientsasystematicreviewandmetaanalysis
AT robertsderekj optimalglycemiccontrolinneurocriticalcarepatientsasystematicreviewandmetaanalysis
AT zygundavida optimalglycemiccontrolinneurocriticalcarepatientsasystematicreviewandmetaanalysis