Intensive
Care Medicine Published: 29
September 2021
Purpose
Hyperglycaemia is an adaptive response to stress commonly
observed in critical illness. Its management remains debated in the intensive
care unit (ICU). Individualising hyperglycaemia management, by targeting the
patient’s pre-admission usual glycaemia, could improve outcome.
Methods
In a multicentre, randomized, double-blind, parallel-group
study, critically-ill adults were considered for inclusion. Patients underwent
until ICU discharge either individualised glucose control by targeting the
pre-admission usual glycaemia using the glycated haemoglobin A1c level at ICU
admission (IC group), or conventional glucose control by maintaining glycaemia
below 180 mg/dL (CC group). A non-commercial web application of a dynamic
sliding-scale insulin protocol gave to nurses all instructions for glucose
control in both groups. The primary outcome was death within 90 days.
Results
Owing to a low likelihood of benefit and evidence of the
possibility of harm related to hypoglycaemia, the study was stopped early. 2075
patients were randomized; 1917 received the intervention, 942 in the IC group
and 975 in the CC group. Although both groups showed significant differences in
terms of glycaemic control, survival probability at 90-day was not
significantly different (IC group: 67.2%, 95% CI [64.2%; 70.3%]; CC group:
69.6%, 95% CI [66.7%; 72.5%]). Severe hypoglycaemia (below 40 mg/dL)
occurred in 3.9% of patients in the IC group and in 2.5% of patients in the CC
group (p = 0.09). A post hoc analysis showed for non-diabetic patients a higher
risk of 90-day mortality in the IC group compared to the CC group (HR 1.3, 95%
CI [1.05; 1.59], p = 0.018).
Conclusion
Targeting an ICU patient’s pre-admission usual glycaemia
using a dynamic sliding-scale insulin protocol did not demonstrate a survival
benefit compared to maintaining glycaemia below 180 mg/dL.
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