Tight versus liberal blood glucose control results in similar ICU outcomes

1. In this randomized controlled trial, tight versus liberal blood glucose control resulted in similar intensive care unit (ICU) outcomes.

2. There were no differences in 90-day mortality following ICU discharge between tight blood glucose control and liberal blood glucose control strategies.

Evidence Rating Level: 1 (Excellent)

Study Rundown: Low blood sugar levels are common among patients admitted to the ICU, and have been found to be associated with poor outcomes. Currently, trials investigating the effect of blood sugar levels amongst these patients have shown conflicting results. This was a multicenter randomized controlled trial comparing the effect of tight blood glucose control against a liberal blood glucose control strategy amongst patients admitted to the ICU who were not receiving early parenteral nutrition on the length of time that ICU care was needed, as well as mortality after discharge. The primary results of the analysis found that there were no significant differences in length-of-stay between the two groups, nor were there significant differences in 90-day mortality after discharge from the ICU. Further, there were no significant differences in the rate of severe hypoglycemia between the groups. However, the tight blood glucose group demonstrated a significantly lower risk of severe kidney injury compared to the liberal blood glucose group, although the clinical relevance of this finding is currently unclear. A key limitation of this study is the risk of bias introduced by changes in ICU policies during the COVID-19 pandemic. However, this study adds to the growing body of evidence that tight blood glucose control may not impact mortality or length of time in the ICU amongst critically ill patients who were not receiving early parenteral nutrition.

Click to read the study in NEJM

In-Depth [randomized controlled trial]: This was a multicenter, randomized, controlled trial evaluating the effect of tight glucose control against liberal glucose control on the duration of time requiring ICU care amongst patients admitted to the ICU for care. The primary outcome of interest was time-to-discharge from the ICU (when patient was alive), as well as a 90-day mortality rate. All adult patients not receiving early parenteral nutrition and who were admitted to the ICU were included. Participants meeting any exclusion criteria were excluded, examples of which included: those with a do-not-resuscitate order, moribund patients, those able to receive oral feeding, without indication for an arterial and central venous line, and those who were registered in a separate trial which precludes co-inclusion in this trial. After the application of the inclusion and exclusion criteria, 9230 were randomized in a 1:1 ratio to receive liberal glucose control (n=4622), or tight glucose control (n=4608). Results of the primary analysis found that there were no differences in the primary outcome between the two groups (hazard ratio 1.00; 95% Confidence Interval [CI], 0.96-1.04; p=0.94). Similarly, there were no significant differences in mortality at 90 days after discharge between the two groups (p=0.51). However, the tight glucose control group had a lower risk of developing a severe AKI (relative risk 0.84; 95% CI 0.73-0.97). There were no significant differences in rates of severe hypoglycemia between the two groups (relative risk with tight control, 1.51, 95% CI, 0.97-2.39). This study provided evidence that the range of permissible blood glucose as determined by a tight or liberal glucose control strategy did not significantly alter length-of-stay in the ICU, nor mortality at 90 days following discharge.

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