Doctors rethink aggressive blood sugar control in ICU

[okarol]

Doctors rethink aggressive blood sugar control in ICU
Last Updated: Tuesday, March 24, 2009 | 1:59 PM ET
CBC News

Trying to aggressively control blood sugar levels of critically ill patients may not be the best approach and could even be dangerous, new research suggests.

Generally, tight control of blood glucose sugars in people with diabetes is beneficial in reducing the risk of blindness, kidney disease and other complications.

The American Diabetes Association and other medical groups recommend that aggressive, labour-intensive approach for critically ill patients.

But now, new research casts doubt on the value of the practice, finding a six-fold increased risk of hypoglycemia or low blood sugar in those receiving the intensive treatment, compared with a control group.

"We suggest that policy-makers reconsider recommendations promoting the use of intensive insulin therapy in all critically ill patients," study author Dr. Donald Griesdale, an anesthesiologist and critical care physician at Vancouver General Hospital, and his co-authors wrote.

The team reviewed 26 trials on the therapy in Tuesday's online issue of the Canadian Medical Association Journal.

Although the study included data from 13,567 people with various levels of illness, the authors noted they can't rule out the possibility that some patients, such as those in the surgical intensive-care unit, may still benefit from intensive insulin therapy.
No benefit beyond lower limit

A related study appearing in Tuesday's online issue of the New England Journal of Medicine, called the NICE-SUGAR study, estimated that for every 38 patients in ICU aggressively treated for high blood sugar, one would die.

The NICE-SUGAR study looked at 6,104 people in Australia, New Zealand, Canada and the United States, 20 per cent of whom had a history of diabetes.

After 90 days of entering ICU, 27.5 per cent of those whose sugar levels were kept below 108 milligrams per decilitre of blood had died, compared with 24.9 per cent whose sugar levels were kept under 180.

There were also more fatal heart attacks among the group with tightly controlled blood sugar levels, the researchers found.

Dangerously low blood sugar levels were found in 6.8 per cent of those receiving the aggressive treatment, compared with 0.5 per cent among those receiving a less aggressive approach.

What hasn't been clear is whether high blood sugar levels were a symptom or a cause, Silvio Inzucchi and Mark Siegel of the Yale University School of Medicine in Connecticut said in a commentary on the findings in the New England Journal of Medicine.

"In retrospect, it may turn out that we have been overly enthusiastic in our attempts to attain" blood sugar control in ICU patients, Inzucchi and Siegel wrote, adding doctors should still aim to control levels.

However, "there is no additional benefit from the lower of blood glucose levels below the range of approximately 140 to 180," they added.

Likewise, last year's ACCORD trial of people with Type 2 diabetes and a high risk of heart disease also found "jarring" results. Lowering blood sugar to what was considered normal levels did not prevent heart attacks and strokes — and was actually more dangerous if a heart attack occurred.

http://www.cbc.ca/health/story/2009/03/24/blood-sugar-critically-ill.html?ref=rss

[Chris]

When I was in ICU and they were using IV insulin to control my blood sugar, on a few occasions I crashed and they had to use D-50 in a huge syringe to pump into IV line to get me back up an conscious.  I remember that hurting and burning, it is not as fluid as saline. I can kinda see the validity of the study, but more research is needed about the cause. Is it bad nurse monitoring, bad doctor orders, etc.