ABSTRACT
Rattan
Juneja MD; Michael E. Stuart, MD; Sheri A. Strite
Background: Hyperglycemia in intensive care patients is
associated with high mortality, but optimal management of this population with
insulin therapy is Methods: We utilized the extensive search from a
recent published meta-analysis and conducted an updated search using MEDLINE (2008-2009),
the Cochrane Central Register of Controlled Trials, and the Cochrane Database
of Systematic Reviews. We assessed bias of trials using a detailed checklist to
document the overall quality of the evidence for mortality and hypoglycemia in intensive
care populations.
Findings: We included a total of 17 clinical trials totaling
12,345 patients. All included trials were rated as being at medium risk of
bias. We identified eight groups of patients in which intensive insulin
treatment has been compared to less intensive insulin therapy. Mortality rates
varied by patient population with rates of < 16% in predominantly surgical
patients with mixed conditions to nearly 75% in neurosurgical patients.
Overall, mortality rates ranged from 4% to 74% but the overall level of
evidence for mortality was inconclusive. Hypoglycemia rates ranged from 0% to
94% and the overall level of evidence for hypoglycemia was borderline.
Interpretation: The evidence is insufficient for
determining the effect of intensive
insulin treatment compared to less intensive treatment in acutely ill
hyperglycemic
patients. The evidence does not justify guideline recommendations for
specific glycemic target ranges for adults being treated in intensive care units.
Further research is needed, but should be carefully planned with attention to
trial bias, populations, type of insulin protocols used, adherence,
co-interventions, and frequency of blood glucose testing to avoid the heterogeneity
and bias present in currently available research.
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