the rise of medical evidence

Blood Sugar Control in the ICU

Before 2001 It was routine to ignore blood

glucose levels of 200 mg/dL (11.1 mmol/L)

Concern mounted when the blood sugar topped 250 mg/dl (14.2 mmol/L)

Action was likely when the blood sugar 300 mg/dl (16.8 mmol/L)

Proc Annu Symp Comput Appl Med Care. 1991:554-8.

6.9 7.8 mmol/L

Ann Thorac Surg 1999;67:352–62Deep sternal wound infection

11.1 mmol/L

Single Center – Surgical ICU

Outcome: Death in ICU Various secondary outcomes

Target = 80-110 mg/dl n=765

Target = 180-200 mg/dl n= 783

Continuous Glucose Monitoring and Control

Admit to SICU

Mean Glucose Levels

5.7mmol/L

8.5mmol/L

Intensive Conventional

Mean difference=50 mg/dl

Major Outcomes

p<.04 p<.01

About 750 patients/group

ORIGINALITY

IMPORTANCE

QUALITY

VALIDITY

Large multi-center trial started

NICE SUGAR

Primary outcome 90 Day mortality

Leuven #1-Published Nov 2001

2001 to 2009 Control of blood glucose in the ICU became a quality measure

ENDOCRINE PRACTICE Vol 10 No. 1 January/February 2004

Intensive Care Med. 2008 Jun;34(6):1160-2

Along the Way

Mixed results, possible harm

P=0.40

ORIGINALITY

IMPORTANCE

QUALITY

VALIDITY

Multicenter – All ICU types

Outcome: Death in 90 days Various secondary outcomes

Target = 80-108 mg/dl n=3054

Target = < 180 mg/dl n= 3050

Continuous Glucose Monitoring and Control

Admit to ICU

Mean difference=35 mg/dl

All-Cause Mortality

ORIGINALITY

IMPORTANCE

QUALITY

VALIDITY

N Engl J Med. 2010 Dec 23;363(26):2540-6.

JAMA Intern Med. 2015;175(5):801-809.