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Cited by 53Hyperglycemia and glycemic control in critically ill and hospitalized patientsDiabetes Management and ResearchIntensive Care Unit Cognitive Disorders

Clinical review: Strict or loose glycemic control in critically ill patients - implementing best available evidence from randomized controlled trials

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Schultz, Marcus J, Harmsen, Robin E, Spronk, Peter E·2010·Critical Care
DOI 10.1186/cc8966PMC PMC2911685
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Abstract

Glycemic control aiming at normoglycemia, frequently referred to as 'strict glycemic control' (SGC), decreased mortality and morbidity of adult critically ill patients in two randomized controlled trials (RCTs). Five successive RCTs, however, failed to show benefit of SGC with one trial even reporting an unexpected higher mortality. Consequently, enthusiasm for the implementation of SGC has declined, hampering translation of SGC into daily ICU practice. In this manuscript we attempt to explain the variances in outcomes of the RCTs of SGC, and point out other limitations of the current literature on glycemic control in ICU patients. There are several alternative explanations for why the five negative RCTs showed no beneficial effects of SGC, apart from the possibility that SGC may indeed not benefit ICU patients. These include, but are not restricted to, variability in the performance of SGC, differences among trial designs, changes in standard of care, differences in timing (that is, initiation) of SGC, and the convergence between the intervention groups and control groups with respect to achieved blood glucose levels in the successive RCTs. Additional factors that may hamper translation of SGC into daily ICU practice include the feared risk of severe hypoglycemia, additional labor associated with SGC, and uncertainties about who the primarily responsible caregiver should be for the implementation of SGC.

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  • Marked glycemic variability (coefficient of variation > 20%) is associated with increased mortality.

    “A number of observational studies confirmed a strong association between severe hyperglycemia (> 180 mg/dl, 10 mmol/l) (355), marked glycemic variability (coefficient of variation > 20%) (356, 357), mild hypoglycemia (< 70 mg/dl, 3.9 mmol/l) (358) and increased mortality.”

    From ESPEN guideline on clinical nutrition in the intensive care unit. (2019) · cites this paper as [356]

    The “Uncertain factors” section reports significant associations between blood-glucose variability and patient outcomes, and its references include a study describing variability as a predictor of mortality. The review does not give a coefficient-of-variation threshold of >20%, so it does not support that specific cutoff. (LLM, conf=0.86)

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Research works printed but not linked: 30

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Cited by

Sorted by citations

Authors
Schultz, M. J., Harmsen, R. E., & Spronk, P. E.
Affiliations
  • Amsterdam UMC Location University of Amsterdam (NL)
  • Gelre Hospitals (NL)
Corresponding author
Schultz, Marcus J
ORCID
Venue
Critical Care
Publisher
Springer Science and Business Media LLC
Published
2010
Volume
14
Issue
3
Pages
223
ISSN
1364-8535 (ISSN-L)
DOI
10.1186/cc8966
PMC
PMC2911685
OpenAlex
W2144509525
Cited by
53
References
8
Citations by year
2025: 1 · 2024: 1 · 2023: 2 · 2021: 2 · 2019: 5 · 2018: 3 · 2017: 5 · 2016: 6 · 2015: 3 · 2014: 7 · 2013: 5 · 2012: 3
FWCI
0.82
Type
journal article
Language
en
Open access
Locations
  • Critical Care (publishedVersion)
  • Europe PMC (PubMed Central) (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
  • UvA-DARE (University of Amsterdam) (publishedVersion, other-oa)
  • Pure Amsterdam UMC (publishedVersion)
  • Data Archiving and Networked Services (DANS) (submittedVersion)
  • UvA-DARE (University of Amsterdam) (submittedVersion, other-oa)
  • Data Archiving and Networked Services (DANS) (submittedVersion, other-oa)
Topics
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Hyperglycemia and glycemic control in critically ill and hospitalized patients
  • Health Sciences › Medicine › Endocrinology, Diabetes and Metabolism › Diabetes Management and Research
  • Health Sciences › Medicine › Critical Care and Intensive Care Medicine › Intensive Care Unit Cognitive Disorders
Keywords
critically ill patients, intensive care unit, glycemic control, hypoglycemia, mortality, evidence-based practice implementation, randomized controlled trials, trial design limitations, normoglycemia
MeSH terms
Blood Glucose, Humans, Hyperglycemia, Hypoglycemia, Randomized Controlled Trials as Topic, Critical Illness, Treatment Outcome, Evidence-Based Medicine, Glycemic Index

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