Glycemic control, mortality, and hypoglycemia in critically ill patients: a systematic review and network meta-analysis of randomized controlled trials
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It is unclear whether tight glycemic control is warranted in all critically ill adults. We employed network meta-analysis to examine the risk of mortality and hypoglycemia associated with different glycemic control targets in critically ill adults.
Electronic databases were searched up to 2016 for randomized controlled trials comparing various insulin regimens in critically ill adults with hyperglycemia. Two reviewers independently extracted information and evaluated quality with the Cochrane risk-of-bias tool. Four glycemic control groups were compared: tight (blood glucose: 4.4 < 6.1 mmol/l), moderate (6.1 < 7.8 mmol/l), mild (7.8 < 10.0 mmol/l), and very mild (10.0 to < 12.2 mmol/l). Network meta-analysis was performed by a frequentist approach with multivariate random effects meta-analysis.
Thirty-six randomized trials (17,996 patients) were identified. Compared with very mild control, tight control did not reduce the risk of short-term mortality [relative risk (RR) 0.94 (95 % CI 0.83–1.07, p = 0.36)], and neither did mild control [RR 0.88 (0.73–1.06), p = 0.18] or moderate control [RR 1.1 (0.66–1.84), p = 0.72]. However, severe hypoglycemia (<2.2 mmol/l) was more frequent with tight control than very mild control [RR 5.49 (3.22–9.38), p < 0.001] or mild control [RR 4.47 (2.5–8.03), p < 0.001]. Stratified analyses (cause of death, ICU type, time period, or diabetes) did not find significant between-group differences. Ranking analysis revealed the following hierarchy for avoiding death (highest to lowest rank): mild control, tight control, and very mild control.
Network meta-analysis showed no mortality benefit of tight glycemic control in critically ill patients, but fivefold more hypoglycemia versus mild or very mild control.
KeywordsGlycemic control Hypoglycemia Mortality Meta-analysis
There was no acknowledgment in this research.
Compliance with ethical statement
T.Yamada was funded by Japan Diabetes Society, Banyu Foundation, KAKENHI (Grants-in-Aid for Scientific Research), Japan Foundation for Applied Enzymology, and Japan Association for Diabetes Education and Care. We declare that these funds have not influenced this research.
Duality of interest
The authors declare that there is no duality of interest associated with this manuscript.
Conflicts of interest
No potential conflicts of interest relevant to this article were reported.
- 14.Higgins J, Green S (2011) Cochrane handbook for systematic reviews of interventions. Version 5.1.0. Cochrane Collaboration. http://handbook.cochrane.org/. Accessed 1 Sep 2015
- 18.White IR (2009) Multivariate random-effects meta-analysis. Stata J 9:40–56Google Scholar
- 28.Bilotta F, Spinelli A, Giovannini F et al (2007) The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: a randomized prospective pilot trial. J Neurosurg Anesthesiol 19(3):156–160PubMedCrossRefGoogle Scholar
- 60.Moghissi ES, Korytkowski MT, DiNardo M, American Association of Clinical Endocrinologists et al (2009) American Diabetes Association. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract 15(4):353–369PubMedCrossRefGoogle Scholar