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The optimal target for acute glycemic control in critically ill patients: a network meta-analysis

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Abstract

Purpose

The optimal target blood glucose concentration for acute glycemic control remains unclear because few studies have directly compared 144–180 with 110–144 or >180 mg/dL. Accordingly, we performed a network meta-analysis to compare four different target blood glucose levels (<110, 110–144, 144–180, and >180 mg/dL) in terms of the benefit and risk of insulin therapy.

Methods

We included all of the studies from three systematic reviews and searched the PubMed and Cochrane databases for other studies investigating glucose targets among critically ill patients. The primary outcome was hospital mortality, and the secondary outcomes were sepsis or bloodstream infection and the risk of hypoglycemia. Network meta-analysis to identify an optimal target glucose concentration.

Results

The network meta-analysis included 18,098 patients from 35 studies. There were no significant differences in the risk of mortality and infection among the four blood glucose ranges overall or in subgroup analysis. Conversely, target concentrations of <110 and 110–144 mg/dL were associated with a four to ninefold increase in the risk of hypoglycemia compared with 144–180 and >180 mg/dL. However, there were no significant differences between the target concentrations of 144–180 and >180 mg/dL.

Conclusions

This network meta-analysis found no significant difference in the risk of mortality and infection among four target blood glucose ranges in critically ill patients, but indicated that target blood glucose levels of <110 and 110–144 mg/dL were associated with a higher risk of hypoglycemia than target levels of 144–180 and >180 mg/dL. Further studies are required to refute or confirm our findings.

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Authors and Affiliations

  1. Department of Anesthesiology and Intensive Care Medicine, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan

    Tomoaki Yatabe

  2. Department of Emergency and Critical Care Medicine, Tokai University Hachioji Hospital, 1838 Ishikawa-cho, Hachioji, Tokyo, 192-0032, Japan

    Shigeaki Inoue

  3. Integrated Center for Advanced Medical Technologies, Kochi Medical School, Kohasu, Oko-cho, Nankoku, Kochi, 783-8505, Japan

    Masahiko Sakaguchi

  4. Department of Anesthesiology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Moritoki Egi

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  1. Tomoaki Yatabe
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  2. Shigeaki Inoue
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  3. Masahiko Sakaguchi
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  4. Moritoki Egi
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Correspondence to Moritoki Egi.

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Additional information

Take-home message: This network meta-analysis suggested (a) that there was no significant difference in the risk of mortality and infection among the four blood glucose ranges evaluated and (b) that targets of <110 and 110–144 mg/dL were associated with a four to ninefold increase in the risk of hypoglycemia compared with 144–180 and >180 mg/dL. There were no significant differences in the risk of hypoglycemia between the 144–180 and >180 mg/dL target blood glucose levels.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 Flow diagram of study selection. CPB cardiopulmonary bypass (TIFF 51 kb)

Supplementary material 2 (DOCX 17 kb)

134_2016_4558_MOESM3_ESM.tiff

Supplementary material 3 Risk of bias in the included randomized controlled trials. The Cochrane Collaboration tool was used to assess the risk of bias. The authors’ judgments were used to assign the risk of bias for each included study. +, low risk of bias; −, high risk of bias; empty space, unclear risk of bias. Eight studies with a high risk of “other bias” did not provide financial support and/or conflict of interest statements (TIFF 2456 kb)

134_2016_4558_MOESM4_ESM.tiff

Supplementary material 4 The network of all eligible comparisons for the meta-analysis. a In-hospital mortality, b incidences of sepsis or bloodstream infection and c incidences of hypoglycemia. Each node (circle) corresponds to a target blood glucose range. Each line represents a direct comparison between the target ranges, and the width of the line is proportional to the number of studies that compared each target pair. N number of studies (TIFF 3199 kb)

Supplementary material 5 (DOCX 15 kb)

134_2016_4558_MOESM6_ESM.tif

Supplementary material 6 Forest plot for network meta-analysis based on the actual achieved mean glycemic levels. The upper row indicates the pairwise meta-analysis result (blue) and the lower row indicates the network meta-analysis result (black) (TIFF 1541 kb)

134_2016_4558_MOESM7_ESM.tiff

Supplementary material 7 Results of the network analysis comparing the 110–144 and 144–180 mg/dL target blood glucose levels. The circles correspond to the odds ratio and the black horizontal lines correspond to the 95 % credible intervals (TIFF 984 kb)

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Yatabe, T., Inoue, S., Sakaguchi, M. et al. The optimal target for acute glycemic control in critically ill patients: a network meta-analysis. Intensive Care Med 43, 16–28 (2017). https://doi.org/10.1007/s00134-016-4558-2

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