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Abstract

Introduction: In a 2001 landmark trial, the potential benefits of tight glycemic control (TGC) were reported, stimulating support to implement TGC strategies in the ICU. By 2006, evidence opposing TGC was subsequently reported culminating in the publication of NICE-SUGAR in 2009. Published guidelines have since recommended against TGC, however, there is no objective description of how the changing literature has affected practice patterns. The purpose of this study is to evaluate annual ICU glycemic control trends between 2005 and 2012 in a large cohort of ICU patients (pts). Methods: All adult non-trauma ICU admissions in the eICU Research Institute database were included, excluding pts admitted with DKA. Hyperglycemia (HG+) was defined by a time-weighted average daily glucose >180 mg/dL and hypoglycemia (HG-) by a glucose value <50 mg/dL. Incidence rate ratios (IRR) for days with HG+ and HG- per total pt days were calculated yearly using negative binomial regression and a robust variance estimator clustered by each ICU and are reported relative to 2012. Results: Overall, 6,249,767 pt-days were evaluated across all ICU types, including: cardiac (n=1,212,865), cardiothoracic (n=714,051), medical (n=512,309), surgical (n=488.895), neurologic (n=319,629) and mixed (n=3,002,018). Between 2005 and 2007, HG+ rates decreased and HG- rates increased. In 2005, the incidence rate (IR) of HG+ was 17.2% (IRR=1.0; 0.94-1.08) and 1.5% (IRR=0.71; 0.63-0.80) for HG-. In 2007, the IR of HG+ was 14.4% (IRR=0.87; 0.83-0.91) and 2.7% (IRR=1.18; 1.12-1.32) for HG-. Rates of HG+ and HG- were relatively stable between 2007 and the publication of NICE-SUGAR in 2009. The proportion of HG+ days has increased annually since 2009. In 2012, the IR of HG+ and HG- were 18.0% and 2.1% respectively. Trends were similar in all ICU types at both teaching and non-teaching facilities. Conclusions: These data objectively describe broad increased adoption of TGC strategies which began to plateau in 2007 and reversed trajectory after publication of NICE-SUGAR in 2009. ICU practice appears to have changed over time in relation to peer-reviewed research publications, preceding the publication of revised national guidelines regarding glycemic control in ICU pts. These data also confirm the inverse relationship of HG+ and HG- exists in real-world settings outside of randomized controlled trials.