Mortality and Glycemic Targets in the Intensive Care Unit: Another Paradigm Shift?

Abstract

Within the past year, providers caring for a patient with cardiovascular disease and diabetes have been made to realize that despite the associations of hyperglycemia and cardiovascular complications, the results from the prospective studies evaluating aggressive glycemic intervention did not follow the predicted script! Specifically, the randomized clinical trials that addressed the question of cardiovascular disease and glycemic control (i.e., Action to Control Cardiovascular Risk in Diabetes [ACCORD], Action in Diabetes and Vascular Disease: Preterax and Diamicron Modified Release Controlled Evaluation [ADVANCE], and Veterans Affairs Diabetes Trial [VADT]) provided results that suggest we take a closer look at the “one size fits all” glycemic target for A1C that has been suggested in the past (1–3). Is it really surprising that we have a similar situation with hyperglycemia and critically ill patients in the intensive care unit (ICU) setting? For years, it has been recognized that hyperglycemia has been associated with mortality in critically ill patients as observed across many cohorts, and as such, there has been intense interest in evaluating the clinical effect of normalizing glycemia in these critically ill subjects (4–7). However, the recently reported observations from the Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation (NICE-SUGAR) trial suggest that attempts to normalize glycemia are not the simple answer to the problem (7). The NICE-SUGAR study was a multicenter, international, and randomized trial that evaluated the effect of intensive versus conventional glucose control on outcomes in hyperglycemic, critically ill subjects. After subjects were identified in the ICU setting, they were randomized either to tight glycemic control, defined as a target blood glucose level of 80–108 mg/dl, or to conventional glycemic control, defined as a blood glucose level in the range of 144–180 mg/dl. Control for each group was achieved by intravenous infusion of …