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Glycemic Control in the ICU
Submit responseWe would like to clarify one aspect of Dr. Comi’s commentary on glucose control in the intensive care and amplify upon another. First, although the NICE-SUGAR control group was stated to have a target glucose level of less than 180mg/dL, it was actually much less than 180mg/dL as insulin infusions were continued until blood glucose reached 144mg/dL.(1) Indeed, the time-weighted mean blood glucose in the control group was 144mg/dL. Data on the mean glucose levels in patients who received insulin therapy were not provided. Thus, it would appear that the standard for glucose control would be closer to 8mmol/L (144mg/dL) rather than below 10mmol/L (180mg/dL) as suggested by Dr. Comi.
Second, regarding the relationship of hypoglycemia and adverse outcome, we believe it is time for increased scrutiny in this area. Our own MICU data (target glucose < 140mg/dL) show that for every episode of blood glucose < 40mg/dL there are 12 episodes of blood glucose between 40 and 70mg/dL. Evaluation of short-term hypoglycemia (mean nadir for 5 minutes of 52mg/dL) in healthy volunteers was associated with significant blunting of neuroendocrine, autonomic nervous system, and metabolic counterregulatory responses with subsequent episodes of hypoglycemia.(2) Also, hypoglycemic-hyperinsulinemic clamp studies in healthy volunteers showed significant increases in IL-6, ACTH, and cortisol at mean blood glucose levels of 50mg/dL.(3) Thus, deleterious effects of hypoglycemia likely begin at glucose levels higher than 40mg/dL.
1. NICE-SUGAR Study Investigators. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.
2. Davis SN, Mann S, Galassetti P, et al. Effects of differing durations of antecedent hypoglycemia on counterregulatory responses to subsequent hypoglycemia in normal humans. Diabetes 2000;49:189701903.
3. Dotson S, Failing HJ, Freeman R, Adler GK. Hypoglycemia increases serum interleukin-6 levels in healthy men and women. Diabetes Care 2008;31:1232-3.
Conflict of Interest:
None declared