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Intensive blood glucose control improves outcome and mortality in a heterogeneous population of critical care patients.

Citation/s: Effect of an Intensive Glucose Management Protocol on the Mortality of Critically Ill Patients: Mayo Clin Proc. August 2004: 79(8): 992-1000
 

Lead author's name and fax: Dr James Krinsley, MD, Director of Critical Care, The Stamford Hospital, 190 W Broad St., CT 06902. mailto:Jkrinsley@stamhealth.org

Three-part Clinical Question: In a heterogeneous patient population does an intensive glucose management protocol improve the outcome of critically ill adult patients?
 

Search Terms: e-library, critical care, insulin and outcome/mortality

The Study: Cohort Study.

The Study Patients: All consecutive patients admitted to the ICU after institution of the protocol. Comparison with historical controls.

Exposure of Interest: Intensive glucose management protocol using both s/c and then iv insulin to maintain a blood glucose of less than 140mg/dL (7.77 mmol/L). The protocol was discontinued on discharge from the ICU.

The Outcome: (a) Mortality. (b) Renal dysfunction: Defined as initial serum creatinine level of 1.5 mg/dL or lower with maximum serum creatinine level of 2.5 mg/dL or higher or initial serum creatinine level lower than 1.5mg/dL with maximum serum creatinine level 2 or more times the initial value.

Subjects were not defined and similar in other important ways. The exposures and outcomes were neither objective nor measured blind. Follow-up was long enough; follow-up was complete enough.

The Evidence (Mortality):

The Evidence (Renal dysfunction):

EBM summary questions:

1) Do the methods allow accurate testing of the hypothesis? No, although the study was of a sufficiently large size, it was not a randomised controlled trial and as such does not represent the gold standard for the analysis of this question. The study fails to demonstrate whether the improved outcome is due to improved glycaemic control or due to another confounding (historical) factor.
2) Do the statistical tests correctly test the results to allow differentiation of statistically significant results? Yes, it utilizes the correct statistical techniques and is sufficiently powered, with the main outcome demonstrating a statistically significant p-value
3) Are conclusions valid in light of the results? Yes, although they do recognize the limits of their study due to the selection of their control group.
4) Did results get omitted, and why? No
5) Did they suggest areas of further research? Yes, they suggest a randomised controlled trial and also further research in to the underlying mechanisms behind the improvement in survival.
6) Did they make any recommendations based on the results and were they appropriate? Yes, they recommend the adoption of a similar strategy, which given evidence from other studies, the interventions low cost and the potential benefits is wholly appropriate.
7) Is the study relevant to my clinical practice? Yes, this study deals with critically ill patients within the intensive care with a wide variety of pathology
8) What level of evidence does this study represent? 2^-
9) What grade of recommendation can I make on this result alone? No recommendation can be made on this study alone

10) What grade of recommendation can I make when this study is considered along with other available evidence? A

11) Should I change my practice because of these results? Yes, given that this study when considered in association with other works ( van de Berghe), offers a relatively cheap and efficient way of improving outcome in ICU, not specific to any particular disease process.
12) Should I audit my current practice because of these results? Yes as improved glycaemic control has been shown to improve mortality and is easily monitored and audited.

Appraised by: Dr. Paul McConnell c/o Dept. of Anaesthesia Royal Alexandra Hospital, Corsebar Road, Paisley; 03 August 2005

Email: joe_jitsu_uk@yahoo.co.uk

Reviewed and Edited by CC & KR

Citation: EBM Critical Appraisals. Scottish Intensive Care Society EBM Group. McConnell P. 2005. Effect of an Intensive Glucose Management Protocol on the Mortality of Critically Ill Patients: Mayo Clin Proc. August 2004: 79(8): 992-1000.
 

Kill or update By: August 2006

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