Effectivement, ne revenons pas complètement en arrière! Le maintien de glycémie "raisonnable" est sans doute souhaitable.
Pour mémoire, dans le dernier numéro de Lancet: Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Vlasselaers D, Milants I, Desmet L, Wouters PJ, Vanhorebeek I, van den Heuvel I, Mesotten D, Casaer MP, Meyfroidt G, Ingels C, Muller J, Van Cromphaut S, Schetz M, Van den Berghe G. Department of Intensive Care Medicine (Paediatric Intensive Care Unit), Catholic University Leuven, Leuven, Belgium. BACKGROUND: Critically ill infants and children often develop hyperglycaemia, which is associated with adverse outcome; however, whether lowering blood glucose concentrations to age-adjusted normal fasting values improves outcome is unknown. We investigated the effect of targeting age-adjusted normoglycaemia with insulin infusion in critically ill infants and children on outcome. METHODS: In a prospective, randomised controlled study, we enrolled 700 critically ill patients, 317 infants (aged <1 year) and 383 children (aged >or=1 year), who were admitted to the paediatric intensive care unit (PICU) of the University Hospital of Leuven, Belgium. Patients were randomly assigned by blinded envelopes to target blood glucose concentrations of 2.8-4.4 mmol/L in infants and 3.9-5.6 mmol/L in children with insulin infusion throughout PICU stay (intensive group [n=349]), or to insulin infusion only to prevent blood glucose from exceeding 11.9 mmol/L (conventional group [n=351]). Patients and laboratory staff were blinded to treatment allocation. Primary endpoints were duration of PICU stay and inflammation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00214916. FINDINGS: Mean blood glucose concentrations were lower in the intensive group than in the conventional group (infants: 4.8 [SD 1.2] mmol/L vs 6.4 [1.2] mmol/L, p<0.0001; children: 5.3 [1.1] mmol/L vs 8.2 [3.3] mmol/L, p<0.0001). Hypoglycaemia (defined as blood glucose <or=2.2 mmol/L) occurred in 87 (25%) patients in the intensive group (p<0.0001) versus five (1%) patients in the conventional group; hypoglycaemia defined as blood glucose less than 1.7 mmol/L arose in 17 (5%) patients versus three (1%) (p=0.001). Duration of PICU stay was shortest in the intensively treated group (5.51 days [95% CI 4.65-6.37] vs 6.15 days [5.25-7.05], p=0.017). The inflammatory response was attenuated at day 5, as indicated by lower C-reactive protein in the intensive group compared with baseline (-9.75 mg/L [95% CI -19.93 to 0.43] vs 8.97 mg/L [-0.9 to 18.84], p=0.007). The number of patients with extended (>median) stay in PICU was 132 (38%) in the intensive group versus 165 (47%) in the conventional group (p=0.013). Nine (3%) patients died in the intensively treated group versus 20 (6%) in the conventional group (p=0.038). INTERPRETATION: Targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome of patients in PICU. The effect on long-term survival, morbidity, and neurocognitive development needs to be investigated. FUNDING: Research Foundation (Belgium); Research Fund of the University of Leuven (Belgium) and the EU Information Society Technologies Integrated project "CLINICIP"; and Institute for Science and Technology (Belgium). Dr Erwan L'Her, MD, PhD Intensiviste et Urgentologue Professeur au Dép. Médecine Familiale et Médecine d'Urgence et titulaire de la Chaire de recherche en médecine d'urgence Université Laval/CHAU Hôtel-Dieu de Lévis patrick archambault <[email protected]> 2009-03-25 15:24 Veuillez répondre à [email protected] A [email protected] cc Objet URG-L: RE URG-L: FW: InfoPOEM: Intensive glucose control ineffective inICUpatients Merci Erwan! La fin de Van den Berghe?!? Il faudra lire l'article avec attention, mais il semble qu'il faudra en effet maintenant viser (comme avant l'étude de Van den Berghe) < 10 comme contrôle glycémique aux soins intensifs! Mais j,aime bien le commentaire de l'éditorial: "Notwithstanding, it would be a disservice to our critically ill patients to infer from the NICE-SUGAR data that neglectful glycemic control involving haphazard therapeutic approaches (e.g., use of insulin "sliding scales") — all too common a decade ago — is again acceptable practice in our ICUs." Patrick 2009/3/25 <[email protected]> Publié hier !!! Intensive versus Conventional Glucose Control in Critically Ill Patients The NICE-SUGAR Study Investigators ABSTRACT Background The optimal target range for blood glucose in critically ill patients remains unclear. Methods Within 24 hours after admission to an intensive care unit (ICU), adults who were expected to require treatment in the ICU on 3 or more consecutive days were randomly assigned to undergo either intensive glucose control, with a target blood glucose range of 81 to 108 mg per deciliter (4.5 to 6.0 mmol per liter), or conventional glucose control, with a target of 180 mg or less per deciliter (10.0 mmol or less per liter). We defined the primary end point as death from any cause within 90 days after randomization. Results Of the 6104 patients who underwent randomization, 3054 were assigned to undergo intensive control and 3050 to undergo conventional control; data with regard to the primary outcome at day 90 were available for 3010 and 3012 patients, respectively. The two groups had similar characteristics at baseline. A total of 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14; 95% confidence interval, 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between operative (surgical) patients and nonoperative (medical) patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycemia (blood glucose level, 40 mg per deciliter [2.2 mmol per liter]) was reported in 206 of 3016 patients (6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39). Conclusions In this large, international, randomized trial, we found that intensive glucose control increased mortality among adults in the ICU: a blood glucose target of 180 mg or less per deciliter resulted in lower mortality than did a target of 81 to 108 mg per deciliter. (ClinicalTrials.gov number, NCT00220987 [ClinicalTrials.gov] .) Dr Erwan L'Her, MD, PhD Intensiviste et Urgentologue Professeur au Dép. Médecine Familiale et Médecine d'Urgence et titulaire de la Chaire de recherche en médecine d'urgence Université Laval/CHAU Hôtel-Dieu de Lévis patrick archambault <[email protected]> 2009-03-25 13:15 Veuillez répondre à [email protected] A [email protected] cc Objet URG-L: FW: InfoPOEM: Intensive glucose control ineffective inICU patients Les résultats de l'étude NICE-Sugar seront très intéressants à avoir lorsque publiés: http://www.ncbi.nlm.nih.gov/pubmed/19281445?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum Patrick Archambault 2009/3/25 M. Chenier <[email protected]> C'est pas la seule dans le domaine du contrôle intensif de la glycémie: http://www.ncbi.nlm.nih.gov/pubmed/18539917?dopt=Abstract http://www.ncbi.nlm.nih.gov/pubmed/18728267?dopt=Abstract M. Chénier [email protected] Alain Vadeboncoeur wrote: Fascinant quand même de nombre d'études qui se publient sur L'ABSENCE de gains dans divers contextes d'un contrôle serré de la glycémie! Alain From: [email protected] [mailto:[email protected]] On Behalf Of Équipe éditoriale de amc.ca Sent: 25 mars 2009 04:00 To: [email protected] Subject: InfoPOEM: Intensive glucose control ineffective in ICU patients Pour assurer la livraison de ce courriel dans votre boîte de réception, veuillez ajouter [email protected] à votre carnet de contacts. Intensive glucose control ineffective in ICU patients Clinical question Does tight control of blood glucose improve survival of patients in a medical surgical intensive care unit? Bottom line Tight control of blood glucose levels -- 80 mg/dL to 110 mg/dL (4.4-6.1 mmol/L) -- did not decrease mortality or other measured outcomes in patients admitted to an intensive care unit (ICU) with hyperglycemia. Hypoglycemia was much more common and was associated with an increased mortality. A meta-analysis has found similar results. (LOE = 1b) Reference Arabi YM, Dabbagh OC, Tamim HM, et al. Intensive versus conventional insulin therapy: A randomized controlled trial in medical and surgical critically ill patients. Crit Care Med 2008;36(12):3190-3197. Study design Randomized controlled trial (nonblinded) Funding Foundation Allocation Concealed Setting Inpatient (ICU only) Obtenez des crédits Mainpro Discutez de cet InfoPOEM Archives Bilan des crédits Plus de FMC / DPC Publicité Bibliothécaire de l'AMC Envoyez-nous vos commentaires Synopsis The Saudi Arabian investigators conducting this study enrolled 523 adults in a medical surgical ICU. The unit was closed and covered at all times by an intensivist. The patients (75% men) did not have type 1 diabetes, though 40% had a history of type 2 diabetes. The average blood glucose level was 194 mg/dL (10.8 mmol/L) in the intensive insulin group and 210 mg/dL (11.7 mmol/L) in the conventional insulin group. Most of the patients were nonoperative and were critically ill; 85% were mechanically ventilated and 65% were receiving vasopressors, with a mortality rate was approximately 15%. All patients received an infusion of regular insulin and were randomly assigned, using concealed allocation, to have their blood glucose maintained at 80 mg/dL to 110 mg/dL (4.4 - 6.1 mmol/L) in the intensive insulin group and 180 mg/dL to 200 mg/dL (10.0-11.1 mmol/L) in the conventional treatment group. Analysis was by intention to treat. The main outcome, in-ICU mortality, was not different between the 2 groups. At least one episode of hypoglycemia occurred in 28.6% of patients in the tight control group and 3.1% of patients in the conventional treatment group. In-ICU mortality was higher among those who had hypoglycemia (23.8% vs 13.7%; P = .02). There was no difference in in-hospital mortality, ICU or hospital length of stay, ventilation duration, infections, or the need for transfusion. These results are similar to those found in a previous meta-analysis (JAMA 2008;300(8):933-944). 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