bonjour, j'espère que tu vas bien et que ton séjour au canada est conforme à tes attentes....
amitiés loic picault > Message du 25/03/09 21:16 > De : [email protected] > A : [email protected] > Copie à : > Objet : URG-L: RE URG-L: RE URG-L: FW: InfoPOEM: Intensive glucose control > ineffectiveinICUpatients > > > 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 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 > 2009-03-25 15:24 Veuillez répondre à > [email protected] > [email protected] cc ObjetURG-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 > > 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 > 2009-03-25 13:15 > Veuillez répondre à > [email protected] > > [email protected] cc ObjetURG-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 > 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). > Discutez de cet InfoPOEM > Archives > InfoPOEMs (contenu anglais) | CLIPs (contenu anglais) | Critique et pratique > Ressources cliniques > Accueil | Manuels * | Revues * | Information médicaments * | Tests de > laboratoire * | InfoPOEMs | Guide de pratique clinique | > > Documents d'information pour les patients * | Bibliothécaire de l'AMC * > Raccourcis > MD Consult * | STAT!Ref * | [email protected] * | OVID Medline * | Revues EBSCO * > | JAMC | Essential Evidence Plus | MedCalc 3000 * > FMC / DPC > Voir les cours en ligne | Bilan des crédits > Gestion de la pratique > Accueil | Créez un site Web de pratique | Clinique informatisée | Bureau | > Dotation en personnel | Finances | Juridique et vie privée > * Service aux membres AMC > > POEMs veut dire "Patient-Oriented Evidence that Matters". > Désirez-vous changer le format de vos courriels d'InfoPOEMs quotidiens ou > votre adresse courriel de la liste d'InfoPOEMs quotidiens? > Gérez vos options d'InfoPOEMs quotidiens à partir du site Web amc.ca. > Cliquez ici pour vous désabonner. > Copyright © 1995-2009 InfoPOEM, Inc. www.infopoems.com. 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