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Optimal Glycemic Control in Neurocritical Care Patients: a Systematic Review and Meta-Analysis Andreas H Kramer1,2*, Derek J Roberts1,3,4 and David a Zygun1,2,3

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Optimal Glycemic Control in Neurocritical Care Patients: a Systematic Review and Meta-Analysis Andreas H Kramer1,2*, Derek J Roberts1,3,4 and David a Zygun1,2,3 Kramer et al. Critical Care 2012, 16:R203 http://ccforum.com/content/16/5/R203 RESEARCH Open Access Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis Andreas H Kramer1,2*, Derek J Roberts1,3,4 and David A Zygun1,2,3 See related commentary by Bilotta and Rosa, http://ccforum.com/content/16/5/163. Abstract Introduction: Hyper- and hypoglycemia are strongly associated with adverse outcomes in critical care. Neurologically injured patients are a unique subgroup, where optimal glycemic targets may differ, such that the findings of clinical trials involving heterogeneous critically ill patients may not apply. Methods: We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing intensive insulin therapy with conventional glycemic control among patients with traumatic brain injury, ischemic or hemorrhagic stroke, anoxic encephalopathy, central nervous system infections or spinal cord injury. Results: Sixteen RCTs, involving 1248 neurocritical care patients, were included. Glycemic targets with intensive insulin ranged from 70-140 mg/dl (3.9-7.8 mmol/L), while conventional protocols aimed to keep glucose levels below 144-300 mg/dl (8.0-16.7 mmol/L). Tight glycemic control had no impact on mortality (RR 0.99; 95% CI 0.83- 1.17; p = 0.88), but did result in fewer unfavorable neurological outcomes (RR 0.91; 95% CI 0.84-1.00; p = 0.04). However, improved outcomes were only observed when glucose levels in the conventional glycemic control group were permitted to be relatively high [threshold for insulin administration > 200 mg/dl (> 11.1 mmol/L)], but not with more intermediate glycemic targets [threshold for insulin administration 140-180 mg/dl (7.8-10.0 mmol/L)]. Hypoglycemia was far more common with intensive therapy (RR 3.10; 95% CI 1.54-6.23; p = 0.002), but there was a large degree of heterogeneity in the results of individual trials (Q = 47.9; p<0.0001; I2 = 75%). Mortality was non- significantly higher with intensive insulin in studies where the proportion of patients developing hypoglycemia was large (> 33%) (RR 1.17; 95% CI 0.79-1.75; p = 0.44). Conclusions: Intensive insulin therapy significantly increases the risk of hypoglycemia and does not influence mortality among neurocritical care patients. Very loose glucose control is associated with worse neurological recovery and should be avoided. These results suggest that intermediate glycemic goals may be most appropriate. Introduction ischemic stroke [27-35] and anoxic brain injury [36-38]. A key paradigm in the care of patients with acute brain The mechanisms whereby hyperglycemia could be harm- and spinal cord injury is prevention of physiological ful are complex. Contributing factors may include free abnormalities that may contribute to secondary neurolo- radical formation and oxidative injury, activation of N- gical damage. Hyperglycemia is common in critically ill methyl-D-aspartate receptors, raised intracellular cal- patients, and has been associated with worsened out- cium, triggering of inflammatory and apoptotic pathways, comes in the setting of traumatic brain injury (TBI) [1-9], and alterations in lactate metabolism with reduced tissue aneurysmal subarachnoid hemorrhage (SAH) [10-19], pH [39]. Despite these observations, it remains unclear spontaneous intracerebral hemorrhage (ICH) [20-26], from human studies whether hyperglycemia is simply a marker for a greater severity of neurological damage or truly contributes to secondary injury in a causative fash- * Correspondence: [email protected] 1Department of Critical Care Medicine, University of Calgary, ICU ion. Hypoglycemia may also be deleterious, since neuro- Administration - Ground Floor, McCaig Tower, 3134 Hospital Dr NW, Calgary, critical care patients are dependent on sufficient glucose AB T2N 2T9, Canada as an energy source for the central nervous system (CNS) Full list of author information is available at the end of the article © 2012 Kramer et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Kramer et al. Critical Care 2012, 16:R203 Page 2 of 13 http://ccforum.com/content/16/5/R203 [40,41]. Even moderate reductions in serum glucose can (defined below) and clinical trials. These concepts were result in pronounced neuroglycopenia [42-44]. created using a combination of Medical Subject Heading Numerous randomized controlled trials (RCTs) have (MeSH) terms and keywords, and were combined using assessed the efficacy and safety of intensive insulin ther- the Boolean operator OR (Additional file 1, Appendix). apy and tight glycemic control regimens in the care of A separate search was performed to identify clinical critically ill patients. Despite initial enthusiasm based on trials involving general critical care patients with hetero- the results of single-center RCTs [45,46], more recent geneous diagnostic categories that were cared for in multi-center RCTs have been unable to confirm any ben- multi-system ICUs. Four published meta-analyses were efit, and have even suggested harm [47-49]. Similarly, used to identify relevant manuscripts [50-53], and the meta-analyses have not demonstrated a reduction in search strategy from one of these was repeated from mortality with tight versus conventional glycemic control March 2008 to November 2011 [51]. The manuscripts of [50-53]. retrieved studies were reviewed to determine if separate Neurocritical care patients are a unique subgroup, in results were reported specifically for neurocritical care which the association between hyperglycemia and patients. We also searched the references of included adverse outcomes in observational studies has been parti- RCTs and previous systematic reviews relating to inten- cularly strong. Although RCTs of tight glycemic control sive insulin therapy. in critically ill patients have focused largely on mortality as the primary outcome, functional recovery is an espe- Study selection cially meaningful endpoint in the neurologically injured. Article selection was performed in two sequential steps. Even if an intervention does not impact on mortality, it First, one investigator (AHK) screened the title, abstract may still be efficacious at improving functional and cog- and keywords of all records retrieved using the search nitive outcomes among survivors. Thus, the findings of strategy. This stage was intended to be inclusive, and RCTs involving heterogeneous populations of critically ill identified all RCTs involving hospitalized patients that patients may not necessarily apply. compared at least two regimens of insulin administration Some meta-analyses have pooled results in specific sub- or glycemic control. Second, the resultant, shorter list groups of brain-injured patients [54-56]. However, results was reviewed independently and in duplicate by two from several RCTs were not included in these reviews. A investigators (AHK, and DJR). comprehensive overview of all clinical trials involving Studies were considered eligible based on the following neurocritical care patients has never been performed, and inclusion criteria: (1) study design (RCTs only); (2) target the optimal approach to glycemic control remains largely population (adults with at least one of the following con- unknown. Therefore, we performed a systematic review ditions: TBI, SAH, ICH, ischemic stroke, anoxic injury, and meta-analysis to assess whether tight glycemic con- spinal cord injury or CNS infection); (3) intervention trol reduces mortality and improves outcomes in neuro- (comparing an intensive glycemic control protocol with a critical care patients. We also conducted stratified conventional (less tight) strategy); and (4) outcome (doc- analyses and meta-regression in an attempt to determine umentation of at least one of the primary or secondary whether particular clinical or study-design characteristics outcomes (see below) in the target population). influence the relationship between tight glycemic control Studies were excluded if other aspects of care, besides and patient outcomes. glycemic control, differed between groups. Thus, RCTs assessing the efficacy of glucose-potassium-insulin (GKI) Materials and methods regimens were not eligible, but were included in a A written protocol, with a pre-specified analysis plan, planned sensitivity analysis. For RCTs involving mixed was developed prior to study initiation in accordance populations, but not presenting separate data for neuro- with the Preferred Reporting Items for Systematic critical care patients, we included the pooled results only Reviews and Meta-analysis (PRISMA) statement [57]. if >75% of patients had a neurocritical care diagnosis. Studies consisting largely of non-emergent, perioperative Search strategy neurosurgical patients were excluded, since these patients Using the OVID interface, we conducted unrestricted did not have an acute neurological injury. searches in MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL) and the Data abstraction and assessment for risk of bias Cochrane Database of Systematic Reviews from their Independently and in duplicate, two investigators (AHK, inception date until the first week of November 2011. To and DJR) abstracted data in an unblinded fashion, using identify RCTs involving
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