3kidlets wrote:John McDougall wrote:Be careful of what you ask for (patient goals).
Tight control of blood sugars even in critically ill children are of more harm than good.
Feb 23, 2017 NEJM:
Tight Glycemic Control in Critically Ill Children
Michael S.D. Agus, M.D., David Wypij, Ph.D., Eliotte L. Hirshberg, M.D., Vijay Srinivasan, M.D., E. Vincent Faustino, M.D., Peter M. Luckett, M.D., Jamin L. Alexander, B.A., Lisa A. Asaro, M.S., Martha A.Q. Curley, R.N., Ph.D., Garry M. Steil, Ph.D., and Vinay M. Nadkarni, M.D., for the HALF-PINT Study Investigators and the PALISI Network*
N Engl J Med 2017; 376:729-741February 23, 2017DOI: 10.1056/NEJMoa1612348
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BACKGROUND
In multicenter studies, tight glycemic control targeting a normal blood glucose level has not been shown to improve outcomes in critically ill adults or children after cardiac surgery. Studies involving critically ill children who have not undergone cardiac surgery are lacking.
METHODS
In a 35-center trial, we randomly assigned critically ill children with confirmed hyperglycemia (excluding patients who had undergone cardiac surgery) to one of two ranges of glycemic control: 80 to 110 mg per deciliter (4.4 to 6.1 mmol per liter; lower-target group) or 150 to 180 mg per deciliter (8.3 to 10.0 mmol per liter; higher-target group). Clinicians were guided by continuous glucose monitoring and explicit methods for insulin adjustment. The primary outcome was the number of intensive care unit (ICU)–free days to day 28.
RESULTS
The trial was stopped early, on the recommendation of the data and safety monitoring board, owing to a low likelihood of benefit and evidence of the possibility of harm. Of 713 patients, 360 were randomly assigned to the lower-target group and 353 to the higher-target group. In the intention-to-treat analysis, the median number of ICU-free days did not differ significantly between the lower-target group and the higher-target group (19.4 days [interquartile range {IQR}, 0 to 24.2] and 19.4 days [IQR, 6.7 to 23.9], respectively; P=0.58). In per-protocol analyses, the median time-weighted average glucose level was significantly lower in the lower-target group (109 mg per deciliter [IQR, 102 to 118]; 6.1 mmol per liter [IQR, 5.7 to 6.6]) than in the higher-target group (123 mg per deciliter [IQR, 108 to 142]; 6.8 mmol per liter [IQR, 6.0 to 7.9]; P<0.001). Patients in the lower-target group also had higher rates of health care–associated infections than those in the higher-target group (12 of 349 patients [3.4%] vs. 4 of 349 [1.1%], P=0.04), as well as higher rates of severe hypoglycemia, defined as a blood glucose level below 40 mg per deciliter (2.2 mmol per liter) (18 patients [5.2%] vs. 7 [2.0%], P=0.03). No significant differences were observed in mortality, severity of organ dysfunction, or the number of ventilator-free days.
CONCLUSIONS
Critically ill children with hyperglycemia did not benefit from tight glycemic control targeted to a blood glucose level of 80 to 110 mg per deciliter, as compared with a level of 150 to 180 mg per deciliter. (Funded by the National Heart, Lung, and Blood Institute and others; HALF-PINT ClinicalTrials.gov number, NCT01565941.)
I can tell you that my daughter can feel when she is 180. She is sluggish and can't focus. Her tennis performance suffers at higher blood sugar. You would never recommend a adult maintain a blood sugar of over 150. Doesn't make sense that a 16 year old should. The beauty of the CGM is it makes this attainable with minimal (as minimal can be with type 1) effort.
The issue is that the panel that oversaw this study found there was no proven health benefit in trying to drive the target blood glucose range to the 80 to 110 range, and in fact, patients in that lower range had a higher rate of health care related infections than the group in the 150 to 180 and a higher rate of hypoglycemia.
