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Tight Glycemic Control Reduces Infection and Improves Neurological Outcome in Critically Ill Neurosurgical and Neurological Patients

Ooi, Yinn Cher MD*; Dagi, T. Forcht MD, MPH, FCCM§; Maltenfort, Mitchell PhD; Rincon, Fred MD, MSc; Vibbert, Matthew MD; Jabbour, Pascal MD; Gonzalez, L. Fernando MD; Rosenwasser, Robert MD; Jallo, Jack MD, PhD

doi: 10.1227/NEU.0b013e3182631eb4
Research-Human-Clinical Studies: Editor's Choice
Editor's Choice

BACKGROUND: Tight glycemic control (TGC) may improve outcomes in hyperglycemic neurosurgical patients. The adoption of TGC has been limited by a lack of adequate data on optimal insulin delivery protocols and serum glucose concentration and by concerns about the risks of hypoglycemia.

OBJECTIVE: This study was designed as a meta-analysis of outcomes to compare intensive insulin therapy and TGC with conventional insulin therapy and conventional glucose control. The secondary objective was to determine retrospectively whether a particular glucose range correlates with better outcomes.

METHODS: Using electronic databases, we retrieved all English language studies published between January 1997 and December 2010 reporting outcomes in neurological and neurosurgical patients as a function of glucose levels and insulin protocols. We conducted a meta-analysis around 4 outcome measures: infection, neurological outcome, hypoglycemia, and mortality. Effect sizes in each study were individually correlated with target intensive insulin therapy glucose levels. Individual studies were assessed for quality by use of the Jadad scale.

RESULTS: Nine studies reporting on 1459 patients met the inclusion criteria. Five were restricted to neurosurgical patients. Four included neurological patients. Compared with conventional glucose control, TGC lowered infection rates (odds ratio, 0.59; 95% confidence interval, 0.47-0.76; P < .001) and yielded better neurological outcomes (odds ratio, 1.72; 95% confidence interval, 1.36-2.16; P < .001). Beneficial effects increased as glucose limits tightened and study quality improved (R2 > 0.9 for both). TGC resulted in a higher rate of hypoglycemic events (odds ratio, 8.04; 95% confidence interval, 4.85-13.31; P < .001). Mortality was not affected.

CONCLUSION: TGC reduced infection risk and improved neurological outcome despite increased rates of hypoglycemic events. An optimal target for serum glucose concentrations could not be determined.

ABBREVIATIONS: CGC, conventional glucose control

CIT, conventional insulin therapy

GOS, Glasgow Outcome Scale

IIT, intensive insulin therapy

TGC, tight glycemic control

*Department of Neurological Surgery, University of California, Los Angeles, California

Thomas Jefferson University Hospital, Department of Neurological Surgery, Philadelphia, Pennsylvania

§Harvard-MIT Program in Health Sciences and Technology, Division of Health Sciences and Technology, Boston, Massachusetts

Correspondence: Jack Jallo, MD, PHD, 909 Walnut St, Philadelphia, Pennsylvania 19107. E-mail: jack.jallo@jefferson.edu

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.neurosurgery-online.com).

Received July 27, 2011

Accepted May 16, 2012

Copyright © by the Congress of Neurological Surgeons