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BMJ 2008; 337 doi: (Published 02 September 2008) Cite this as: BMJ 2008;337:a1510

In critically ill people, tight glucose control may do more harm than good

In 2001, a trial found that keeping blood glucose below 8.3 mmol/l or 6.1 mmol/l (moderately tight and very tight glucose control, respectively) by infusing insulin during part or all of the stay in intensive care reduced in-hospital mortality by one third in critically ill surgical patients. Since then, tight glucose control in all critically ill patients has been recommended and endorsed by a growing number of guidelines and professional societies. However, later studies have largely failed to replicate the original finding.

A systematic review and meta-analysis based on 29 randomised trials and nearly 8500 critically ill patients now shows that, compared with usual care, tight glucose control does not improve survival during hospital stay and does not reduce the need for new onset dialysis, although it reduces the risk of septicaemia (10.9% v 13.4%; relative risk 0.76, 95% CI 0.59 to 0.97), but only for patients in surgical intensive care units. Most notably, hypoglycaemia—which is associated with serious neurological events in critically ill patients, ranging from seizures to coma—is five times more common with tight glucose control than with usual care (13.7% v 2.5%; 5.13, 4.09 to 6.43).

The editorialists (p 963) say that these findings may surprise many clinicians, but it is still unclear whether tight glucose control in critically ill patients is right or wrong. Standards and definitions need to be universally agreed upon, and the hunt is still on for the optimal conditions in which tight glucose control might confer benefits to patients.

One in five ayurvedic drugs contains too much lead, mercury, or arsenic

A previous study showed that 20% of traditional Indian ayurvedic medicines manufactured in South Asia and sold in Boston, USA, contained lead, mercury, or arsenic (or a combination thereof). If taken in the doses indicated on the packaging, use of these drugs would lead to a higher than recommended daily intake …

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