Is boosting the immune system in sepsis appropriate?

A relative immunosuppression is observed in patients after sepsis, trauma, burns, or any severe insults. It is currently proposed that selected patients will benefit from treatment aimed at boosting their immune systems. However, the host immune response needs to be considered in context with pathogen-type, timing, and mainly tissue specificity. Indeed, the immune status of leukocytes is not universally decreased and their activated status in tissues contributes to organ failure. Accordingly, any new immune-stimulatory therapeutic intervention should take into consideration potentially deleterious effects in some situations

Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients

International audienceIntroduction Using a randomized controlled trial comparing tight glucose control with a computerized decision-support systems and conventional protocols (post hoc analysis), we tested the hypothesis that hypoglycemia is associated with a poor outcome, even when controlling for initial severity. Methods We looked for moderate (2.2-3.3mmol/l) and severe (<2.2mmol/l) hypoglycemia, multiple hypoglycemic events (n[greater than or equal to]3), and the other main components of glycemic control (mean blood glucose level and blood glucose coefficient of variation (CV)). The primary end-point was 90-day mortality. We used both a multivariable analysis taking into account only variables observed at admission and a multivariable matching process (greedy matching algorithm, caliper width of 105 digit with no replacement). Results A total of 2,601 patients were analyzed and divided into three groups: no hypoglycemia (n=1,474), moderate hypoglycemia (n=874, 34%), and severe hypoglycemia (n=253, 10%). Patients with moderate or severe hypoglycemia had a poorer prognosis as shown by a higher mortality rate (36% and 54% respectively, vs. 28%) and decreased number of treatment-free days. In the multivariable analysis, severe (OR 1.50, 95% CI 1.36-1.56, P=0.043) and multiple hypoglycemic events (OR 1.76, 95% CI 1.31-3.37, P<0.001) were significantly associated with mortality whereas blood glucose CV was not. Using multivariable matching, patients with severe (53 vs. 35%, P<0.001), moderate (33 vs. 27%, P=0.029), and multiple hypoglycemic events (46 vs. 32%, P<0.001), had a higher 90-day mortality. Conclusion In a large cohort of ICU patients, severe hypoglycemia and multiple hypoglycemic events were associated with increased 90-day mortality. Trial registration Clinicaltrials.gov Identifier NCT01002482 Registered 26 Octobrer 2009

Tight Computerized versus Conventional Glucose Control in the ICU. A Randomized Controlled Study

International audiencePurpose: Both the blood glucose target range in critically ill adult patients and the optimal method to reach this target range remain a matter of debate. To test whether a Computer Decision Support System (CDSS) might improve the outcome of critically ill adult patients through facilitation of a tighter blood glucose control. Methods: We conducted a multicenter randomized trial in 34 French closed-format intensive care units in 19 university hospitals and 15 nonuniversity hospitals from October 2009 to June 2011. Adult patients who were expected to require treatment in the ICU at least 3 days were randomly assigned without blinding to undergo tight computerized glucose control with CDSS or conventional glucose control, with the respective blood glucose targets of 80 to 110 and < 180 mg per deciliter. The primary outcome was all-cause death within 90 days after ICU admission. Results: Of the 2,684 patients who underwent randomization, 1,351 were assigned to tight computerized glucose control and 1,333 to conventional glucose control. Data with regard to the primary outcome were available for 1,335 and 1,311 patients, respectively. A total of 431 (32.3%) patients in the tight computerized glucose control group and 447 (34.1%) in the conventional glucose control group died at day 90 (odds ratio for death in the tight computerized glucose control, 0.92; 95% CI, 0.78-1.78; p = 0.32). Severe hypoglycemia (< 40 mg/dL) was reported in 174 of 1,317 patients (13.2%) in the tight computerized glucose control group and 79 of 1,284 patients (6.2%) in the conventional glucose control group (p < 0.001). Conclusions: In critically ill patients, tight computerized glucose control with CDSS did not significantly change 90-day mortality and is associated with more frequent severe hypoglycemia in comparison with conventional glucose control performed without CDSS