Glucose control and its implications for the general surgeon.

In the face of these conflicting data, how should the practicing surgeon approach the issue of tight glucose control in their critically ill surgical patients? The answer to that question may well change over time as new data emerge. For now, however, it seems reasonable to conclude that tight glucose control to the normal range (80-110 mg/dL) in critically ill general surgery patients (i.e., the Van den Berghe model) is an intriguing but unproven hypothesis that needs to be confirmed by prospective randomized trials in different ICUs and in a relevant patient population. It is quite possible, and probably likely, that levels of hyperglycemia that were previously thought to be inconsequential (180-200 mg/dL) may be harmful when sustained over prolonged periods of time and that better glucose control in the ICU than previously practiced is merited. However, given the detrimental effects of hypoglycemia, great care must be exercised in trying to achieve better glucose control so as not to induce harm. Technical considerations such as differences in glucose measuring systems, use of morning versus all glucose values, and nutritional regimens all need to be considered. The ICU is by definition a complex environment involving multiple teams of consulting specialists whose orders for medications, dialysis treatments, radiographic studies, and interruptions of enteral nutrition may all disrupt the ability to establish stable blood glucose levels. These factors need to be accounted for in daily clinical practice and their roles need to be better understood in future clinical trials. At present, it seems reasonable to attempt to control blood glucose levels in critically ill general surgery patients to moderate levels that avoid deleterious hypoglycemia but have been associated with encouraging clinical results until better data emerge. Until that time, the clinician will need to attempt to balance the potentially detrimental effects of hyperglycemia with the risk of hypoglycemia carefully until future trials involving general surgery patients are completed to clarify this issue.