{'fraction_non_alphanumeric': 0.029882604055496264, 'fraction_numerical': 0.021344717182497332, 'mean_word_length': 5.105863192182411, 'pattern_counts': {'":': 0, '<': 0, '<?xml version=': 0, '>': 0, 'https://': 0, 'lorem ipsum': 0, 'www.': 0, 'xml': 0}, 'pii_count': 0, 'substrings_counts': 1, 'word_list_counts': {'cursed_substrings.json': 0, 'profanity_word_list.json': 0, 'sexual_word_list.json': 0, 'zh_pornsignals.json': 0}}
A Step Toward Personalized Glycemic Control.

DOI: 10.1097/CCM.0000000000003107 The optimal glycemic target and the ideal assessment of performance have been eagerly discussed among experts during the 2 last decades (1). As in many other areas of Critical Care Medicine, the “one size fits all” rule progressively vanished and is progressively replaced by the concept of personalized care. Among the criteria of personalization, the concept of targeting the average chronic blood glucose (BG) value is supported by observational or post hoc findings. Indeed, there is a rightward shift of the relation between mortality or outcome and admission or average BG in patients with diabetes (as compared to patients without diabetes) presenting with acute myocardial infarction (2) or other conditions (3, 4). Likewise, once reanalyzed, the data from the Leuven study demonstrated that the benefit of tight glycemic control by intensive insulin therapy was restricted to patients without diabetes (5). Hence, the incorporation of an index of prestress average BG value in the determination of BG target appears logical and is actually used in diabetology to define the BG target. The equation proposed by Nathan et al (6) is commonly used to calculate the estimated average glucose and hence to define the target BG to achieve in patients with diabetes. A calculator can be used to convert glycosylated hemoglobin into average estimated BG and is available on the website of the American Diabetes Association (7). In the support of a potential benefit of a personalized glycemic target in critically ill patients, we recently reported a U-shaped relationship between the glycemic ratio (GR), calculated as admission BG/estimated average BG, and mortality in the ICU, with a nadir when GR was in the 0.97–1.2 quartile (8) (Fig. 1). The use of different BG targets according to the chronic BG levels has been proposed but is not yet widely applied in ICUs. Krinsley et al (9) recently reported an improvement of the observed/ expected mortality ratio of patients with diabetes when BG target was raised from 90–120 mg/dL to 80–140 or 110–160 mg/ dL when glycosylated hemoglobin was lower or higher than 7%, respectively. In this issue of Critical Care Medicine (10), the results, by Luethi et al (10), of a prospective, open-label, and sequential period study are presented and merely confirm the feasibility of looser or more liberal glucose control in patients with diabetes. Of note, Luethi et al (10) reported an average value of BG within the targeted range in both groups, even though the time in the desired range was below 50% in both arms. The frequency of mild hypoglycemia was remarkably high in the conventional group. These important findings highlight the need for improvement of the safety and quality of glycemic control, that is, the ability to achieve rapidly and safely a predefined target. Recent technological progresses, including continuous glucose monitoring, and computer-guided therapeutic algorithms will likely improve the quality of care (1). Closed-loop systems have been assessed, and promising results of pilot studies have been released (11, 12). The use of estimated average BG to define an individualized BG target and to reach it via therapeutic algorithms has been assessed in the unpublished multicenter French Controlling (CONTRÔLe INdividualisé de la Glycémie en reanimation) study (ClinicalTrials.gov NCT02244073). Meanwhile, important contributions like the study by Luethi et al (10) are needed to delineate the rooms for improvements when a personalized therapeutic strategy is implemented and thereby fosters collaborations between clinicians and bioengineers to create adapted and clinically useful tools (13).