Glycemic control, diabetic status, and mortality in a heterogeneous population of critically ill patients before and during the era of intensive glycemic management: six and one-half years experience at a university-affiliated community hospital

Stress hyperglycemia ratio as an independent predictor of acute kidney injury in critically ill patients with acute myocardial infarction: a retrospective U.S. cohort study

BACKGROUND

Acute kidney injury (AKI) is a frequent and severe complication in critically ill patients with acute myocardial infarction (AMI), significantly worsening prognosis. Identifying early risk markers for AKI in AMI patients is critical for timely intervention. The stress hyperglycemia ratio (SHR), a marker of acute glycemic response to physiological stress, has been proposed as a predictor of AKI, but its role remains unclear.

OBJECTIVE

This study investigates the association between SHR and AKI development in critically ill patients with AMI, using data from the MIMIC-III and MIMIC-IV databases.

METHODS

A total of 4,663 critically ill AMI patients were analyzed. SHR was evaluated for its association with AKI incidence using logistic regression, restricted cubic splines, and mediation analysis. Subgroup and sensitivity analyses were performed to confirm robustness. Additionally, Cox regression and Kaplan-Meier survival analysis were used to explore SHR's association with in-hospital mortality in the overall cohort and AKI subgroup.

RESULTS

Higher SHR levels were independently associated with an increased risk of AKI, demonstrating a J-shaped relationship. Mediation analysis revealed that neutrophil count and albumin partially mediated this effect. Kaplan-Meier survival curves showed significant differences in in-hospital mortality among SHR quartiles (log-rank p < 0.001). However, Cox regression analysis indicated that SHR was not an independent predictor of in-hospital mortality in either the full cohort or the AKI subgroup.

CONCLUSIONS

SHR serves as an early and independent marker for AKI risk in critically ill AMI patients, offering potential utility in clinical risk stratification. However, its role in predicting in-hospital mortality appears limited. These findings underscore the importance of glycemic monitoring and management in AMI patients at risk of AKI.

The effect of percentage of time spent above different glucose levels on 90 days mortality of critically ill patients - A retrospective cohort study

INTRODUCTION

Glycemic control is a major concern during critical illness. Several prospective studies have yielded conflicting results regarding its mortality effect. Current recommendations are to initiate insulin therapy for all patients when glucose levels are higher than 180 mg/dL. Some suggest decreasing this threshold for non-diabetic patients to 140 mg/dL. These thresholds haven't been compared to each other or to other glucose thresholds. This study aimed to find out whether different glucose levels are associated with 90-d mortality.

METHODS

A retrospective cohort study. Critically ill patients who were admitted from 2019 to 2022 to a mixed medical-surgical intensive care unit for more than 48 h were included. Collected data included baseline characteristics, and all glucose levels recorded (time-indexed to the admission time). Glucose levels were considered constant until the following glucose level. The percentage of time above several chosen glucose cutoff levels was calculated and analyzed for mortality adjusted to other baseline covariates.

RESULTS

45,512 glucose measurements of 1429 patients were included in the study; 21.76 % of the patients had diabetes. Mean glucose level and glucose variability were higher in diabetic patients (165.86 mg/dL vs 135.47 mg/dL, p < 0.0001, and 30.81 % vs 20.86 %, p < 0.0001, respectively), along with a higher incidence of hypoglycemia (40.84 % vs 24.89 %, p < 0.001). 90-d mortality was higher in diabetic patietns (42.12 % vs 32.41 %, p = 0.0014) and was found associated with age, acute physiology and chronic health evaluation 2 score, medical or surgical admission reasons. Percentage of time above cutoffs ≥150 mg/dL was associated with 90-d mortality only in non-diabetic patients.

CONCLUSIONS

In non-diabetic patients, hyperglycemia greater than 150 mg/dL, was associated with increased 90-day mortality.

Between blood glucose and mortality in critically ill patients: Retrospective analysis of the MIMIC-IV database

AIMS/INTRODUCTION

Mean blood glucose (MBG) level is associated with mortality among critically ill patients. We undertook a cohort study to investigate the relationship between MBG and mortality in critically ill patients.

MATERIALS AND METHODS

Critically ill patients were enrolled from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. MBG was calculated to represent the overall glycemic status during intensive care unit (ICU) hospitalization, and a multivariate logistic regression determined the relationship between MBG and ICU mortality in different subgroups of critically ill patients.

RESULTS

A total of 8,973 patients were included in the study, 1,244 of whom died within 28 days, including 5,402 men and 3,571 women. Multivariate adjusted restricted cubic spline analyses suggested that the relationship between MBG and ICU mortality was a "J" shape. Logistic regression showed 28 day mortality in group 3 (glucose ≥10 mmol/L): the adjusted odds ratio was 2.06 (95% confidence interval 1.65-2.57). The results of subgroup analysis showed that hyperglycemia had a more significant impact on ICU mortality in patients without diabetes, hypoglycemia and liver disease, and the ICU mortality risk of non-diabetes patients was always higher than that of diabetes patients with the same hyperglycemia level.

CONCLUSIONS

Current evidence suggested a J-shaped relationship between MBG and mortality in critically ill patients.

Effects of Glycemic Variability in Critically Ill Patients with Coronavirus Disease 2019: A Retrospective Observational Study

Aim and background

Hyperglycemia is considered an adaptive metabolic manifestation of stress and is associated with poor outcomes. Herein, we analyzed the association between glycemic variability (GV) and hospital mortality in patients with coronavirus disease 2019 (COVID-19) admitted to the intensive care unit (ICU), and the association between GV and mechanical ventilation (MV), ICU stay, length of hospital stays, renal replacement therapy (RRT), hypoglycemia, nosocomial infections, insulin use, and corticosteroid class.

Materials and methods

In this retrospective observational study, we collected information on blood glucose levels during the first 10 days of hospitalization in a cohort of ICU patients with COVID-19 and its association with outcomes.

Results

In 239 patients, an association was observed between GV and hospital mortality between the first and last quartiles among patients without diabetes [odds ratio (OR), 3.78; confidence interval, 1.24-11.5]. A higher GV was associated with a greater need for RRT (p = 0.002), regular insulin (p < 0.001), and episodes of hypoglycemia (p < 0.001). Nosocomial infections were associated with intermediate GV quartiles (p = 0.02). The corticosteroid class had no association with GV (p = 0.21).

Conclusion

Glycemic variability was associated with high mortality in patients with COVID-19 and observed in the subgroup of patients without diabetes.

Clinical significance

Glycemic control in critically ill patients remains controversial and hyperglycemia is associated with worse outcomes. Diabetes mellitus (DM) is one of the most prevalent comorbidities in patients with COVID-19. In addition, they require corticosteroids due to pulmonary involvement, representing a challenge and an opportunity to better understand how glycemic changes can influence the outcome of these patients.

How to cite this article

Boschi E, Friedman G, Moraes RB. Effects of Glycemic Variability in Critically Ill Patients with Coronavirus Disease 2019: A Retrospective Observational Study. Indian J Crit Care Med 2024;28(4):381-386.

A Consensus Statement for Continuous Glucose Monitoring Metrics for Inpatient Clinical Trials

Diabetes Technology Society organized an expert consensus panel to develop metrics for research in the use of continuous glucose monitors (CGMs) in a hospital setting. The experts met virtually in small groups both before and after an April 13, 2023 virtual meeting of the entire panel. The goal of the panel was to develop consensus definitions in anticipation of greater use of CGMs in hospital settings in the future. Establishment of consensus definitions of inpatient analytical metrics will be easier to compare outcomes between studies. Panelists defined terms related to 10 dimensions of measurements related to the use of CGMs including (1) hospital hypoglycemia, (2) hospital hyperglycemia, (3) hospital time in range, (4) hospital glycemic variability, (5) hospital glycemia risk index, (6) accuracy of CGM devices and reference methods for CGMs in the hospital, (7) meaningful time blocks for hospital glycemic goals, (8) hospital CGM data sufficiency, (9) using CGM data for insulin dosing, and (10) miscellaneous factors. The panelists voted on 51 proposed recommendations. Based on the panel vote, 51 recommendations were classified as either strong (43) or mild (8). Additional research is needed on CGM performance in the hospital. This consensus report is intended to support that type of research intended to improve outcomes for hospitalized people with diabetes.

Large vessel occlusion stroke outcomes in diabetic vs. non-diabetic patients with acute stress hyperglycemia

OBJECTIVE

This study assesses whether stress-induced hyperglycemia is a predictor of poor outcome at 3 months for patients with acute ischemic stroke (AIS) treated by endovascular treatment (EVT) and impacted by their previous blood glucose status.

METHODS

This retrospective study collected data from 576 patients with AIS due to large vessel occlusion (LVO) treated by EVT from March 2019 to June 2022. The sample was composed of 230 and 346 patients with and without diabetes mellitus (DM), respectively, based on their premorbid diabetic status. Prognosis was assessed with modified Rankin Scale (mRS) at 3-month after AIS. Poor prognosis was defined as mRS>2. Stress-induced hyperglycemia was assessed by fasting glucose-to-glycated hemoglobin ratio (GAR). Each group was stratified into four groups by quartiles of GAR (Q1-Q4). Binary logistic regression analysis was used to identify relationship between different GAR quartiles and clinical outcome after EVT.

RESULTS

In DM group, a poor prognosis was seen in 122 (53%) patients and GAR level was 1.27 ± 0.44. These variables were higher than non-DM group and the differences were statistically significant (p < 0.05, respectively). Patients with severe stress-induced hyperglycemia demonstrated greater incidence of 3-month poor prognosis (DM: Q1, 39.7%; Q2, 45.6%; Q3, 58.6%; Q4, 68.4%; p = 0.009. Non-DM: Q1, 31%; Q2, 32.6%; Q3, 42.5%; Q4, 64%; p < 0.001). However, the highest quartile of GAR was independently associated with poor prognosis at 3 months (OR 3.39, 95% CI 1.66-6.96, p = 0.001), compared to the lowest quartile in non-DM patients after logistic regression. This association was not observed from DM patients.

CONCLUSION

The outcome of patients with acute LVO stroke treated with EVT appears to be influenced by premorbid diabetes status. However, the poor prognosis at 3-month in patients with DM is not independently correlated with stress-induced hyperglycemia. This could be due to the long-term damage of persistent hyperglycemia and diabetic patients' adaptive response to stress following acute ischemic damage to the brain.

Low stress hyperglycemia ratio predicts worse prognosis in diabetic acute heart failure patients

INTRODUCTION

Acute blood glucose but not glycated hemoglobin (HbA1c) predicts poor outcome in acute heart failure (HF). The stress hyperglycemia ratio (SHR) has been proposed as a prognostic predictor in various clinical settings.

OBJECTIVES

We assessed the prognostic implications of the SHR in acute HF patients with and without diabetes.

METHODS

We performed a retrospective analysis of an acute HF registry conducted between 2009 and 2010. Estimated average glucose (eAG) was calculated as (28.7×HbA1c)-46.7 and SHR as acute blood glucose divided by eAG. The primary endpoint was all-cause mortality. Follow-up was three months. Patients were grouped by SHR tertiles (≤0.88, 0.89-1.16, and >1.16). Cox regression analysis was used to test the association of SHR (cut-off 0.88) with all-cause mortality. Analysis was stratified according to the presence of diabetes. Multivariate models were built accounting for acute blood glucose and for eAG (models 1 and 2, respectively).

RESULTS

We studied 599 patients, mean age 76±12 years, of whom 62.1% had reduced ejection fraction and 50.9% had diabetes. Median acute blood glucose, eAG and SHR were 136 (107-182) mg/dl, 131 (117-151) mg/dl, and 1.02 (0.20-3.34), respectively. During follow-up 102 (17.0%) died. In patients with diabetes, those in the lowest SHR tertile had a hazard ratio (HR) of 2.24 (95% CI: 1.05-5.22) (model 1) and 2.34 (1.25-4.38) (model 2). In patients without diabetes, the HR of three-month death in the lowest SHR tertile was 0.71 (95% CI: 0.36-1.39) and 1.02 (0.58-1.81). Significant interaction was observed between diabetes and SHR.

CONCLUSIONS

In HF patients with diabetes, a SHR ≤0.88 was associated with a more than twofold higher three-month mortality risk. No such association was found in non-diabetic patients. The presence of diabetes influences the association of the SHR with mortality.

Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill

Context

The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM).

Objective

This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM).

Methods

This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality).

Results

Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM.

Conclusion

These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.

Stress Hyperglycemia Does Not Affect Clinical Outcome of Diabetic Patients Receiving Intravenous Thrombolysis for Acute Ischemic Stroke

Although stress hyperglycemia represents a main risk factor for poor outcome among patients with acute ischemic stroke (AIS) undergoing recanalization therapy, we have limited information regarding a possible influence of the premorbid diabetic status on this association. We recruited consecutive patients admitted to the Udine University Hospital with AIS who were treated with intravenous thrombolysis (IVT) from January 2015 to September 2020. On the basis of the premorbid diabetic status, our sample was composed of 130 patients with and 371 patients without diabetes. The glucose-to-glycated hemoglobin ratio (GAR) was used to measure stress hyperglycemia. Patients were stratified into 3 groups by tertiles of GAR (Q1–Q3). The higher GAR index was, the more severe stress hyperglycemia was considered. Among diabetic patients we did not observe any significant association between severe stress hyperglycemia and outcome measures (three-month poor outcome: Q1, 53.7%; Q2, 53.5%; Q3, 58.7%; p = 0.854; three-month mortality: Q1, 14.6%; Q2, 9.3%; Q3, 23.9%; p = 0.165; symptomatic intracranial hemorrhage: Q1, 7.3%; Q2, 14%; Q3, 19.6%; p = 0.256). Differently, non-diabetic subjects with more severe stress hyperglycemia showed a higher prevalence of three-month poor outcome (Q1, 32.2%; Q2, 27.7%; Q3, 60.3%; p = 0.001), three-month mortality (Q1, 9.1%; Q2, 8.4%; Q3, 18.3%; p = 0.026), and symptomatic intracranial hemorrhage (Q1, 0.8%; Q2, 0.8%; Q3, 9.9; p = 0.001). After controlling for several confounders, severe stress hyperglycemia remained a significant predictor of three-month poor outcome (OR 2.1, 95% CI 1.03–4.28, p = 0.041), three-month mortality (OR 2.39, 95% CI 1.09–5.26, p = 0.029) and symptomatic intracranial hemorrhage (OR 12.62, 95% CI 1.5–106, p = 0.02) among non-diabetics. In conclusion, premorbid diabetic status seems to influence outcome in AIS patients receiving IVT. Indeed, odds of functional dependency, mortality and hemorrhagic complications were significantly increased in patients with more severe stress hyperglycemia only when they were not affected by diabetes.

The Interaction of Acute and Chronic Glycemia on the Relationship of Hyperglycemia, Hypoglycemia, and Glucose Variability to Mortality in the Critically Ill

OBJECTIVES

To determine the relationship between preadmission glycemia, reflected by hemoglobin A1c level, glucose metrics, and mortality in critically ill patients.

DESIGN

Retrospective cohort investigation.

SETTING

University affiliated adult medical-surgical ICU.

PATIENTS

The investigation included 5,567 critically ill patients with four or more blood glucose tests and hemoglobin A1c level admitted between October 11, 2011 and November 30, 2019. The target blood glucose level was 90-120 mg/dL for patients admitted before September 14, 2014 (n = 1,614) and 80-140 mg/dL or 110-160 mg/dL for patients with hemoglobin A1c less than 7% or greater than or equal to 7% (n = 3,953), respectively, subsequently.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were stratified by hemoglobin A1c: less than 6.5.(n = 4,406), 6.5-7.9% (n = 711), and greater than or equal to 8.0% (n = 450). Increasing hemoglobin A1c levels were associated with significant increases in mean glycemia, glucose variability, as measured by coefficient of variation, and hypoglycemia (p for trend < 0.0001, < 0.0001, and 0.0010, respectively). Among patients with hemoglobin A1c less than 6.5%, mortality increased as mean glycemia increased; however, among patients with hemoglobin A1c greater than or equal to 8.0%, the opposite relationship was observed (p for trend < 0.0001 and 0.0027, respectively). Increasing glucose variability was independently associated with increasing mortality only among patients with hemoglobin A1c less than 6.5%. Hypoglycemia was independently associated with higher mortality among patients with hemoglobin A1c less than 6.5% and 6.5-7.9% but not among those with hemoglobin A1c greater than or equal to 8.0%. Mean blood glucose 140-180 and greater than or equal to 180 mg/dL were independently associated with higher mortality among patients with hemoglobin A1c less than 6.5% (p < 0.0001 for each). Among patients with hemoglobin A1c greater than or equal to 8.0% treated in the second era, mean blood glucose greater than or equal to 180 mg/dL was independently associated with decreased risk of mortality (p = 0.0358).

CONCLUSIONS

Preadmission glycemia, reflected by hemoglobin A1c obtained at the onset of ICU admission, has a significant effect on the relationship of ICU glycemia to mortality. The different responses to increasing mean glycemia support a personalized approach to glucose control practices in the ICU.

Using a Diabetes Risk Score to Identify Patients Without Diabetes at Risk for New Hyperglycemia in the Hospital

OBJECTIVE

To assess the value of a validated diabetes risk test, the Cambridge Risk Score (CRS), to identify patients admitted to hospital without diabetes at risk for new hyperglycemia (NH).

METHODS

This retrospective cross-sectional study included adults admitted to a hospital over a 4-year period. Patients with no diabetes diagnosis and not on antidiabetics were included. The CRS was calculated for each patient, and those with available glycated hemoglobin (HbA1C) results were investigated in a second analysis. Multivariate regression analyses were performed to assess the association among CRS, HbA1C, and the risk for NH.

RESULTS

A total of 19,830 subjects comprised the sample, of which 38% were found to have developed NH, defined as a blood glucose level ≥140 mg/dL. After accounting for covariates, the CRS was significantly associated with NH (odds ratio [OR], 1.19 [1.16, 1.22]; P < .001). Only 17% of patients had their HbA1C values checked within 6 months of admission. Compared with patients without diabetes, patients with prediabetes based on their HbA1C level (OR, 1.59 [1.37, 1.86]; P < .001) and patients with undiagnosed diabetes (OR, 5.95 [3.50, 10.65]; P < .001) were also significantly more likely to have NH.

CONCLUSION

Results of this study show that the CRS and HbA1C levels were significantly associated with the risk of developing NH in inpatient adults without diabetes. Given that an HbA1C level was missing in most medical records of hospitalized patients without diabetes, the CRS could be a useful tool for early identification and management of NH, possibly leading to better outcomes.

Clinical Management of Diabetes Mellitus in the Era of COVID-19: Practical Issues, Peculiarities and Concerns

The management of patients with diabetes mellitus (DM) in the era of the COVID-19 pandemic can be challenging. Even if they are not infected, they are at risk of dysregulated glycemic control due to the restrictive measures which compromise and disrupt healthcare delivery. In the case of infection, people with DM have an increased risk of developing severe complications. The major principles of optimal care for mild outpatient cases include a patient-tailored therapeutic approach, regular glucose monitoring and adherence to medical recommendations regarding lifestyle measures and drug treatment. For critically ill hospitalized patients, tight monitoring of glucose, fluids, electrolytes, pH and blood ketones is of paramount importance to optimize outcomes. All patients with DM do not have an equally increased risk for severity and mortality due to COVID-19. Certain clinical and biological characteristics determine high-risk phenotypes within the DM population and such prognostic markers need to be characterized in future studies. Further research is needed to examine which subgroups of DM patients are expected to benefit the most from specific antiviral, immunomodulatory and other treatment strategies in the context of patient-tailored precision medicine, which emerges as an urgent priority in the era of COVID-19.

Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial

BACKGROUND

Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes.

OBJECTIVE

To detail the protocol, analysis and reporting plans for a randomised clinical trial - the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial - which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes.

DESIGN, SETTING, PARTICIPANTS AND INTERVENTION

A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0-14.0 mmol/L) or usual care (target 6.0-10.0 mmol/L).

MAIN OUTCOME MEASURES

The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes.

RESULTS AND CONCLUSION

The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised.

TRIAL REGISTRATION

This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.

Is it time to abandon glucose control in critically ill adult patients?

PURPOSE OF REVIEW

To summarize the advances in literature that support the best current practices regarding glucose control in the critically ill.

RECENT FINDINGS

There are differences between patients with and without diabetes regarding the relationship of glucose metrics during acute illness to mortality. Among patients with diabetes, an assessment of preadmission glycemia, using measurement of Hemoglobin A1c (HgbA1c) informs the choice of glucose targets. For patients without diabetes and for patients with low HgbA1c levels, increasing mean glycemia during critical illness is independently associated with increasing risk of mortality. For patients with poor preadmission glucose control the appropriate blood glucose target has not yet been established. New metrics, including stress hyperglycemia ratio and glycemic gap, have been developed to describe the relationship between acute and chronic glycemia.

SUMMARY

A 'personalized' approach to glycemic control in the critically ill, with recognition of preadmission glycemia, is supported by an emerging literature and is suitable for testing in future interventional trials.

Insulin-Based Infusion System: Preliminary Study

BACKGROUND

Optimal glucose control has been shown to be useful in critical care as well as in other settings. Glucose concentrations in patients admitted to critical care are characterized by marked variability and hypoglycemia due to inadequate sensing and treatment technologies.

METHODS

The insulin balanced infusion system (IBIS) is a closed-loop system that uses a system controller, two syringe pumps, and capillary glucose sensor intravenously infusing regular insulin and/or dextrose. The IBIS performance was evaluated in terms of glucose stability in response to various conditions in subjects with type 1 and insulin requiring type 2 diabetes mellitus (n = 15) with frequent intermittent capillary measurements, entered into the system and an adaptive algorithm adjusting the treatment modalities without other nursing intervention.

RESULTS

Target glucose concentrations (80-125 mg/dl) were achieved from hyperglycemic levels in 2.49 hours in the first study with mean and standard deviation of 105.2 mg/dl and 11.5 mg/dl, respectively.

CONCLUSION

Preliminary studies using a prototype closed-loop glucose control system for critical care produced noticeable results. Improvements were initiated within the system and further studies performed.

Glucose control in the ICU

PURPOSE OF REVIEW

Critically ill patients usually develop hyperglycemia, which is associated with adverse outcome. Controversy exists whether the relationship is causal or not. This review summarizes recent evidence regarding glucose control in the ICU.

RECENT FINDINGS

Despite promising effects of tight glucose control in pioneer randomized controlled trials, the benefit has not been confirmed in subsequent multicenter studies and one trial found potential harm. This discrepancy could be explained by methodological differences between the trials rather than by a different case mix. Strategies to improve the efficacy and safety of tight glucose control have been developed, including the use of computerized treatment algorithms.

SUMMARY

The ideal blood glucose target remains unclear and may depend on the context. As compared with tolerating severe hyperglycemia, tight glucose control is well tolerated and effective in patients receiving early parenteral nutrition when provided with a protocol that includes frequent, accurate glucose measurements and avoids large glucose fluctuations. All patient subgroups potentially benefit, with the possible exception of patients with poorly controlled diabetes, who may need less aggressive glucose control. It remains unclear whether tight glucose control is beneficial or not in the absence of early parenteral nutrition.

Association of transcription factor 7-like 2 gene (TCF7L2) polymorphisms with stress-related hyperglycaemia (SRH) in intensive care and resulting outcomes: The READIAB study

OBJECTIVE

The study aimed to evaluate the impact of the single nucleotide polymorphism (SNP) rs7903146 on the transcription factor 7-like 2 (TCF7L2) gene in stress-related hyperglycaemia (SRH), defined as blood glucose≥11mmol/L in at least two blood samples during the first 3 days in the intensive care unit (ICU), and on 28-day and 1-year mortality, and incidence of type 2 diabetes (T2D) at 6 months and 1 year in patients hospitalized in the ICU.

METHODS

This prospective observational (non-interventional) multicentre READIAB study, carried out during 2012-2016 in six French ICUs, involved adult patients admitted to ICUs for at least two organ failures; patients admitted for<48h were excluded. During the 3-day ICU observational period, genetic testing, blood glucose values and insulin treatment were recorded.

MAIN RESULTS

The association of rs7903146 with SRH was assessed using logistic regression models. Cox proportional hazards regression models assessed the associations between rs7903146 and mortality and between SRH and mortality, both at 28 days and 1 year. A total of 991 of the 1000 enrolled patients were included in the READIAB-G4 cohort, but 242 (24.4%) had preexisting diabetes and were excluded from the analyses. SRH occurred within the first 3 days in the ICU for one-third of the non-diabetes patients. The association between the rs7903146 polymorphism and SRH did not reach significance (P=0.078): OR_{(peroneTcopy)}: 1.24, 95% CI: 0.98-1.58. A significant association was found between rs7903146 and 28-day mortality after adjusting for severity scores (P=0.026), but was no longer significant at 1 year (P=0.61). At 28 days, mortality was increased in patients with SRH (HR: 2.09, 95% CI: 1.43-3.06; P<0.001), and remained significant at 1 year after adjusting for severity scores (HR: 1.73, 95% CI: 1.32-2.28; P<0.001). On admission, non-diabetes patients with SRH had a higher incidence of T2D at 6 months vs. those without SRH (16.0% vs. 7.6%, RR: 2.11, 95% CI: 1.07-4.20; P=0.030). At 1 year, these figures were 13.4% vs. 9.2%, RR: 1.45, 95% CI: 0.71-2.96; P=0.31). Moreover, the rs7903146 polymorphism was not significantly associated with T2D development at either 6 months (P=0.72) or 1 year (P=0.64).

CONCLUSION

This study failed to demonstrate any significant association between rs7903146 and SRH. Nevertheless, the issue remains an important challenge, as SRH may be associated with increased rates of both mortality and T2D development.

Intravenous Insulin Infusion Protocol Compared With Subcutaneous Insulin for the Management of Hyperglycemia in Critically Ill Adults

Background: The use of an intravenous insulin infusion protocol (IIP) is recommended for management of hyperglycemia in the intensive care unit (ICU); however, limited evidence of comparison has been made with subcutaneous (SC) insulin regimens. Objective: This study aims to evaluate the safety and effectiveness of an IIP compared with SC insulin regimens in an ICU patient sample since the implementation of an IIP using a computerized clinical-decision support tool. Methods: This investigation was a retrospective cohort study of patients who were treated for hyperglycemia while admitted to any of the ICUs at a Veterans Affairs Medical Center. Patients who were treated with either an IIP or a scheduled SC insulin regimen between May 1, 2015, and May 25, 2016, were included for evaluation. Results: Blood glucose (BG) was within the normoglycemia range (70-180 mg/dL) for 63.0% of the measurements in patients treated with an IIP (n = 171) compared with 45.7% in those treated with SC insulin regimens (n = 121; P < 0.01). Overall, patients managed with an IIP had a lower proportion of hypoglycemic BG measurements (1.2% vs 2.1%, P < 0.01), a lower proportion of hyperglycemic BG measurements (35.8% vs 52.2%, P < 0.01), and a lower mean BG (172.4 vs 194.3 mg/dL, P < 0.01). Conclusion and Relevance: The results of this study suggest that an IIP in a sample of adult ICU patients was associated with better BG control and lower occurrence of hypoglycemia compared with SC insulin regimens.

Acute glycemic control in diabetics. How sweet is oprimal? Con: Just as sweet as in nondiabetic is better

This review is for Con side of "Pro-Con debate" on the optimal target of blood glucose levels in patients with chronic hyperglycemia (e.g. premorbid HbA1c level > 7%). Currently, international guideline recommended that blood glucose level ≤ 180 mg/dL in critically ill patients irrespective of presence or absence of premorbid diabetes. However, there are several studies to generate the hypothesis that liberal glycemic control (e.g., target blood glucose level 180-250 mg/dL) may be beneficial in critically ill patients with premorbid hyperglycemia. Although there is before-after study to report its safety and feasibility, it should be noted that this strategy may have a potential to increase the risk of infection, glycosuria, and polyneuropathy. Furthermore, there is randomized controlled study which showed the potential harm of liberal glycemic control in patients with premorbid hyperglycemia. Additionally, there are lots of uncertainty about the candidate and methodology of such a permissive hyperglycemia. With considering these facts, it might be better to keep target of blood glucose level in patients with diabetes the same as patients without diabetes (≤ 180 mg/dL), until randomized control study as like LUCID (the Liberal GlUcose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes) trial will justify its risk and benefit.

Perioperative insulin therapy

Surgical patients commonly develop hyperglycemia secondary to the neuroendocrine stress response. Insulin treatment of hyperglycemia is required to overcome the perioperative catabolic state and acute insulin resistance. Besides its metabolic actions on glucose metabolism, insulin also displays nonmetabolic physiological effects. Preoperative glycemic assessment, maintenance of normoglycemia, and avoidance of glucose variability are paramount to optimize surgical outcomes. This review discusses the basic physiology and effects of insulin as well as practical issues pertaining to its management during the perioperative period.

Diabetic status and the relationship of blood glucose to mortality in adults with carbapenem-resistant Acinetobacter baumannii complex bacteremia

BACKGROUND/PURPOSE

Diabetes is associated with increased mortality in Acinetobacter baumannii (AB) complex infection. This study investigated the risk factors and relationship of diabetic status and glycemic indices to mortality in patients with carbapenem-resistant (CR) AB complex bacteremia.

METHODS

Relationship of glycemic indices to mortality were compared in adult diabetes (DM) and nondiabetes (non-DM) patients with CRAB complex bacteremia hospitalized from January 2010 to December 2015 in MacKay Memorial Hospital, Taiwan.

RESULTS

Of 317 patients with CRAB complex bacteremia, 146 (46.06%) had diabetes. DM patients were elderly (mean age of 69.23 years) and the mortality rate was higher (64.38% vs. 52.05%, p = 0.036) than in non-DM patients. By multivariate analysis, septic shock was associated with increased mortality in DM patients. Hypoglycemia was associated with increased mortality in non-DM patients only (100% vs. 50.33%, p = 0.006). The lowest mortality was for the blood glucose range 70-100 mg/dL in non-DM patients (43.24%) and 100-140 mg/dL for DM patients (56.52%). Increased glycemic variability (coefficient of variation (CV) > 40% compared to < 20%) was associated with increased mortality in non-DM patients (86.36% vs. 47.12%, p = 0.003).

CONCLUSION

Effects of dysglycemia on mortality due to CRAB complex bacteremia differ according to diabetic status. Mortality was higher in DM patients. In non-DM patients, hypoglycemia and increased CV were associated with increased mortality. The lowest mortality was for the blood glucose range 70-100 mg/dL in non-DM patients and 100-140 mg/dL for DM patients.

Comparison of sevoflurane and propofol anesthesia on the incidence of hyperglycemia in patients with type 2 diabetes undergoing lung surgery

Background

The type and regimen of anesthesia may affect perioperative hyperglycemia following major surgical stress. This study compared the effects of sevoflurane and propofol on the incidence of hyperglycemia and clinical outcomes in diabetic patients undergoing lung surgery.

Methods

This retrospective study included 176 patients with type 2 diabetes mellitus who had undergone lung surgery. Blood glucose levels and clinical outcomes from the preoperative period to the first 2 post-operative days (PODs) were retrospectively examined in patients who received sevoflurane (group S, n= 87) and propofol (group P, n=89) for maintenance of general anesthesia. The primary endpoint was the incidence of persistent hyperglycemia (2 consecutive blood glucose levels >180 mg/dL [10.0 mmol/L]) during the perioperative period. The secondary composite endpoint was the incidence of major postoperative complications and 30-day mortality rate after surgery.

Results

Blood glucose levels similarly increased from the preoperative period to the second POD in both groups (p=0.857). Although blood glucose levels at 2 hours after surgery were significantly lower in group P than in group S (p=0.022; 95% confidence interval for mean difference, -27.154 to -2.090), there was no difference in the incidence of persistent hyperglycemia during the perioperative period (group S, 70%; group P, 69%; p=0.816). The composite of major postoperative complications and all-cause in-hospital and 30-day mortality rates were also comparable between the two groups.

Conclusion

Sevoflurane and propofol were associated with a comparable incidence of perioperative hyperglycemia and clinical outcomes in diabetic patients undergoing lung surgery.

Lower Glucose Target Is Associated With Improved 30-Day Mortality in Cardiac and Cardiothoracic Patients

BACKGROUND

Practice guidelines recommend against intensive insulin therapy in patients who are critically ill based on trials that had high rates of severe hypoglycemia. Intermountain Healthcare uses a computerized IV insulin protocol that allows choice of blood glucose (BG) targets (80-110 vs 90-140 mg/dL) and has low rates of severe hypoglycemia. We sought to study the effects of BG target on mortality in adult patients in cardiac ICUs that have very low rates of severe hypoglycemia.

METHODS

Critically ill patients receiving IV insulin were treated with either of two BG targets (80-110 vs 90-140 mg/dL). We created a propensity score for BG target using factors thought to have influenced clinicians' choice, and then we performed a propensity score-adjusted regression analysis for 30-day mortality.

RESULTS

There were 1,809 patients who met inclusion criteria. Baseline patient characteristics were similar. Median glucose was lower in the 80-110 mg/dL group (104 vs 122 mg/dL, P < .001). Severe hypoglycemia occurred at very low rates in both groups (1.16% vs 0.35%, P = .051). Unadjusted 30-day mortality was lower in the 80-110 mg/dL group (4.3% vs 9.2%, P < .001). This remained after propensity score-adjusted regression (OR, 0.65; 95% CI, 0.43-0.98; P = .04).

CONCLUSIONS

Tight glucose control can be achieved with low rates of severe hypoglycemia and is associated with decreased 30-day mortality in a cohort of largely patients in cardiac ICUs. Although such findings should not be used to guide clinical practice at present, the use of tight glucose control should be reexamined using a protocol that has low rates of severe hypoglycemia.

Perioperative management of adult diabetic patients. Intraoperative period

Perioperative hyperglycaemia (>1.80g/L or 10mmol/L) increases morbidity (particularly due to infection) and mortality. Hypoglycaemia can be managed in the perioperative period by decreasing blood sugar levels with insulin between 0.90 and 1.80g/L but it may occur more frequently when the goal is strict normoglycaemia. We propose continuous administration of insulin therapy via an electronic syringe (IVES) in type-1 diabetes (T1D) and type-2 diabetes (T2D) patients if required or in cases of stress hyperglycaemia. Stopping a personal insulin pump requires immediate follow on with IVES insulin. We recommend 4mg dexamethasone for the prophylaxis of nausea and vomiting, rather than 8mg, combined with another antiemetic drug. The use of regional anaesthesia (RA), when possible, allows for better control of postoperative pain and should be prioritised. Analgesic requirements are higher in patients with poorly controlled blood sugar levels than in those with HbA1c<6.5%. The struggle to prevent hypothermia, the use of RA and multimodal analgesia (which allow for a more rapid recovery of bowel movements), limitation of blood loss, early ambulation and minimally invasive surgery are the preferred measures to regulate perioperative insulin resistance. Finally, diabetes does not change the usual rules of fasting or of antibiotic prophylaxis.

The Long and Winding Road Toward Personalized Glycemic Control in the Critically Ill

Hyperglycemia is very common in critically ill patients and interventional studies of intensive insulin therapy with the goal of returning ICU glycemia to normal levels have demonstrated mixed results. A large body of literature has demonstrated that diabetes, per se, is not independently associated with increased risk of mortality in this population and that the relationship of glucose metrics to mortality is different for patients with and without diabetes. Moreover, these relationships are confounded by preadmission glycemia; in this regard, patients with diabetes and good preadmission glucose control, as reflected by HbA1c levels obtained at the time of ICU admission, are similar to patients without diabetes. These data point the way toward an era when blood glucose targets in the ICU will be "personalized," based on assessment of preadmission glycemia.

Glycemic control in acute illness

Hyperglycemia is commonly observed in critical illness. A landmark large randomized controlled trial (RCT) reported that the incidence of hyperglycemia (blood glucose concentration > 108 mg/dl) was as high as 97.2% in critically ill patients. During the past two decades, a number of RCTs and several meta-analyses and network meta-analyses have been conducted to determine the optimal target for acute glycemic control. The results of those studies suggest that serum glucose concentration would be better to be maintained between 144 and 180 mg/dl. Although there have been studies showing an association of hypoglycemia with worsened clinical outcomes, a causal link has yet to be confirmed. Nonetheless, some researchers are of the view that the data suggest even mild hypoglycemia should be avoided in critically ill patients. Since acutely ill patients who receive insulin infusion are at a higher risk of hypoglycemia, a reliable devices for measuring blood glucose concentrations, such as an arterial blood gas analyzer, should be used frequently. Acute glycemic control in patients with premorbid hyperglycemia is a novel issue. Available literature suggests that blood glucose concentrations considered to be desirable and/or safe in non-diabetic critically ill patients might not be desirable in patients with diabetes. Moreover, the optimal target for acute blood glucose control may be higher in critically ill patients with premorbid hyperglycemia. Further study is required to assess optimal blood glucose control in acutely ill patients with premorbid hyperglycemia.

Glucose Control, Diabetes Status, and Mortality in Critically Ill Patients: The Continuum From Intensive Care Unit Admission to Hospital Discharge

OBJECTIVE

To describe the relationships among glycemic control, diabetes mellitus (DM) status, and mortality in critically ill patients from intensive care unit (ICU) admission to hospital discharge.

PATIENTS AND METHODS

This is a retrospective investigation of 6387 ICU patients with 5 or more blood glucose (BG) tests and 4462 ICU survivors admitted to 2 academic medical centers from July 1, 2010, through December 31, 2014. We studied the relationships among mean BG level, hypoglycemia (BG level <70 mg/dL [to convert to mmol/L, multiply by 0.0555]), high glucose variability (coefficient of variation ≥20%), DM status, and mortality.

RESULTS

The ICU mortality for patients without DM with ICU mean BG levels of 80 to less than 110, 110 to less than 140, 140 to less than 180, and at least 180 mg/dL was 4.50%, 7.30%, 12.16%, and 32.82%, respectively. Floor mortality for patients without DM with these BG ranges was 2.74%, 2.64%, 7.88%, and 5.66%, respectively. The ICU and floor mean BG levels of 80 to less than 110 and 110 to less than 140 mg/dL were independently associated with reduced ICU and floor mortality compared with mean BG levels of 140 to less than 180 mg/dL in patients without DM (odds ratio [OR] [95% CI]: 0.43 (0.28-0.66), 0.62 (0.45-0.85), 0.41 (0.23-0.75), and 0.40 (0.25-0.63), respectively) but not in patients with DM. Both ICU and floor hypoglycemia and increased glucose variability were strongly associated with ICU and floor mortality in patients without DM, and less so in those with DM. The independent association of dysglycemia occurring in either setting with mortality was cumulative in patients without DM.

CONCLUSION

These findings support the importance of glucose control across the entire trajectory of hospitalization in critically ill patients and suggest that the BG target of 140 to less than 180 mg/dL is not appropriate for patients without DM. The optimal BG target for patients with DM remains uncertain.

Association of In-Hospital Mortality and Dysglycemia in Septic Patients

Background

The associations between dysglycemia and mortality in septic patients with and without diabetes are yet to be confirmed. Our aim was to analyze the association of diabetes and sepsis mortality, and to examine how dysglycemia (hyperglycemia, hypoglycemia and glucose variability) affects in-hospital mortality of patients with suspected sepsis in emergency department (ED) and intensive care units.

Methods

Clinically suspected septic patients admitted to ED were included, and stratified into subgroups according to in-hospital mortality and the presence of diabetes. We analyzed patients’ demographics, comorbidities, clinical and laboratory parameters, admission glucose levels and severity of sepsis. Odds ratio of mortality was assessed after adjusting for possible confounders. The correlations of admission glucose and CoV (blood glucose coefficients of variation) and mortality in diabetes and non-diabetes were also tested.

Results

Diabetes was present in 58.3% of the patients. Diabetic patients were older, more likely to have end-stage renal disease and undergoing hemodialysis, but had fewer malignancies, less sepsis severity (lower Mortality in Emergency Department Sepsis Score), less steroid usage in emergency department, and lower in-hospital mortality rate (aOR:0.83, 95% CI 0.65–0.99, p = 0.044). Hyperglycemia at admission (glucose≥200 mg/dL) was associated with higher risks of in-hospital mortality among the non-diabetes patients (OR:1.83 vs. diabetes, 95% CI 1.20–2.80, p = 0.005) with the same elevated glucose levels at admission. In addition, CoV>30% resulted in higher risk of death as well (aOR:1.88 vs. CoV between 10 and 30, 95%CI 1.24–2.86 p = 0.003).

Conclusions

This study indicates that while diabetes mellitus seems to be a protective factor in sepsis patients, hyper- or hypoglycemia status on admission, and increased blood glucose variation during hospital stays, were independently associated with increased odds ratio of mortality.

[Metabolic control in the critically ill patient an update: hyperglycemia, glucose variability hypoglycemia and relative hypoglycemia]

BACKGROUND

Metabolic changes of glucose in critically ill patients increase morbidity and mortality. The appropriate level of blood glucose has not been established so far and should be adjusted for different populations. However concepts such as glucose variability and relative hypoglycemia of critically ill patients are concepts that are changing management methods and achieving closer monitoring.

OBJECTIVES

The purpose of this review is to present new data about the management and metabolic control of patients in critical areas.

CONCLUSIONS

Currently glucose can no longer be regarded as an innocent element in critical patients; both hyperglycemia and hypoglycemia increase morbidity and mortality of patients. Protocols and better instruments for continuous measurement are necessary to achieve the metabolic control of our patients.

Glucose Control in the ICU: A Continuing Story

In the present era of near-continuous glucose monitoring (CGM) and automated therapeutic closed-loop systems, measures of accuracy and of quality of glucose control need to be standardized for licensing authorities and to enable comparisons across studies and devices. Adequately powered, good quality, randomized, controlled studies are needed to assess the impact of different CGM devices on the quality of glucose control, workload, and costs. The additional effects of continuing glucose control on the general floor after the ICU stay also need to be investigated. Current algorithms need to be adapted and validated for CGM, including effects on glucose variability and workload. Improved collaboration within the industry needs to be encouraged because no single company produces all the necessary components for an automated closed-loop system. Combining glucose measurement with measurement of other variables in 1 sensor may help make this approach more financially viable.

Glucagon orchestrates stress-induced hyperglycaemia

Hyperglycaemia is commonly observed on admission and during hospitalization for medical illness, traumatic injury, burn and surgical intervention. This transient hyperglycaemia is referred to as stress-induced hyperglycaemia (SIH) and frequently occurs in individuals without a history of diabetes. SIH has many of the same underlying hormonal disturbances as diabetes mellitus, specifically absolute or relative insulin deficiency and glucagon excess. SIH has the added features of elevated blood levels of catecholamines and cortisol, which are not typically present in people with diabetes who are not acutely ill. The seriousness of SIH is highlighted by its greater morbidity and mortality rates compared with those of hospitalized patients with normal glucose levels, and this increased risk is particularly high in those without pre-existing diabetes. Insulin is the treatment standard for SIH, but new therapies that reduce glucose variability and hypoglycaemia are desired. In the present review, we focus on the key role of glucagon in SIH and discuss the potential use of glucagon receptor blockers and glucagon-like peptide-1 receptor agonists in SIH to achieve target glucose control.

Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients

BACKGROUND AND AIMS

The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA1c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients.

MATERIALS AND METHODS

Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A1c (HbA1c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients.

RESULTS

Without considering the history of diabetes, nonsurvivors had significantly higher HbA1c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004-1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA1c increased the risk of death; with each increase in HbA1c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933-1.58, RR: 1.2).

CONCLUSIONS

Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia.

Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications

Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as "stress hyperglycemia" (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.

The intraoperative glycemic response to intravenous insulin during noncardiac surgery: a subanalysis of the DeLiT randomized trial

Patient characteristics may affect patients' response to insulin. We examined the impact of body weight and presence of diabetes on the response to insulin during noncardiac surgery. We studied 202 patients who were enrolled in the DeLiT Trial and received intraoperative intravenous insulin. Univariable and multivariable analyses (Bonferroni corrected) assessed the relationship between patient's response to the initial intraoperative I.V. bolus of regular insulin and the factors of interest. Blood glucose concentrations decreased 8.3 ± 10mg/dL (0.46 ± 0.56mmol/L) per unit of I.V. insulin in 30minutes. The response to insulin was similar in patients with or without diabetes (adjusted mean difference [97.5% confidence interval], 0.2 [-3.9, 4.2] mg/dL, 0.01 [-0.22, 0.24] mmol/L; P = .93). No relationship was found between insulin response and body weight (P=0.38). Our results suggest that adjustment for body weight and the presence of diabetes may not improve intraoperative insulin treatment algorithms.

Stress-induced hyperglycemia is associated with higher mortality in severe traumatic brain injury

BACKGROUND

An association between stress-induced hyperglycemia (SIH) and increased mortality has been demonstrated following trauma. Experimental animal model data regarding the association between hyperglycemia and outcomes following traumatic brain injury (TBI) are inconsistent, suggesting that hyperglycemia may be harmful, neutral, or beneficial. The purpose of this study was to examine the effects of SIH versus diabetic hyperglycemia (DH) on severe TBI.

METHODS

Admission glycosylated hemoglobin (HbA1c), glucose levels, and comorbidity data were collected during a 4-year period from September 2009 to December 2013 for patients with severe TBI (i.e., admission Glasgow Coma Scale [GCS] score of 3-8 and head Abbreviated Injury Scale [AIS] score ≥ 3). Diabetes mellitus was determined by patient history or admission HbA1c of 6.5% or greater. SIH was determined by the absence of diabetes mellitus and admission glucose of 200 mg/dL or greater. A Cox proportional hazards model adjusted for age, sex, injury mechanism, and Injury Severity Score (ISS) was used to calculate hazard ratios (HRs) and associated 95% confidence intervals (CIs) for the association between SIH and the outcomes of interest.

RESULTS

During the study period, a total of 626 patients were included in the study group, having severe TBI defined by both GCS score of 3 to 8 and head AIS score being 3 or greater and also had available HbA1c and admission glucose levels. A total of 184 patients were admitted with hyperglycemia; 152 patients (82.6%) were diagnosed with SIH, and 32 patients (17.4%) were diagnosed with DH. When comparing patients with severe TBI adjusted for age, sex, injury mechanism, ISS, Revised Trauma Score (RTS), and lactic acid greater than 2.5 mmol/L, patients with SIH had a 50% increased mortality (HR, 1.49; 95% CI, 1.13-1.95) compared with the nondiabetic normoglycemia patients. DH patients did not have a significant increase in mortality (HR, 0.94; 95% CI, 0.56-1.58).

CONCLUSION

SIH is associated with higher mortality after severe TBI. This association was not observed among patients with DH, which suggests that hyperglycemia related to diabetes is of less importance compared with SIH in terms of mortality in the acute trauma and TBI patient. Further research is warranted to identify mechanisms causing SIH and subsequent worse outcomes after TBI.

LEVEL OF EVIDENCE

Prognostic/epidemiologic study, leve III.

Tight glycemic control and cardiovascular effects in type 2 diabetic patients

Diabetes Mellitus (DM) with poor glycemic control is one of the leading causes for cardiovascular mortality in diabetic patients. Tight glycemic control with glycosylated haemoglobin of <7 gms% is recommended as a routine and < 6.5 gms% is recommended for young and newly diagnosed diabetics. Treatment goal aims at achieving near normal blood glucose level, and directed at management of other co morbid conditions such as obesity, hypertension and dyslipidemia. Oral hypoglycemic agents are the preferred drugs, alone or in combination. Preference for glitazones is declining due to the increasing evidences of associated adverse events. Gliptins appear as promising agents with lesser tendency to cause hypoglycemia, but their long term safety and efficacy is yet to be established. We emphasize the role of preventive measures in prediabetics and in established DM, treatment should be individualized and customized to minimize hypoglycemic effects and to retain quality of life.

Evaluation of glucose management during therapeutic hypothermia at a Tertiary Academic Medical Center

STUDY AIM

Alterations in metabolic function during therapeutic hypothermia (TH) decrease responsiveness to insulin and increase the risk of hyperglycemia. Glycemic control is associated with improved outcomes in selected patients; however, glycemic management strategies during TH are not defined. The objective of this analysis was to evaluate the glycemic metrics and IV insulin administration in critically ill patients during the cooling and rewarming phases of TH.

METHODS

Data from 37 patients who received at least 6h of therapeutic hypothermia for cardiac arrest between January 2007 and January 2010 were retrospectively evaluated, 14 (37.8%) of whom had diabetes.

RESULTS

The mean blood glucose was 9.16±3.22mmol/L and 6.54±2.45mmol/L; p<0.01 during cooling and rewarming, respectively. Twelve (32.4%) patients experienced at least one hypoglycemic event, defined as a blood glucose <4mmol/L. Nineteen (51.4%) patients experienced at least one hyperglycemic event, defined as a blood glucose >11.11mmol/L and 15 (40.5%) patients received IV insulin therapy. Patients on IV insulin had a higher incidence of diabetes (9 vs. 5; p<0.05), higher admission blood glucose (13.89±6.13 vs. 11.03±4.65mmol/L; p=0.11), and a higher incidence of hyperglycemia (14 vs. 2; p<0.01) and hypoglycemia (8 vs. 4; p<0.05). Of the patients on IV insulin, mean insulin requirements during cooling and rewarming were 15.2±16.1 and 7±12.5units/h, respectively.

CONCLUSION

TH is commonly associated with hyperglycemia, hypoglycemia, and the use of IV insulin therapy. Further research is needed to determine optimal glycemic management strategies to prevent hyper- and hypoglycemia in patients during the different phases of TH.

The diabetes paradox: diabetes is not independently associated with mortality in critically ill patients

Intensive monitoring of blood glucose levels and treatment of hyperglycemia in critically ill patients has become a standard of care over the past decade. Although diabetes is associated with a large burden of illness in outpatients, the "diabetes paradox" suggests that in patients admitted to intensive care units, the presence of diabetes as a comorbidity is not independently associated with increased risk of mortality. This review article 1) describes prospective trial and observational cohort literature addressing this issue, 2) addresses the potential mechanisms underlying the diabetes paradox, and 3) discusses implications for patient care and future research.

Diabetes and stress hyperglycemia in the intensive care unit: outcomes after cardiac surgery

BACKGROUND

Hyperglycemia is common in the post-cardiac surgery population and has been associated with increased mortality rates, surgical length of stay, and infection rates. Although hospitalized patients with diabetes are known to have more complications, recent studies in various hospital settings have reported worse outcomes in patients with stress hyperglycemia than in those with diabetes.

AIM

The primary objective of this study was to analyze 30- and 90-day mortality rates in post-cardiac surgery patients with stress hyperglycemia and diabetes who were managed to achieve similar moderate blood glucose goals using the University of Michigan Hospital (Ann Arbor, MI) insulin protocol between 2005 and 2008. The secondary outcomes were rates of postoperative complications, including hypoglycemia.

METHODS

A standardized glucose management program was followed to treat all patients in the cardiac intensive care unit, with a blood glucose goal of 100 to 140 mg/dL. Data from 1973 patients with either diabetes or stress hyperglycemia were analyzed to identify associations between mean postoperative blood glucose levels and mortality, incidence of hypoglycemia, and complication rates.

RESULTS

Mortality rates did not differ between patients with diabetes and stress hyperglycemia (3.4 and 2.3%; P = 0.2). Rates of severe hypoglycemia were low (1%) for both groups and were not associated with an increase in mortality (P = 0.95). Other complication rates were similar between patients with diabetes and stress hyperglycemia.

CONCLUSION

Maintaining a blood glucose range between 100 to 140 mg/dL in post-cardiac surgery patients was associated with a low mortality rate, low risk of hypoglycemia, and with complications rates that were similar in patients with diabetes and stress hyperglycemia.

Glucose control in intensive care: usability, efficacy and safety of Space GlucoseControl in two medical European intensive care units

BACKGROUND

The Space GlucoseControl system (SGC) is a nurse-driven, computer-assisted device for glycemic control combining infusion pumps with the enhanced Model Predictive Control algorithm (B. Braun, Melsungen, Germany). We aimed to investigate the performance of the SGC in medical critically ill patients.

METHODS

Two open clinical investigations in tertiary centers in Graz, Austria and Zurich, Switzerland were performed. Efficacy was assessed by percentage of time within the target range (4.4-8.3 mmol/L; primary end point), mean blood glucose, and sampling interval. Safety was assessed by the number of hypoglycemic episodes (≤2.2 mmol/L) and the percentage of time spent below this cutoff level. Usability was analyzed with a standardized questionnaire given to involved nursing staff after the trial.

RESULTS

Forty medical critically ill patients (age, 62 ± 15 years; body mass index, 30.0 ± 8.9 kg/m2; APACHE II score, 24.8 ± 5.4; 27 males; 8 with diabetes) were included for a period of 6.5 ± 3.7 days (n = 20 in each center). The primary endpoint (time in target range 4.4 to 8.3 mmol/l) was reached in 88.3% ± 9.3 of the time and mean arterial blood glucose was 6.7 ± 0.4 mmol/l. The sampling interval was 2.2 ± 0.4 hours. The mean daily insulin dose was 87.2 ± 64.6 IU. The adherence to the given insulin dose advice was high (98.2%). While the percentage of time spent in a moderately hypoglycemic range (2.2 to 3.3 mmol/L) was low (0.07 ± 0.26% of the time), one severe hypoglycemic episode (<2.2 mmol/L) occurred (2.5% of patients or 0.03% of glucose readings).

CONCLUSIONS

SGC is a safe and efficient method to control blood glucose in critically ill patients as assessed in two European medical intensive care units.

Glucose control in the ICU: is there a time for more ambitious targets again?

During the last 2 decades, the treatment of hyperglycemia in critically ill patients has become one of the most discussed topics in the intensive medicine field. The initial data suggesting significant benefit of normalization of blood glucose levels in critically ill patients using intensive intravenous insulin therapy have been challenged or even neglected by some later studies. At the moment, the need for glucose control in critically ill patients is generally accepted yet the target glucose values are still the subject of ongoing debates. In this review, we summarize the current data on the benefits and risks of tight glucose control in critically ill patients focusing on the novel technological approaches including continuous glucose monitoring and its combination with computer-based algorithms that might help to overcome some of the hurdles of tight glucose control. Since increased risk of hypoglycemia appears to be the major obstacle of tight glucose control, we try to put forward novel approaches that may help to achieve optimal glucose control with low risk of hypoglycemia. If such approaches can be implemented in real-world practice the entire concept of tight glucose control may need to be revisited.

Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality

PURPOSE

Hyperglycaemia is common in the critically ill. The objectives of this study were to determine the prevalence of critical illness-associated hyperglycaemia (CIAH) and recognised and unrecognised diabetes in the critically ill as well as to evaluate the impact of premorbid glycaemia on the association between acute hyperglycaemia and mortality.

METHODS

In 1,000 consecutively admitted patients we prospectively measured glycated haemoglobin (HbA1c) on admission, and blood glucose concentrations during the 48 h after admission, to the intensive care unit. Patients with blood glucose ≥7.0 mmol/l when fasting or ≥11.1 mmol/l during feeding were deemed hyperglycaemic. Patients with acute hyperglycaemia and HbA1c <6.5% (48 mmol/mol) were categorised as 'CIAH', those with known diabetes as 'recognised diabetes', and those with HbA1c ≥6.5% but no previous diagnosis of diabetes as 'unrecognised diabetes'. The remainder were classified as 'normoglycaemic'. Hospital mortality, HbA1c and acute peak glycaemia were assessed using a logistic regression model.

RESULTS

Of 1,000 patients, 498 (49.8%) had CIAH, 220 (22%) had recognised diabetes, 55 (5.5%) had unrecognised diabetes and 227 (22.7%) were normoglycaemic. The risk of death increased by approximately 20% for each increase in acute glycaemia of 1 mmol/l in patients with CIAH and those with diabetes and HbA1c levels <7% (53 mmol/mol), but not in patients with diabetes and HbA1c ≥7%. This association was lost when adjusted for severity of illness.

CONCLUSIONS

Critical illness-associated hyperglycaemia is the most frequent cause of hyperglycaemia in the critically ill. Peak glucose concentrations during critical illness are associated with increased mortality in patients with adequate premorbid glycaemic control, but not in patients with premorbid hyperglycaemia. Optimal glucose thresholds in the critically ill may, therefore, be affected by premorbid glycaemia.

Should guidelines for glycemic control of the critically ill be individualized?: Weighing the evidence from randomized and observational investigations

The monitoring of blood glucose and treatment of hyperglycemia has been a standard of care in intensive care units since the publication of a single-center randomized controlled trial (RCT) of intensive insulin therapy in 2001 that demonstrated marked improvements in mortality. Professional societies created guidelines based on the results of this investigation, and revised them based on the results of a very small group of RCTs that followed. This commentary reviews the weight of evidence provided by the RCTs in comparison to the large body of evidence from observational studies regarding glycemic control of the critically ill, and suggests that the totality of evidence should be considered in the formulation of clinical practice paradigms.

Coefficient of glucose variation is independently associated with mortality in critically ill patients receiving intravenous insulin

INTRODUCTION

Both patient- and context-specific factors may explain the conflicting evidence regarding glucose control in critically ill patients. Blood glucose variability appears to correlate with mortality, but this variability may be an indicator of disease severity, rather than an independent predictor of mortality. We assessed blood glucose coefficient of variation as an independent predictor of mortality in the critically ill.

METHODS

We used eProtocol-Insulin, an electronic protocol for managing intravenous insulin with explicit rules, high clinician compliance, and reproducibility. We studied critically ill patients from eight hospitals, excluding patients with diabetic ketoacidosis and patients supported with eProtocol-insulin for < 24 hours or with < 10 glucose measurements. Our primary clinical outcome was 30-day all-cause mortality. We performed multivariable logistic regression, with covariates of age, gender, glucose coefficient of variation (standard deviation/mean), Charlson comorbidity score, acute physiology score, presence of diabetes, and occurrence of hypoglycemia < 60 mg/dL.

RESULTS

We studied 6101 critically ill adults. Coefficient of variation was independently associated with 30-day mortality (odds ratio 1.23 for every 10% increase, P < 0.001), even after adjustment for hypoglycemia, age, disease severity, and comorbidities. The association was higher in non-diabetics (OR = 1.37, P < 0.001) than in diabetics (OR 1.15, P = 0.001).

CONCLUSIONS

Blood glucose variability is associated with mortality and is independent of hypoglycemia, disease severity, and comorbidities. Future studies should evaluate blood glucose variability.