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

Comparison of all-cause mortality with different blood glucose control strategies in patients with diabetes in the ICU: a network meta-analysis of randomized controlled trials

BACKGROUND

The optimal glucose control strategy for intensive care unit (ICU) patients with diabetes remains a topic of debate. This study aimed to compare the effects of strict glucose control, intermediate strict glucose control, liberal glucose control, and very liberal glucose control on reducing all-cause mortality in ICU patients with diabetes through a network meta-analysis.

METHODS

We conducted a search in PubMed, Cochrane Library, Embase, and Web of Science for randomized controlled trials comparing different glucose control strategies in ICU patients with diabetes up to October 1, 2024. The primary outcome was all-cause 90-day mortality. The Risk of Bias 2 tool was used to assess bias in the included studies. Data analysis was performed using Stata (version 17).

RESULTS

A total of 12 randomized controlled trials involving 5,297 participants were included in the final analysis. The results showed that there was no statistically significant difference between the four glucose control strategies in reducing all-cause 90-day mortality. The surface under the cumulative ranking (SUCRA), which was used to rank the strategies and display the probability of each strategy being ranked first, showed the following: intermediate strict control (SUCRA 88%), liberal control (SUCRA 55.3%), very liberal control (SUCRA 40.3%), and strict control (SUCRA 16.5%). The cumulative probability of each strategy's rank in reducing all-cause mortality, from best to worst, showed that the most likely ranking was intermediate strict control, liberal control, very liberal control, and strict control.

CONCLUSIONS

In ICU patients with diabetes, no significant statistical difference was observed among the four glucose control strategies in reducing all-cause 90-day mortality. The SUCRA rankings are hypothesis-generating and require further validation. Therefore, the current evidence is insufficient to definitively conclude that any one strategy is superior to the others in reducing mortality.

Stress hyperglycemia ratio and the clinical outcome of patients with heart failure: a meta-analysis

Background

Stress hyperglycemia ratio (SHR) is a newly suggested measure of stress-induced hyperglycemia that combines both short-term and long-term glycemic conditions. The study aimed to explore the association between SHR and the incidence of adverse clinical events with heart failure (HF) through a meta-analysis.

Methods

Cohort studies relevant to the aim of the meta-analysis were retrieved by search of electronic databases including PubMed, Web of Science, Embase, Wanfang, and CNKI. A random-effects model was used to combine the data by incorporating the influence of between-study heterogeneity.

Results

Ten studies involving 15250 patients with HF were included. Pooled results showed that compared to patients with lower SHR at baseline, those with a higher SHR were associated with an increased risk of all-cause mortality during follow-up (risk ratio [RR]: 1.61, 95% confidence interval [CI]: 1.17 to 2.21, p = 0.003; I2 = 82%). Further meta-regression analysis suggests that different in the cutoff of SHR significantly modify the results (coefficient = 1.22, p = 0.02), and the subgroup analysis suggested a more remarkable association between SHR and all-cause mortality in studies with cutoff of SHR ≥ 1.05 than those with cutoff of SHR < 1.05 (RR: 2.29 versus 1.08, p for subgroup difference < 0.001). Subsequent meta-analyses also showed that a high SHR at baseline was related to the incidence of cardiovascular death (RR: 2.19, 95% CI: 1.55 to 3.09, p < 0.001; I2 = 0%), HF-rehospitalization (RR: 1.83, 95% CI: 1.44 to 2.33, p < 0.001; I2 = 0%), and major adverse cardiovascular events (RR: 1.54, 95% CI: 1.15 to 2.06, p = 0.004; I2 = 74%) during follow-up.

Conclusion

A high SHR at baseline is associated with a poor clinical prognosis of patients with HF.

Systematic review registration

https://inplasy.com, identifier INPLASY202430080.

Accuracy of point-of-care capillary blood sugar measurements in critically ill patients: An observational study

Background

Accurately monitoring blood glucose levels is vital for critically ill individuals. Point-of-care (POC) glucose meters are commonly used in local intensive care units (ICUs). This study aimed to assess the precision of POC glucose meter readings in critically ill individuals with specific evaluation in patients with and without shock against the reference standard of venous blood glucose measurements.

Methods

An observational study was done on adult patients admitted in the ICU at a teaching institution. Capillary blood samples were collected from the patient's fingertip using lancet device with aseptic measures. The sample was analyzed using the GlucoCare Sense Glucometer (RMD Mediaids Limited, Taiwan). At the same time, 2 ml of blood was drawn from the patient's peripheral veins and analyzed by glucose oxidase-peroxidase method as reference.

Results

POC glucose measurements averaged 140 ± 20.23 mg/dl, while laboratory values were recorded as 116.10 ± 17.13 mg/dl. The difference between the two methods was 24.34 ± 12.01 mg/dl. A strong correlation (r = 0.805) was found between capillary and laboratory blood glucose levels, indicating a significant association (P < 0.0001). Twenty-two (44%) patients were in shock during the study. The mean difference between laboratory and POC blood glucose levels was higher in patients with circulatory shock (36.82 ± 4.84 mg/dl) than those without shock (14.61 ± 4.49 mg/dl), P < 0.05.

Conclusion

POC glucose meters may lead to underdetection of hypoglycemia in critically ill patients, as their values are higher than laboratory values. Moreover, the results showed that POC glucometers are inaccurate for monitoring glucose in hypotensive patients in shock. Standard venous glucose monitoring methods may be more appropriate for these patients.

Tight versus liberal blood-glucose control in the intensive care unit: special considerations for patients with diabetes

Stress hyperglycaemia, hypoglycaemia, and diabetes are common in critically ill patients and related to clinical endpoints. To avoid complications related to hypoglycaemia and hyperglycaemia, it is recommended to start insulin therapy for the majority of critically ill patients with persistent blood glucose concentrations higher than 10·0 mmol/L (>180 mg/dL), targeting a range of 7·8-10·0 mmol/L (140-180 mg/dL). However, management and evidence-based targets for blood glucose control are under debate, particularly for patients with diabetes. Recent randomised controlled clinical trials now challenge current recommendations. In this Personal View, we aim to highlight these developments and the important differences between critically ill patients with and without diabetes, taking into account the considerable heterogeneity in this patient group. We critically discuss evidence from prospective randomised controlled trials and observational studies on the safety and efficacy of glycaemic control, specifically in the context of patients with diabetes in intensive care units.

Relationship between time-weighted average glucose and mortality in critically ill patients: a retrospective analysis of the MIMIC-IV database

Blood glucose management in intensive care units (ICU) remains a controversial topic. We assessed the association between time-weighted average glucose (TWAG) levels and ICU mortality in critically ill patients in a real-world study. This retrospective study included critically ill patients from the Medical Information Mart for Intensive Care IV database. Glycemic distance is the difference between TWAG in the ICU and preadmission usual glycemia assessed with glycated hemoglobin at ICU admission. The TWAG and glycemic distance were divided into 4 groups and 3 groups, and their associations with ICU mortality risk were evaluated using multivariate logistic regression. Restricted cubic splines were used to explore the non-linear relationship. A total of 4737 adult patients were included. After adjusting for covariates, compared with TWAG ≤ 110 mg/dL, the odds ratios (ORs) of the TWAG > 110 mg/dL groups were 1.62 (95% CI 0.97-2.84, p = 0.075), 3.41 (95% CI 1.97-6.15, p < 0.05), and 6.62 (95% CI 3.6-12.6, p < 0.05). Compared with glycemic distance at - 15.1-20.1 mg/dL, the ORs of lower or higher groups were 0.78 (95% CI 0.50-1.21, p = 0.3) and 2.84 (95% CI 2.12-3.82, p < 0.05). The effect of hyperglycemia on ICU mortality was more pronounced in non-diabetic and non-septic patients. TWAG showed a U-shaped relationship with ICU mortality risk, and the mortality risk was minimal at 111 mg/dL. Maintaining glycemic distance ≤ 20.1 mg/dL may be beneficial. In different subgroups, the impact of hyperglycemia varied.

Acute and Chronic Glucose Control in Critically Ill Patients With Diabetes: The Impact of Prior Insulin Treatment

BACKGROUND

Emerging data highlight the interactions of preadmission glycemia, reflected by admission HbA1c levels, glycemic control during critical illness, and mortality. The association of preadmission insulin treatment with outcomes is unknown.

METHODS

This observational cohort study includes 5245 patients admitted to the medical-surgical intensive care unit of a university-affiliated teaching hospital. Three groups were analyzed: patients with diabetes with prior insulin treatment (DM-INS, n = 538); patients with diabetes with no prior insulin treatment (DM-No-INS, n = 986); no history of diabetes (NO-DM, n = 3721). Groups were stratified by HbA1c level: <6.5%; 6.5%-7.9% and >8.0%.

RESULTS

Among the three strata of HbA1c, mean blood glucose (BG), coefficient of variation (CV), and hypoglycemia increased with increasing HbA1c, and were higher for DM-INS than for DM-No-INS. Among patients with HbA1c < 6.5%, mean BG ≥ 180 mg/dL and CV > 30% were associated with lower severity-adjusted mortality in DM-INS compared to patients with mean BG 80-140 mg/dL and CV < 15%, (P = .0058 and < .0001, respectively), but higher severity-adjusted mortality among DM-No-INS (P = .0001 and < .0001, respectively) and NON-DM (P < .0001 and < .0001, respectively). Among patients with HbA1c ≥ 8.0%, mean BG ≥ 180 mg/dL was associated with lower severity-adjusted mortality for both DM-INS and DM-No-INS than was mean BG 80-140 mg/dL (p < 0.0001 for both comparisons).

CONCLUSIONS

Significant differences in mortality were found among patients with diabetes based on insulin treatment and HbA1c at home and post-admission glycemic control. Prospective studies need to confirm an individualized approach to glycemic control in the critically ill.

Is it time to personalise glucose targets during critical illness?

PURPOSE OF REVIEW

Dysglycaemia complicates most critical care admissions and is associated with harm, yet glucose targets, particularly in those with preexisting diabetes, remain controversial. This review will summarise advances in the literature regarding personalised glucose targets in the critically ill.

RECENT FINDINGS

Observational data suggest that the degree of chronic hyperglycaemia in critically ill patients with diabetes attenuates the relationship between mortality and several metrics of dysglycaemia, including blood glucose on admission, and mean blood glucose, glycaemic variability and hypoglycaemia in the intensive care unit. The interaction between acute and chronic hyperglycaemia has recently been quantified with novel metrics of relative glycaemia including the glycaemic gap and stress hyperglycaemia ratio. Small pilot studies provided preliminary data that higher blood glucose thresholds in critically ill patients with chronic hyperglycaemia may reduce complications of intravenous insulin therapy as assessed with biomakers. Although personalising glycaemic targets based on preexisting metabolic state is an appealing concept, the recently published CONTROLLING trial did not identify a mortality benefit with individualised glucose targets, and the effect of personalised glucose targets on patient-centred outcomes remains unknown.

SUMMARY

There is inadequate data to support adoption of personalised glucose targets into care of critically ill patients. However, there is a strong rationale empowering future trials utilising such an approach for patients with chronic hyperglycaemia.

Glycemic control in critically ill patients with or without diabetes

Background

Early randomized controlled trials have demonstrated the benefits of tight glucose control. Subsequent NICE-SUGAR study found that tight glucose control increased mortality. The optimal glucose target in diabetic and nondiabetic patients remains unclear. This study aimed to evaluate the relationship between blood glucose levels and outcomes in critically ill patients with or without diabetes.

Methods

This was a retrospective analysis of the eICU database. Repeat ICU stays, ICU stays of less than 2 days, patients transferred from other ICUs, those with less than 2 blood glucose measurements, and those with missing data on hospital mortality were excluded. The primary outcome was hospital mortality. Generalised additive models were used to model relationship between glycemic control and mortality. Models were adjusted for age, APACHE IV scores, body mass index, admission diagnosis, mechanical ventilation, and use of vasopressor or inotropic agents.

Results

There were 52,107 patients in the analysis. Nondiabetes patients exhibited a J-shaped association between time-weighted average glucose and hospital mortality, while this association in diabetes patients was right-shifted and flattened. Using a TWA glucose of 100 mg/dL as the reference value, the adjusted odds ratio (OR) of TWA glucose of 140 mg/dL was 3.05 (95% confidence interval (CI) 3.03–3.08) in nondiabetes and 1.14 (95% CI 1.08–1.20) in diabetes patients. The adjusted OR of TWA glucose of 180 mg/dL were 4.20 (95% CI 4.07–4.33) and 1.49 (1.41–1.57) in patients with no diabetes and patients with diabetes, respectively. The adjusted ORs of TWA glucose of 80 mg/dL compared with 100 mg/dL were 1.74 (95% CI 1.57–1.92) in nondiabetes and 1.36 (95% CI 1.12–1.66) in patients with diabetes. The glucose ranges associated with a below-average risk of mortality were 80–120 mg/dL and 90–150 mg/dL for nondiabetes and diabetes patients, respectively. Hypoglycemia was associated with increased hospital mortality in both groups but to a lesser extent in diabetic patients. Glucose variability was positively associated with hospital mortality in nondiabetics.

Conclusions

Time-weighted average glucose, hypoglycemia, and glucose variability had different impacts on clinical outcomes in patients with and without diabetes. Compared with nondiabetic patients, diabetic patients showed a more blunted response to hypo- and hyperglycemia and glucose variability. Glycemic control strategies should be reconsidered to avoid both hypoglycemia and hyperglycemia.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-022-01769-4.

The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A multicenter, parallel-group, open-label, randomized clinical trial

Rationale Blood glucose concentrations affect outcomes in critically ill patients but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objective To evaluate the effects of a 'liberal' approach to targeted blood glucose range during intensive care unit (ICU) admission. Methods This mutlicenter, parallel-group, open-label, randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dL and titrated to a target range of 180 to 252 mg/dL. In the comparator group insulin was commenced at a blood glucose >180 mg/dL and titrated to a target range of 108 to 180 mg/dL. The primary outcome was incident hypoglycemia (<72 mg/dL). Secondary outcomes included glucose metrics and clinical outcomes. Main Results At least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio: 0.21 (95% CI, 0.09 to 0.49); P<0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability and less relative hypoglycaemia (P<0.001 for all comparisons). By day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference 4.6 percentage points (95%CI, -3.9 to 13.2%); P=0.29). Conclusions A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registration available at www.anzctr.org.au, ID: ACTRN12616001135404.

Relative Hypoglycemia and Lower Hemoglobin A1c-Adjusted Time in Band Are Strongly Associated With Increased Mortality in Critically Ill Patients

OBJECTIVES

To determine the associations of relative hypoglycemia and hemoglobin A1c-adjusted time in blood glucose (BG) band (HA-TIB) with mortality in critically ill patients.

DESIGN

Retrospective cohort investigation.

SETTING

University-affiliated adult medical-surgical ICU.

PATIENTS

Three thousand six hundred fifty-five patients with at least four BG tests and hemoglobin A1c (HbA1c) level admitted between September 14, 2014, and November 30, 2019.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients were stratified for HbA1c bands of <6.5%; 6.5-7.9%; greater than or equal to 8.0% with optimal affiliated glucose target ranges of 70-140, 140-180, and 180-250 mg/dL, respectively. HA-TIB, a new glycemic metric, defined the HbA1c-adjusted time in band. Relative hypoglycemia was defined as BG 70-110 mg/dL for patients with HbA1c ≥ 8.0%. Further stratification included diabetes status-no diabetes (NO-DM, n = 2,616) and preadmission treatment with or without insulin (DM-INS, n = 352; DM-No-INS, n = 687, respectively). Severity-adjusted mortality was calculated as the observed:expected mortality ratio (O:EMR), using the Acute Physiology and Chronic Health Evaluation IV prediction of mortality. Among NO-DM, mortality and O:EMR, decreased with higher TIB 70-140 mg/dL (p < 0.0001) and were lowest with TIB 90-100%. O:EMR was lower for HA-TIB greater than or equal to 50% than less than 50% and among all DM-No-INS but for DM-INS only those with HbA1 greater than or equal to 8.0%.Among all patients with hba1c greater than or equal to 8.0% And no bg less than 70 mg/dl, mortality was 18.0% For patients with relative hypoglycemia (bg, 70-110 mg/dl) (p < 0.0001) And was 0.0%, 12.9%, 13.0%, And 34.8% For patients with 0, 0.1-2.9, 3.0-11.9, And greater than or equal to 12.0 Hours of relative hypoglycemia (p < 0.0001).

CONCLUSIONS

These findings have considerable bearing on interpretation of previous trials of intensive insulin therapy in the critically ill. Moreover, they suggest that BG values in the 70-110 range may be deleterious for patients with HbA1c greater than or equal to 8.0% and that the appropriate target for BG should be individualized to HbA1c levels. These conclusions need to be tested in randomized trials.

What Is the Role of Steroids for Septic Shock in 2021?

Corticosteroids have been used for decades in the adjunctive treatment of severe infections in intensive care. The most frequent scenario in intensive care is in septic shock, where low doses of glucocorticoids appear to restore vascular responsiveness to norepinephrine. There is a strong body of evidence suggesting that hydrocortisone reduces time on vasopressor, and may modulate the immune response. In this review, we explore the current evidence supporting the use of corticosteroids in septic shock, its benefits, and potential harms. In addition to landmark clinical trials, we will also describe new frontiers for the use of corticosteroids in septic shock which should be explored in future studies.

Individualised versus conventional glucose control in critically-ill patients: the CONTROLING study-a randomized clinical trial

Purpose

Hyperglycaemia is an adaptive response to stress commonly observed in critical illness. Its management remains debated in the intensive care unit (ICU). Individualising hyperglycaemia management, by targeting the patient’s pre-admission usual glycaemia, could improve outcome.

Methods

In a multicentre, randomized, double-blind, parallel-group study, critically-ill adults were considered for inclusion. Patients underwent until ICU discharge either individualised glucose control by targeting the pre-admission usual glycaemia using the glycated haemoglobin A1c level at ICU admission (IC group), or conventional glucose control by maintaining glycaemia below 180 mg/dL (CC group). A non-commercial web application of a dynamic sliding-scale insulin protocol gave to nurses all instructions for glucose control in both groups. The primary outcome was death within 90 days.

Results

Owing to a low likelihood of benefit and evidence of the possibility of harm related to hypoglycaemia, the study was stopped early. 2075 patients were randomized; 1917 received the intervention, 942 in the IC group and 975 in the CC group. Although both groups showed significant differences in terms of glycaemic control, survival probability at 90-day was not significantly different (IC group: 67.2%, 95% CI [64.2%; 70.3%]; CC group: 69.6%, 95% CI [66.7%; 72.5%]). Severe hypoglycaemia (below 40 mg/dL) occurred in 3.9% of patients in the IC group and in 2.5% of patients in the CC group (p = 0.09). A post hoc analysis showed for non-diabetic patients a higher risk of 90-day mortality in the IC group compared to the CC group (HR 1.3, 95% CI [1.05; 1.59], p = 0.018).

Conclusion

Targeting an ICU patient’s pre-admission usual glycaemia using a dynamic sliding-scale insulin protocol did not demonstrate a survival benefit compared to maintaining glycaemia below 180 mg/dL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06526-8.

Application of Peak Glucose Range and Diabetes Status in Mortality Risk Stratification in Critically Ill Patients with Sepsis

The effects of diabetes and glucose on the outcomes of patients with sepsis are somewhat conflicting. This retrospective study enrolled 1214 consecutive patients with sepsis, including a subpopulation of 148 patients with immune profiles. The septic patients were stratified according to their Diabetes mellitus (DM) status or peak glucose level (three-group tool; P1: ≤140 mg/dL, P2: 141–220 mg/dL, P3: >220 mg/dL) on day 1. Although the DM group had a lower hazard ratio (HR) for 90-day mortality compared to non-DM patients, the adjusted HRs were insignificant. The modified sequential organ failure assessment-glucose (mSOFA-g) score can predict 90-day survival in patients with and without diabetes (β = 1.098, p < 0.001; β = 1.202, p < 0.001). The goodness of fit of the mSOFA-g score was 5% higher than the SOFA score of the subgroup without diabetes. The SOFA score and human leukocyte antigen-D-related (HLA-DR) expression were comparable between the groups. The P3 group had lower HLA-DR expression on days 1 and 3 and a higher 90-day mortality. The three-group tool was useful for predicting 90-day mortality in patients with separate Kaplan-Meier survival curves and mortality HRs in the construction and validation cohorts. The peak glucose level, instead of diabetes status, can be used as an easy adjunctive tool for mortality risk stratification in critically ill septic patients.

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.

Hyperglycemia in Medically Critically Ill Patients: Risk Factors and Clinical Outcomes

BACKGROUND

We aimed to robustly categorize glycemic control in our medical intensive care unit (ICU) as either acceptable or suboptimal based on time-weighted daily blood glucose averages of <180 mg/dL or >180 mg/dL; identify clinical risk factors for suboptimal control; and compare clinical outcomes between the 2 glycemic control categories.

METHODS

This was a retrospective cohort study in an academic tertiary and quaternary medical ICU.

RESULTS

Out of total of 974 unit stays over a 2-year period, 920 had complete data sets available for analysis. Of unit stays 63% (575) were classified as having acceptable glycemic control and the remaining 37% were classified (345) as having suboptimal glycemic control. Adjusting for covariables, the odds of suboptimal glycemic control were highest for patients with diabetes mellitus (odds ratio [OR] 5.08, 95% confidence interval [CI] 3.72-6.93), corticosteroid use during the ICU stay (OR 4.50, 95% CI 3.21-6.32), and catecholamine infusions (OR 1.42, 95% CI 1.04-1.93). Adjusting for acuity, acceptable glycemic control was associated with decreased odds of hospital mortality but not ICU mortality (OR 0.65, 95% CI 0.48-0.88 and OR 0.81, 95% CI 0.55-1.17, respectively). Suboptimal glycemic control was associated with increased odds of longer-than-predicted ICU and hospital stays (OR 1.76, 95% CI 1.30-2.38 and OR 1.50, 95% CI 1.12-2.01, respectively).

CONCLUSIONS

In our high-acuity medically critically ill patient population, achieving time-weighted average daily blood glucose levels <180 mg/dL reliably while in the ICU significantly decreased the odds of subsequent hospital mortality. Suboptimal glycemic control during the ICU stay, on the other hand, significantly increased the odds of longer-than-predicted ICU and hospital stay.

Intraoperative hyperglycemia in patients with an elevated preoperative C-reactive protein level may increase the risk of acute kidney injury after cardiac surgery

PURPOSE

The effect of hyperglycemia on acute kidney injury (AKI) in patients undergoing cardiac surgery is unclear and may involve as yet unexplored factors. We hypothesized differential effects of intraoperative hyperglycemia on AKI after cardiac surgery depending on baseline inflammatory status, as reflected by the C-reactive protein (CRP) level.

METHODS

This retrospective study included patients who underwent cardiac surgery seen at our hospital from 2008 to 2018. Patients were classified into four groups according to their preoperative CRP level (≥ 1 or < 1 mg/dl) and their intraoperative time-weighted average glucose concentration (> 140 or ≤ 140 mg/dl): low CRP and normoglycemia, low CRP and hyperglycemia, high CRP and normoglycemia, and high CRP and hyperglycemia. The data were analyzed by multivariable logistic regression analysis.

RESULTS

The data of 3625 patients were analyzed. The logistic regression showed that patients in the high CRP and hyperglycemia group had a significantly higher risk of AKI than patients in the low CRP and normoglycemia group [odds ratio (OR), 1.58; 95% confidence interval (CI) 1.10-2.27], low CRP with hyperglycemia group (OR, 1.69; 95% CI 1.16-2.47) and high CRP with normoglycemia group (OR, 1.50; 95% CI 1.01-2.23).

CONCLUSIONS

Intraoperative hyperglycemia in patients with an elevated preoperative CRP level was significantly related to an increased risk of AKI after cardiac surgery. Individualized perioperative glycemic control may therefore be necessary in these patients.

Mean amplitude of glycemic excursions in septic patients and its association with outcomes: A prospective observational study using continuous glucose monitoring

PURPOSE

To apply continuous glucose monitoring (CGM) and determine the mean amplitude of glycemic excursions (MAGE) in septic patients and to assess the associations of MAGE with outcomes and oxidative stress.

MATERIALS AND METHODS

This study was conducted in adult septic patients expected to require intensive care for >48 h. We continuously measured blood glucose level for the first 48 h in the ICU using FreeStyle Libre®. MAGE was calculated using glycemic information obtained by CGM during the study period of 48 h. The primary outcome was 90-day all-cause mortality. The secondary outcomes were 90-day ICU-free days and the concentration of urinary 8-isoprostaglandinF2α measured 48 h after commencement of the study as a surrogate of oxidative stress.

RESULTS

Forty patients were included in this study. Median of MAGE was higher in non-survivors than in survivors: 68.8 (IQR;39.7-97.2) vs. 39.3 (IQR;19.9-53.3), p = 0.02. In multivariate analysis, MAGE was independently associated with 90-day all-cause mortality rate (p = 0.02), urinary 8-isoprostaglandinF2α level (p = 0.03) and 90-day ICU-free survival days (p = 0.03).

CONCLUSIONS

In the current study, MAGE for the first 48 h of treatment that was obtained by using CGM was associated with 90-day all-cause mortality, 90-day ICU-free days and urinary 8-isoprostaglandinF2α level in septic patients.

Accuracy of Blood Glucose Measurement and Blood Glucose Targets

BACKGROUND

To summarize new evidence regarding the methodological aspects of blood glucose control in the intensive care unit (ICU).

METHODS

We reviewed the literature on blood glucose control in the ICU up to August 2019 through Ovid Medline and Pubmed.

RESULTS

Since the publication of the Leuven studies, the benefits of glycemic control have been recognized. However, the methodology of blood glucose control, notably the blood glucose measurement accuracy and the insulin titration protocol, plays an important but underestimated role. This may partially explain the negative results of the large, pragmatic multicenter trials and made everyone realize that tight glycemic control with less-frequent glucose measurements on less accurate blood glucose meters is neither feasible nor advisable in daily practice. Blood gas analyzers remain the gold standard. New generation point-of-care blood glucose meters may be an alternative when using whole blood of critically ill patients in combination with a clinically validated insulin dosing algorithm.

CONCLUSION

When implementing blood glucose management in an ICU one needs to take into account the interaction between aimed glycemic target and blood glucose measurement methodology.

Dietary management of blood glucose in medical critically ill patients with overweight/obesity

PURPOSE OF REVIEW

As the obesity epidemic continues, there is a greater proportion of patients with overweight, obesity, and other forms of adiposity-based chronic disease that require intensive care. Nutrition therapy in the ICU is a vital part of critical care but can be challenging in this setting because of the increased risk of stress hyperglycemia and adverse impact of obesity- and diabetes-related complications.

RECENT FINDINGS

Current guidelines favor early nutritional therapy with a hypocaloric, high-protein diet in patients with overweight/obesity. More aggressive protein intake may be useful in those with greater severity of overweight/obesity with an upper limit of 3 g/kg ideal body weight per day. Although there is no specific recommendation, choosing enteral formulas with higher fat content and slower digesting carbohydrates may assist with glucose control. Supplementation with immunonutrients is recommended, given their known benefits in obesity and in reducing inflammation, but must be done in an individualized manner.

SUMMARY

Aggressive nutritional therapy is crucial in patients with overweight/obesity to support ongoing metabolic demands. Although a hypocaloric high-protein feeding strategy is a starting point, nutritional therapy should be approached in an individualized manner taking into account age, weight and BMI, basal metabolism, nutrition status, complications, and comorbidities.