Admission blood glucose predicts mortality and length of stay in patients admitted through the emergency department

Associations of Glycemic Measures in the Normal Range With All-Cause Mortality in the Absence of Traditional Risk Factors

CONTEXT

The investigation of the association between blood glucose within normal range and all-cause mortality among individuals without traditional risk factors is limited.

OBJECTIVE

To determine the associations of 3 glycemic measures (fasting plasma glucose [FPG], hemoglobin A1c [HbA1c], and 2-hour glucose) in the normal range with all-cause mortality among individuals without traditional risk factors.

METHODS

Retrospective cohort study of US National Health and Nutrition Examination Survey in 1988-1994 and 1999-2018. Nonpregnant adults who had a measurement of 2-hour glucose, FPG, and HbA1c, and absence of traditional risk factors were included. Cox proportional hazard models were performed to examine the associations of normal FPG (n = 5793), normal HbA1c (n = 8179), and normal 2-hour glucose (n = 3404) with all-cause mortality.

RESULTS

A significant association was found between 2-hour glucose within the normal range and all-cause mortality among those without traditional risk factors. Compared with participants with 2-hour glucose <80 mg/dL, participants with a higher normal 2-hour glucose level had a higher risk of all-cause mortality (110-139 mg/dL; HR 1.80, 95% CI 1.03-3.15). In the subgroup analysis, significant associations were also found among people aged ≥60 years and men. No significant associations were found between normal FPG and HbA1c levels and all-cause mortality.

CONCLUSION

Among US adults without traditional risk factors, high normal 2-hour glucose level was positively associated with all-cause mortality. This result highlights the potential importance of maintaining a lower normal level of 2-hour glucose for preventing mortality in individuals who are conventionally considered to be cardiovascular healthy.

Admission Blood Glucose Level with a Cutoff Value of 15 mmol/L Is a Reliable Predictor of Mortality in Polytraumatized Patients-a Prospective, Observational, Longitudinal Study From a North African Level One Trauma Center

BACKGROUND

Abnormal admission blood glucose levels were proved to have a mortality predictive value in polytraumatized patients, as reported by studies in developed countries. Reports from developing countries are scarce.

OBJECTIVE

To evaluate the reliability of on-admission blood glucose levels in predicting mortality in polytraumatized patients presented to a North African (developing country) trauma center. The secondary objectives were to investigate other possible mortality predictors and if a cutoff value for each could be obtained.

METHODS

In this prospective longitudinal study, over one year, we included adult (≥18 years) patients who were polytraumatized (ISS ≥17) and presented to our trauma center within six hours of the trauma incident. Various clinical, laboratory, and trauma scores were collected. Blood glucose levels were assessed from blood samples obtained directly after admission. Patients were divided into five groups based on the admission blood glucose levels.

RESULTS

We included 202 patients, having a mean age of 44±13.9 (20 to 70) years, and 52% were females. The mortality rate was 10.9% (including all patients presented with blood glucose levels≥15 mmol/L). The following were significant mortality predictors, admission blood glucose (OR=3.31, 95% CI=1.902-5.763, p<0.001), serum lactate levels (OR=4.017, 95% CI=1.627-9.917, p=0.003), length of hospital stay (OR=1.18, 95% CI= 1.058-1.305, p=0.003), RTS score (OR=1.43, 95% CI=1.023-2.005, p=0.037), and TRISS score (OR=1.099, 95% CI=1.052-1.148, p<0.001). Admission blood glucose levels cutoff value of 15 mmol/L can significantly differentiate between survivors and non-survivors with sensitivity, specificity, PPV, and NPV of 86.4%, 100%, 100%, and 88%, respectively.

CONCLUSION

Abnormal admission blood glucose with a cutoff value of 15mmol/L is a significant mortality predictor in polytraumatized patients from developing country trauma center, among other clinical, laboratory, and trauma scores parameters.

Predictors of 7-day mortality in critically ill patients with hyperglycemic crisis : A single center retrospective analysis

AIM/HYPOTHESIS

The main aim of the study was to identify point of care available laboratory and clinical predictors of 7‑day mortality in critically ill patients with a hyperglycemic crisis.

METHODS

A retrospective study of 990 patients with the first hospitalization due to hyperglycemia was performed. Patients were classified as having diabetic ketoacidosis (DKA) or being in a hyperosmolar hyperglycemic state (HHS) according to the recommendations of the American Diabetes Association (ADA). Patients not fulfilling the ADA criteria for DKA or HHS were summarized in a third group (unclassifiable hyperglycemia, UCH). The primary outcome was 7‑day mortality, potentially relevant factors were analyzed as secondary outcomes.

RESULTS

Overall, the 7‑day mortality was 7.5%, with no significant differences between DKA (7.8%), HHS (14.5%) and UCH (6.1%). Blood lactate levels were significantly higher in nonsurvivors than survivors in all three groups (mean level of 6.3 mmol/l vs. 3.4 mmol/l in DKA, 5.3 mmol/l vs. 3.1 mmol/l in HHS, 5 mmol/l vs. 2.5 mmol/l in UCH). Measured and calculated osmolality were significantly higher in nonsurvivors in the DKA group (measured osmolality 359 mosmol/kg vs. 338 mosmol/kg, calculated osmolality 315 mosmol/kg vs. 305 mosmol/kg) and patients with UCH (354 mosmol/kg vs. 325 mosmol/kg; 315 mosmol/kg vs. 298 mosmol/kg) but not in patients with HHS. Survival analysis for the DKA group showed no significant differences in 7‑day mortality when patients were compared by the ADA criteria of severity (severe, moderate, or mild). Patients with elevated calculated osmolality (> 320 mosmol/kg) and lactate (> 4 mmol/l) had the lowest 7‑day survival rate (66.7%).

CONCLUSION/INTERPRETATION

Our data showed that elevated lactate levels were associated with higher mortality in all types of hyperglycemic crises.

Mixed insulin can improve control of prednisolone-induced hyperglycaemia

BACKGROUND

Hyperglycaemia is a common side effect of prednisolone, although there are no widely accepted guidelines for the management of glucocorticoid-induced hyperglycaemia (GIH). Our institution uses mixed insulin in a pre-breakfast or pre-breakfast and pre-lunch regimen, with the rationale that this profile of insulin action matches the physiological effect of prednisolone on blood glucose levels (BGLs).

AIM

Evaluate the use of the mixed insulin (NovoMix30) in a pre-breakfast or pre-breakfast and pre-lunch regimen as management for GIH in a tertiary hospital setting.

METHOD

We retrospectively evaluated all inpatients coprescribed prednisolone ≥7.5 mg and NovoMix30 for at least 48 hours over a 19-month period. BGLs were evaluated with repeated-measures analysis within four time periods across the day, beginning from the day prior to NovoMix30 administration.

RESULTS

A total of 53 patients were identified. NovoMix30 significantly reduced BGLs in the morning (mean 12.7 ± 4.5 vs. 9.2 ± 3.9 mmol/L, P < 0.001), afternoon (mean 13.6 ± 3.8 vs. 11.9 ± 3.8 mmol/L, P = 0.001) and evening (12.1 ± 3.8 vs. 10.8 ± 3.8 mmol/L, P = 0.01). With uptitration of insulin over 3 days, 43% of all BGLs were within the target range, compared with 23% on day 0 (P < 0.001). The final median dose of NovoMix30 was 0.15 (0.10-0.22) units/kg bodyweight, or 0.40 (0.23-0.69) units/mg of prednisolone, which is lower than our hospital guideline recommends. One overnight hypoglycaemic event was observed.

CONCLUSION

Mixed insulin as a pre-breakfast or pre-breakfast and pre-lunch regimen can target the hyperglycaemic pattern induced by prednisolone and minimise overnight hypoglycaemia. However, higher doses of insulin than those used in our study are likely required for optimal BGL control.

Hyperglycemia Management Prior to Admission in an Urban Emergency Department

BACKGROUND AND OBJECTIVES

The aim of this quality improvement project was to decrease the percentage of emergency department (ED) patients admitted with blood glucose (BG) level above 250 mg/dL to less than 20%.

METHODS

A work group comprised physicians, pharmacists, and endocrinologists collaborated to standardize management of ED hyperglycemia. Plan-Do-Study-Act cycles included education, monitoring of patients with BG level above 200 mg/dL, and development of an ED-specific insulin protocol.

RESULTS

Following the initiative, 24.8% fewer patients were admitted with BG level above 250 mg/dL. The average admission BG level was reduced by 65.8 mg/dL, creating a significant shift toward improved average BG level. No difference was seen in hospital mortality, hospital length of stay, ED length of stay, hypoglycemia, or inhospital diabetic ketoacidosis or hyperglycemic hyperosmolar syndrome.

CONCLUSION

Implementation of a standardized hyperglycemia treatment protocol along with pharmacist interventions reduced average admission BG and the percentage of patients with BG level above 250 mg/dL on admission.

In-Hospital Mortality and Glycemic Control in Patients with Hospital Hyperglycemia

BACKGROUND

Stress-induced hyperglycemia is a phenomenon that occurs typically in patients hospitalized for acute disease and resolves spontaneously after regression of the acute illness. However, it can also occur in diabetes patients, a fact that is sometimes overlooked. It is thus important to make a proper diabetes diagnosis if hospitalized patients with episodes of hyperglycemia with and without diabetes are studied.

AIMS

To estimate the extent of the association between stress-induced hyperglycemia and in-hospital mortality in patients with hospital hyperglycemia (HH), and to explore potential differences between patients diagnosed with diabetes (HH-DBT) and those with stress-induced hyperglycemia (SH), but not diagnosed with diabetes.

METHODS

A cohort of adults with hospital hyperglycemia admitted to a tertiary, university hospital in Buenos Aires, Argentina, was analyzed retrospectively.

RESULTS

In the study, 2,955 patients were included and classified for analysis as 1,579 SH and 1,376 HH-DBT. Significant differences were observed in glycemic goal (35.53% SH versus 25.80% HH-DBT, p < 0.01), insulin use rate (26.66% SH versus 46.58% HH-DBT, p < 0.01), and severe hypoglycemia rate (1.32% SH versus 1.74% HH-DBT, p < 0.01). There were no differences in hypoglycemia rate (8.23% SH versus 10.53% HH-DBT) and hospital mortality. There was no increase in risk of mortality in the SH group adjusted for age, non-scheduled hospitalization, major surgical intervention, critical care, hypoglycemia, oncological disease, cardiovascular comorbidity, and prolonged hospitalization.

CONCLUSIONS

In this study, we observed better glycemic control in patients with SH than in those with HH-DBT, and there was no difference in hospital mortality.

Admission Blood Glucose in the Emergency Department is Associated with Increased In-Hospital Mortality in Nontraumatic Critically Ill Patients

BACKGROUND

Abnormal admission blood glucose was reported as a useful predictor of outcome in critically ill patients.

OBJECTIVES

To identify patients at higher risk, this study aimed to evaluate the relationship between admission blood glucose levels and patient mortality during the management of nontraumatic critically ill patients in the emergency department (ED).

METHODS

In this prospective, single-center observational study in a German university ED, all adult patients admitted to the resuscitation room of the ED were included between September 1, 2014 and August 31, 2015. Directly after resuscitation room admission, blood samples for admission blood glucose were taken, and adult patients were divided into groups according to predefined cut-offs between the admission blood glucose. Study endpoint was in-hospital mortality.

RESULTS

During the study period, 532 patients were admitted to the resuscitation room. The data of 523 patients (98.3%) were available for analysis. The overall in-hospital mortality was 34.2%. In comparison with an in-hospital mortality of 25.2% at an admission blood glucose of 101-136 mg/dL (n = 107), admission blood glucose of ≤ 100 mg/dL (n = 25, odds ratio [OR] 6.30, 95% confidence interval [CI] 2.44-16.23, p < 0.001), 272-361 mg/dL (n = 63, OR 2.53, 95% CI 1.31-4.90, p = 0.007), and ≥ 362 mg/dL (n = 44, OR 2.96, 95% CI 1.42-6.18, p = 0.004) were associated with a higher mortality.

CONCLUSIONS

Abnormal admission blood glucose is associated with a high in-hospital mortality. Admission blood glucose is an inexpensive and rapidly available laboratory parameter that may predict mortality and help to identify critically ill patients at risk in a general nontraumatic critically ill ED patient cohort. The breakpoint for in-hospital mortality may be an admission blood glucose ≤ 100 and ≥ 272 mg/dL.

Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care

Stress hyperglycemia (SH) is a manifestation of altered glucose metabolism in acutely ill patients which worsens outcomes and may represent a risk factor for diabetes. Continuity of care can assess this risk, which depends on quality of hospital clinical documentation. We aimed to determine the incidence of SH and documentation tendencies in hospital discharge summaries and continuity notes. We retrospectively examined diagnoses during a 12-months period. A 3-months representative sample of discharge summaries and continuity clinic notes underwent manual abstraction. Over 12-months, 495 admissions had ≥ 2 blood glucose measurements ≥ 10 mmol/L (180 mg/dL), which provided a SH incidence of 3.3%. Considering other glucose states suggestive of SH, records showing ≥ 4 blood glucose measurements ≥ 7.8 mmol/L (140 mg/dL) totaled 521 admissions. The entire 3-months subset of 124 records lacked the diagnosis SH documentation in discharge summaries. Only two (1.6%) records documented SH in the narrative of hospital summaries. Documentation or assessment of SH was absent in all ambulatory continuity notes. Lack of documentation of SH contributes to lack of follow-up after discharge, representing a disruptor of optimal care. Activities focused on improving quality of hospital documentation need to be integral to the education and competency of providers within accountable health systems.

Relationship between 24-h venous blood glucose variation and mortality among patients with acute respiratory failure

Evidence indicates that glucose variation (GV) plays an important role in mortality of critically ill patients. We aimed to investigate the relationship between the coefficient of variation of 24-h venous blood glucose (24-hVBGCV) and mortality among patients with acute respiratory failure. The records of 1625 patients in the Multiparameter Intelligent Monitoring in Intensive Care II (MIMIC II) database were extracted. The 24-hVBGCV was calculated as the ratio of the standard deviation (SD) to the mean venous blood glucose level, expressed as a percentage. The outcomes included ICU mortality and in-hospital mortality. Participants were divided into three subgroups based on tertiles of 24-hVBGCV. Multivariable logistic regression models were used to evaluate the relationship between 24-hVBGCV and mortality. Sensitivity analyses were also performed in groups of patients with and without diabetes mellitus. Taking the lowest tertile as a reference, after adjustment for all the covariates, the highest tertile was significantly associated with ICU mortality [odds ratio (OR), 1.353; 95% confidence interval (CI), 1.018–1.797] and in-hospital mortality (OR, 1.319; 95% CI, 1.003–1.735), especially in the population without diabetes. The 24-hVBGCV may be associated with ICU and in-hospital mortality in patients with acute respiratory failure in the ICU, especially in those without diabetes.

Intravenous insulin for the management of non-emergent hyperglycemia in the emergency department

PURPOSE

There is currently no consensus regarding the necessity of emergency department (ED) glucose reduction to manage hyperglycemia in patients presenting without a hyperglycemic emergency. Known consequences of intravenous (IV) insulin administration include hypoglycemia, hypokalemia, and increased ED length of stay. The primary objective of this study was to assess the impact of IV regular insulin on glucose reduction and ED length of stay in patients presenting to the ED with non-emergent hyperglycemia. Secondary objectives included the characterization of potential adverse events.

METHODS

This was a retrospective, observational study of patients ≥18 years who received IV regular insulin and were discharged from the ED at a large academic Trauma Center. Univariate and multivariable regression analyses were utilized to determine if an association existed between IV insulin administration and blood glucose as well as ED length of stay.

RESULTS

A total of 405 patients were included in the analysis. An insulin dose >5 units was associated with a greater reduction in blood glucose (difference = 37.4 mg/dL; p < .001) but no difference in ED length of stay relative to ≤5 units. Furthermore, 7.9% of patients developed hypokalemia and 0.4% developed hypoglycemia.

CONCLUSION

The use of >5 units of IV regular insulin for the management of isolated hyperglycemia in the ED was associated with a modest reduction in blood glucose and no difference in ED length of stay compared with those that received ≤5 units. However, use of IV insulin for this purpose resulted in a 7.9% occurrence of hypokalemia.

Admission glucose level was associated with increased short-term mortality and length-of-stay irrespective of diagnosis, treating medical specialty or concomitant laboratory values

BACKGROUND

Glucose is a routine emergency sample. General guidelines for inpatient hyperglycemia are scarce, except in myocardial infarction, stroke, and perioperative/ICU. Previous studies found admission glucose associated with increased mortality in specific conditions. Scandinavian data, and for general patients, are scarcer. We investigated admission glucose levels, 30-day mortality, and length-of-stay (LoS), in a Swedish hospital.

METHODS

From 8146 emergency visits data regarding age, gender, dates of admission, discharge and death, diagnoses, admission p-glucose, s-sodium, s-potassium, b-hemoglobin, b-WBC and s-CRP, was collected, and for 6283 information regarding diagnosis of diabetes the previous 5 years. Visits were grouped in hypoglycemia (≤4.0), normoglycemia (>4.0-≤7.0), modest (>7.0-≤11.1) and severe hyperglycemia (>11.1) mmol/l.

RESULTS

Short-term mortality was 1.5% in the normoglycemic, 2.6% in the hypoglycemic, 4.0-4.5% in modest and severe hyperglycemia, p < 0.001; Cox proportional hazard ratios (HR) for groups of patients without/with diabetes were 6.8; 1; 3.4; 4.4/7.3; 3.9; 4.0; 2.1 compared to the normoglycemic without diabetes (p 0.0001-0.05); adjusted for age, and concurrent levels of sodium, potassium, Hb, WBC and CRP 1.51 (1.07-2.1, p 0.02) with modest hyperglycemia, and 1.08 (0.60-1.95, p 0.80) in severe hyperglycemia. Mean LoS was 1.2 and 1.7 days longer with modest and severe hyperglycemia.

CONCLUSIONS

Short-term mortality increased substantially with admission hypo- and hyperglycemia for patients both with and without diabetes, irrespective of treating medical specialty, main discharge diagnosis, or concurrent laboratory values. Patients with diabetes (16%) were older, with higher glucose levels at admission, and with a different pattern of the association of admission glucose and mortality.

Glucose and Lactate Levels at Admission as Predictors of In-hospital Mortality

Objective

Glucose and lactate levels in patients at the time of admission have been studied in diverse patient groups. Some studies suggest that elevated glucose levels at admission predict worse outcomes. Elevated Lactate levels have also been reported to be directly associated with increased mortality. We wanted to determine if the combination of admission glucose and lactate levels improves the predictability of inpatient mortality and length of stay (LOS).

Methods

This is a retrospective study. We included all adult patients admitted at an academic medical center from October 1, 2015 to September 30, 2016. We collected basic clinical information, including age, gender, admission glucose and lactate levels, LOS, and mortality. We separated outcomes based on glucose and lactate levels by dividing them into quartiles. We also stratified patients based on normal lactate (<2.0 mmol/L), high lactate (2.0-4.0 mmol/L), and very high lactate (>4 mmol/L) levels; and on normal glucose (60-140 mg/dl), high glucose (140-200 mg/dl), and very high glucose (>200 mg/dl) levels.

Results

A total of 5,436 adult patients were included in our study. The median age was 58 years, and 57% of the patients were male. The median LOS was 6 days, and the overall in-hospital mortality rate was 11%. When the patients were separated in quartiles based on admission glucose values, mortality was higher in the 4th quartile (≥173 mg/dL): 14.87%, probability value (p): <0.001. When the patients were separated in quartiles based on lactate levels, the mortality was higher in the 4th quartile (≥2.23 mmol/L): 21.95%, p: 0.001. When the patients were paired according to normal, high, or very high lactate and glucose levels, the groups that had higher mortality were as follows: normal glucose/very high lactate: 32.43%; high glucose/very high lactate: 34.04%; and very high glucose and very high lactate: 39.15%. The groups with very high glucose and very high lactate had increased odds of mortality when compared with the other groups (p: <0.001).

Conclusions

Admission glucose and lactate levels provide useful information in the estimation of inpatient mortality. The LOS was shortened in the groups with higher glucose, lactate, or both. The combination of glucose and lactate levels predicted mortality better than either value alone. 

Development and Implementation of a Subcutaneous Insulin Clinical Decision Support Tool for Hospitalized Patients

BACKGROUND

Insulin is one of the highest risk medications used in hospitalized patients. Multiple complex factors must be considered in determining a safe and effective insulin regimen. We sought to develop a computerized clinical decision support (CDS) tool to assist hospital-based clinicians in insulin management.

METHODS

Adapting existing clinical practice guidelines for inpatient glucose management, a design team selected, configured, and implemented a CDS tool to guide subcutaneous insulin dosing in non-critically ill hospitalized patients at two academic medical centers that use the EpicCare® electronic medical record (EMR). The Agency for Healthcare Research and Quality (AHRQ) best practices in CDS design and implementation were followed.

RESULTS

A CDS tool was developed in the form of an EpicCare SmartForm, which generates an insulin regimen by integrating information about the patient's body weight, diabetes type, home and hospital insulin requirements, and nutritional status. Total daily recommended insulin doses are distributed into respective basal and nutritional doses with a tailored correctional insulin scale. Preimplementation, several approaches were used to communicate this new tool to clinicians, including emails, lectures, and videos. Postimplementation, a support team was available to address user technical issues. Feedback from stakeholders has been used to continuously refine the tool. Inclusion of the programming in the EMR vendor's community library has allowed dissemination of the tool outside our institution.

CONCLUSIONS

We have developed an EMR-based tool to guide SQ insulin dosing in non-critically ill hospitalized patients. Further studies are needed to evaluate adoption and clinical effectiveness of this intervention.

Retrospective study of inpatient diabetes management service, length of stay and 30-day readmission rate of patients with diabetes at a community hospital

Background: Hospitalized patients with diabetes are at risk of complications and longer length of stay (LOS). Inpatient Diabetes Management Services (IDMS) are known to be beneficial; however, their impact on patient care measures in community, non-teaching hospitals, is unknown.

Objectives: To evaluate whether co-managing patients with diabetes by the IDMS team reduces LOS and 30-day readmission rate (30DR).

Methods: This retrospective quality improvement cohort study analyzed LOS and 30DR among patients with diabetes admitted to a community hospital. The IDMS medical team consisted of an endocrinologist, nurse practitioner, and diabetes educator. The comparison group consisted of hospitalized patients with diabetes under standard care of attending physicians (mostly internal medicine-trained hospitalists). The relationship between study groups and outcome variables was assessed using Generalized Estimating Equation models.

Results: 4,654 patients with diabetes (70.8 ± 0.2 years old) were admitted between January 2016 and May 2017. The IDMS team co-managed 18.3% of patients, mostly with higher severity of illness scores (p < 0.0001). Mean LOS in patients co-managed by the IDMS team decreased by 27%. Median LOS decreased over time in the IDMS group (p = 0.046), while no significant decrease was seen in the comparison group. Mean 30DR in patients co-managed by the IDMS decreased by 10.71%. Median 30DR decreased among patients co-managed by the IDMS (p = 0.048).

Conclusions: In a community hospital setting, LOS and 30DR significantly decreased in patients co-managed by a specialized diabetes team. These changes may be translated into considerable cost savings.

Associations between multimorbidity, all-cause mortality and glycaemia in people with type 2 diabetes: A systematic review

Introduction

Type 2 diabetes (T2D) is a major health priority worldwide and the majority of people with diabetes live with multimorbidity (MM) (the co-occurrence of ≥2 chronic conditions). The aim of this systematic review was to explore the association between MM and all-cause mortality and glycaemic outcomes in people with T2D.

Methods

The search strategy centred on: T2D, MM, comorbidity, mortality and glycaemia. Databases searched: MEDLINE, EMBASE, CINAHL Complete, The Cochrane Library, and SCOPUS. Restrictions included: English language, quantitative empirical studies. Two reviewers independently carried out: abstract and full text screening, data extraction, and quality appraisal. Disagreements adjudicated by a third reviewer.

Results

Of the 4882 papers identified; 41 met inclusion criteria. The outcome was all-cause mortality in 16 studies, glycaemia in 24 studies and both outcomes in one study. There were 28 longitudinal cohort studies and 13 cross-sectional studies, with the number of participants ranging from 96–892,223. Included studies were conducted in high or upper-middle-income countries. Fifteen of 17 studies showed a statistically significant association between increasing MM and higher mortality. Ten of 14 studies showed no significant associations between MM and HbA1c. Four of 14 studies found higher levels of MM associated with higher HbA1c. Increasing MM was significantly associated with hypoglycaemia in 9/10 studies. There was no significant association between MM and fasting glucose (one study). No studies explored effects on glycaemic variability.

Conclusions

This review demonstrates that MM in T2D is associated with higher mortality and hypoglycaemia, whilst evidence regarding the association with other measures of glycaemic control is mixed. The current single disease focused approach to management of T2D seems inappropriate. Our findings highlight the need for clinical guidelines to support a holistic approach to the complex care needs of those with T2D and MM, accounting for the various conditions that people with T2D may be living with.

Systematic review registration

International Prospective Register of Systematic Reviews CRD42017079500

Increased glycemic variability associated with a poor 30-day functional outcome in acute intracerebral hemorrhage

The authors analyzed the association between the standard deviation or the coefficient of variation in the glucose value, strong independent indexes for determining glycemic variability, and the prognosis of intracerebral hemorrhage. They found that glycemic variability may be associated with a poor outcome in intracerebral hemorrhage.

Association between Glycemic Gap and Adverse Outcomes in Critically Ill Patients with Diabetes

OBJECTIVES

Glycemic excursions are commonly seen in patients admitted to the Intensive Care Unit (ICU) and are related to adverse outcomes. Glycemic gap is a marker of this excursion in patients with diabetes. It can be used to predict adverse outcomes in patients with diabetes admitted to the ICU. It is calculated by subtracting A1C-derived average glucose (ADAG) = ([28.7 × HbA1c]-46.7) from plasma glucose at admission. Objective of this study was to correlate glycemic gap and adverse outcomes in patients with type 2 diabetes mellitus (DM) admitted to the ICU.

MATERIALS AND METHODS

We conducted an ambispective study to include patients with type 2 DM admitted to the ICUs from July 2015 to June 2016. The following adverse outcomes were recorded: Multiorgan dysfunction syndrome (MODS), acute respiratory distress syndrome (ARDS), shock, upper gastrointestinal (UGI) bleed, acute kidney injury (AKI), and acute respiratory failure (ARF).

RESULTS

A total of 200 patients were enrolled, with a mean age ± standard deviation of 62 ± 11.24 years, and 64.5% were males. The median (interquartile range) duration of hospital stay and ICU stay were 8 (6-12) days and 4 (3-7) days, respectively. The most common primary diagnosis was cardiovascular (39.5%) followed by neurological (16.5%), infection at diagnosis (16.5%), respiratory (14%), gastrointestinal (7.5%), and others (6%). A higher glycemic gap was associated with occurrence of MODS (P < 0.01), ARDS (P = 0.026), shock (P = 0.043), UGI bleed (P = 0.013), AKI (P = 0.01), and ARF (P < 0.01). Glycemic gap cutoffs of 43.31, 45.26, and 39.12 were found to be discriminatory for predicting ICU mortality (area under the receiver operating characteristic [AUROC]=0.631, P = 0.05), MODS (AUROC = 0.725, P < 0.001), and ARF (AUROC = 0.714, P < 0.001).

CONCLUSION

This study showed that higher glycemic gap levels were associated with an increased risk of MODS, ARDS, shock, UGI bleed, AKI, and ARF. Glycemic gap is a tool that can be used to determine prognosis in patients with diabetes admitted to the ICU.

Does diabetes mellitus comorbidity affect in-hospital mortality and length of stay? Analysis of administrative data in an Italian Academic Hospital

AIMS

Hospitalized patients with comorbid diabetes mellitus may have worse outcomes than the others. We conducted a study to assess whether comorbid diabetes affects in-hospital mortality and length of stay.

METHODS

For this population-based study, we analyzed the administrative databases of the Regional Health Information System of the Region Friuli Venezia Giulia, where the Hospital of Udine is located. Hospital discharge data were linked at the individual patient level with the regional Diabetes Mellitus Registry to identify diabetic patients. For each 3-digit ICD-9-CM discharge diagnosis code, we assessed the difference in length of stay and in-hospital mortality between diabetic and non-diabetic patients. We conducted both univariate and multivariate analyses, adjusted for age, sex, Charlson's comorbidity score, and urgency of hospitalization, through linear and logistic regression models.

RESULTS

After adjusting for potential confounders, diabetes significantly increased the risk of in-hospital death among patients hospitalized for bacterial pneumonia (OR = 1.94) and intestinal obstruction (OR = 4.23) and length of stay among those admitted for several diagnoses, including acute myocardial infarction and acute renal failure. Admission glucose blood level was associated with in-hospital death in patients with pneumonia and intestinal obstruction, and increased length of stay for several conditions.

CONCLUSIONS

Patients with diabetes mellitus who are hospitalized for other health problems may have increased risk of in-hospital death and longer hospital stay. For this reason, diabetes should be promptly recognized upon admission and properly managed.

Blood sugar changes and hospital mortality in multiple trauma

OBJECTIVES

Hyperglycemia with unknown mechanism plays a predictive role in determining the prognosis of multiple trauma patients. The exact time of blood sugar measurement and the role of blood sugar changes in the monitoring of these patients have not been well established.

METHODS

This follow-up study was done on multiple trauma patients (>18years) with an Injury Severity Scores (ISS)>16. These patients didn't have any history of diabetes, underlying disease, or drug or alcohol use. Data collection was done by the questionnaire (checklist), and the patients were followed by the medical records. Cox regression was used to measure the effect of independent variables on the patients' hospital mortality.

RESULTS

Of a total of 963 patients, 280 patients were enrolled. Of those, 202 were male (72.1%) and 78 were female (27.9%). Hospital mortality was 18 (6.4%). Cox regression analysis suggested that those who had high blood sugar 3h after admission had higher hospital mortality (P=0.04). Changes in blood sugar, ΔBS (BS 3h after admission - BS on admission), in these patients was also significantly correlated with hospital mortality (P<0.001). The multivariate model using the backward conditional method showed that ΔBS (P<0.001), international normalized ration (INR) (P<0.001), and heart rate (P=0.036) were significantly correlated with hospital mortality.

CONCLUSIONS

In multiple trauma patients, blood sugar changes in the early hours of admission to the emergency department may help predict hospital mortality, but further studies are needed. Blood sugar monitoring in these patients during this time frame may be helpful in predicting these patients' outcomes. In addition, coagulopathy and tachycardia were significantly associated with hospital mortality.

Management of Hyperglycemia and Diabetes in the Emergency Department

PURPOSE OF REVIEW

Hyperglycemia in the emergency department (ED) is being recognized as a public health problem and presents a clinical challenge. This review critically summarizes available evidence on the burden, etiology, diagnosis, and practical management strategies for hyperglycemia in the ED.

RECENT FINDINGS

Diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar state (HHS) are hyperglycemic emergencies that commonly present to the ED. However, the most common form of hyperglycemia in ED is associated with non-hyperglycemic medical emergencies. The presence of hyperglycemia increases the mortality and morbidity associated with the primary condition. The related hospital admission rates and costs are also elevated. The frequency of DKA or HHS related mortality and morbidity has remained high over the last decade. However, attempts have been made to improve management of all hyperglycemia in the ED. Evidence suggests that better management of hyperglycemia in the ED with proper follow-up improves clinical outcomes and prevents readmission. Optimization of the hyperglycemia management in the ED may improve clinical outcomes. However, more clinical trial data on the outcomes and cost-effectiveness of various management strategies or protocols are needed.

Efficacy of basal-bolus insulin regimens in the inpatient management of non-critically ill patients with type 2 diabetes: A systematic review and meta-analysis

Hyperglycemia during hospitalization is associated with increased rates of complications and longer hospital stays. Various insulin regimens are used in the inpatient diabetes management of non-critically ill patients. In this systematic review and meta-analysis, we aimed to assess the efficacy and safety of basal-bolus insulin therapy (BBI) by summarizing evidence from studies of BBI versus sliding scale insulin therapy (SSI) in the management of hospitalized non-critically ill type 2 diabetes patients. We searched MEDLINE, EMBASE, Scopus, and the Cochrane Library for studies comparing BBI therapy with SSI therapy in hospitalized non-critically ill patients with type 2 diabetes. Primary outcome was mean daily blood glucose (BG) during admission. Secondary outcomes were incidence of hypoglycemia and length of hospital stay. Results of included randomized controlled trials (RCT) were pooled and meta-analysed to provide estimates of the efficacy of BBI therapy. Five RCTs and seven observational studies were included in the review. Meta-analysis of RCTs showed significantly lower mean daily BG with BBI than SSI. Mean difference in daily BG between the two regimens ranged from 14 to 29 mg/dl. BBI therapy was associated with increased risk of mild hypoglycemia (BG ≤ 70 mg/dl, RR 5.75; 95% CI 2.79-11.83), (BG ≤ 60 mg/dl, RR 4.21; 95% CI 1.61-11.02) compared with SSI therapy. There was no difference in risk of severe hypoglycemia (BG ≤ 40 mg/dl) and no difference in mean length of stay. In conclusion, basal-bolus insulin in the inpatient diabetes management results in significantly lower mean daily BG than sliding scale insulin but is associated with increased risk of mild hypoglycemia.

An Elevated Glycemic Gap is Associated with Adverse Outcomes in Diabetic Patients with Acute Myocardial Infarction

Acute hyperglycemia is a frequent finding in patients presenting to the emergency department (ED) with acute myocardial infarction (AMI). The prognostic role of hyperglycemia in diabetic patients with AMI remains controversial. We retrospectively reviewed patients' medical records to obtain demographic data, clinical presentation, major adverse cardiac events (MACEs), several clinical scores and laboratory data, including the plasma glucose level at initial presentation and HbA1c levels. The glycemic gap, which represents changes in serum glucose levels during the index event, was calculated from the glucose level upon ED admission minus the HbA1c-derived average glucose (ADAG). We enrolled 331 patients after the review of medical records. An elevated glycemic gap between admission serum glucose levels and ADAG were associated with an increased risk of mortality in patients. The glycemic gap showed superior discriminative power regarding the development of MACEs when compared with the admission glucose level. The calculation of the glycemic gap may increase the discriminative powers of established clinical scoring systems in diabetic patients presenting to the ED with AMI. In conclusion, the glycemic gap could be used as an adjunct parameter to assess the severity and prognosis of diabetic patients presenting with AMI. However, the usefulness of the glycemic gap should be further explored in prospective longitudinal studies.

Hyperglycemia is a predictor of prognosis in traumatic brain injury: Tertiary intensive care unit study

Background:

Hyperglycemia is frequently encountered in critically ill patients and has been shown to contribute to both morbidity and mortality. We aimed to study the predictive role of blood glucose level in clinical outcomes of mechanically ventilated patients with traumatic brain injury during intensive care unit (ICU) stay and to explore its relationship with Glasgow coma scale (GCS) and acute physiology and chronic health examination (APACHE) II scores that are used in the evaluation of ICU patients as predictor.

Materials and Methods:

A total of 185 patients with craniocerebral trauma who were hospitalized in the ICU were included in the study. Comparisons of mean glucose values (MGVs) and APACHE II scores between survivors and nonsurvivors were made with Student's t-test and chi-square test. Survival analysis was performed with log rank (Mantel-Cox) test and Cox regression was used for mortality risk factors analysis.

Results:

MGVs at the initial, last, and all measurements were significantly higher for nonsurvivors than for survivors. Hazard rate at any given time point for patients with mean glucose value (MGV) between 150 and 179 was found to be 3.691 times that of patients with MGV values between 110 and 149. The hazard rate at any given time point for patients with MGV values ≥180 was found to be 6.571 times that of patients with MGV values between 110 and 149.

Conclusion:

High glucose level is an independent risk factor for mortality in mechanically ventilated ICU patients with traumatic brain injury.