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Okazaki T, Nabeshima T, Santanda T, Hoshina Y, Kondo Y, Yaegashi Y, Nakazawa T, Tokuda Y, Norisue Y. Association of Relative Dysglycemia With Hospital Mortality in Critically Ill Patients: A Retrospective Study. Crit Care Med 2024:00003246-990000000-00329. [PMID: 38656278 DOI: 10.1097/ccm.0000000000006313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
OBJECTIVES Relative dysglycemia has been proposed as a clinical entity among critically ill patients in the ICU, but is not well studied. This study aimed to clarify associations of relative hyperglycemia and hypoglycemia during the first 24 hours after ICU admission with in-hospital mortality and the respective thresholds. DESIGN A single-center retrospective study. SETTING An urban tertiary hospital ICU. PATIENTS Adult critically ill patients admitted urgently between January 2016 and March 2022. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Maximum and minimum glycemic ratio (GR) was defined as maximum and minimum blood glucose values during the first 24 hours after ICU admission divided by hemoglobin A1c-derived average glucose, respectively. Of 1700 patients included, in-hospital mortality was 16.9%. Nonsurvivors had a higher maximum GR, with no significant difference in minimum GR. Maximum GR during the first 24 hours after ICU admission showed a J-shaped association with in-hospital mortality, and a mortality trough at a maximum GR of approximately 1.12; threshold for increased adjusted odds ratio for mortality was 1.25. Minimum GR during the first 24 hours after ICU admission showed a U-shaped relationship with in-hospital mortality and a mortality trough at a minimum GR of approximately 0.81 with a lower threshold for increased adjusted odds ratio for mortality at 0.69. CONCLUSIONS Mortality significantly increased when GR during the first 24 hours after ICU admission deviated from between 0.69 and 1.25. Further evaluation will necessarily validate the superiority of personalized glycemic management over conventional management.
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Affiliation(s)
- Tomoya Okazaki
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Tadanori Nabeshima
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Takushi Santanda
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Yuiko Hoshina
- Strategic Planning and Analysis Division, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Yuki Kondo
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Yu Yaegashi
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Taichi Nakazawa
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
| | - Yasuharu Tokuda
- Muribushi Okinawa Project for Okinawa Residency Programs, Urasoe, Okinawa, Japan
| | - Yasuhiro Norisue
- Department of Emergency and Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
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Long C, Fan W, Liu Y, Hong K. Stress hyperglycemia is associated with poor outcome in critically ill patients with pulmonary hypertension. Front Endocrinol (Lausanne) 2024; 15:1302537. [PMID: 38464971 PMCID: PMC10924302 DOI: 10.3389/fendo.2024.1302537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 02/06/2024] [Indexed: 03/12/2024] Open
Abstract
Background and objective Stress hyperglycemia is common in critically ill patients and is associated with poor prognosis. Whether this association exists in pulmonary hypertension (PH) patients is unknown. The present cohort study investigated the association of stress hyperglycemia with 90-day all-cause mortality in intensive care unit (ICU) patients with PH. Methods Data of the study population were extracted from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. A new index, the ratio of admission glucose to HbA1c (GAR), was used to evaluate stress hyperglycemia. The study population was divided into groups according to GAR quartiles (Q1-Q4). The outcome of interest was all-cause mortality within 90 days, which was considered a short-term prognosis. Result A total of 53,569 patients were screened. Ultimately, 414 PH patients were enrolled; 44.2% were male, and 23.2% were admitted to the cardiac ICU. As the GAR increased from Q2 to Q4, the groups had lower creatinine levels, longer ICU stays, and a higher proportion of renal disease. After adjusting for confounding factors such as demographics, vital signs, and comorbidities, an elevated GAR was associated with an increased risk of 90-day mortality. Conclusion Stress hyperglycemia assessed by the GAR was associated with increased 90-day mortality in ICU patients with PH.
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Affiliation(s)
- Chuyan Long
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Weiguo Fan
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Yang Liu
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
| | - Kui Hong
- Department of Cardiology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Department of Genetic Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
- Jiangxi Key Laboratory of Molecular Medicine, Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China
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Bergmann F, Pracher L, Sawodny R, Blaschke A, Gelbenegger G, Radtke C, Zeitlinger M, Jorda A. Efficacy and Safety of Corticosteroid Therapy for Community-Acquired Pneumonia: A Meta-Analysis and Meta-Regression of Randomized, Controlled Trials. Clin Infect Dis 2023; 77:1704-1713. [PMID: 37876267 DOI: 10.1093/cid/ciad496] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Indexed: 10/26/2023] Open
Abstract
BACKGROUND Community-acquired pneumonia (CAP) is associated with high morbidity and mortality. In the present study, we aimed to assess the effect of corticosteroids on all-cause mortality in patients hospitalized with CAP. METHODS For this meta-analysis and meta-regression, we conducted a systematic search of trials that evaluated the effect of corticosteroid therapy in patients hospitalized with CAP through March 2023. We included randomized, controlled trials, comparing adjunctive corticosteroid therapy with the standard of care alone for treatment of patients hospitalized with CAP and reporting all-cause mortality. We excluded retrospective analyses, observational data, and trial protocols. The primary outcome was all-cause mortality within 30 days after hospital admission. The safety analysis included the frequency of adverse events and steroid-associated adverse events. RESULTS The literature search identified 35 713 citations, of which 15 studies and 3367 patients were eligible for the final analysis. The all-cause mortality at 30 days was significantly lower in the corticosteroid group (104 of 1690, 6.15%) than in the control group (152 of 1677, 9.06%; risk ratio [RR], 0.67; 95% confidence interval [CI], .53 to .85; P = .001; I2 = 0%). In 9 studies (2549 patients) that reported the occurrence of adverse events, corticosteroid therapy was not associated with an increased risk of developing any adverse event compared with standard care (RR, 0.90; 95% CI, .65 to 1.24; P = .5; I2 = 88%). CONCLUSIONS Adjunctive systemic corticosteroid therapy in patients hospitalized with CAP was associated with a reduction in all-cause mortality by day 30. The benefits were more pronounced in patients with severe pneumonia.
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Affiliation(s)
- Felix Bergmann
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Lena Pracher
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Rebecca Sawodny
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Amelie Blaschke
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Christine Radtke
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
- Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anselm Jorda
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
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The Role of Nondiabetic Hyperglycemia in Critically Ill Patients with Acute Ischemic Stroke. J Clin Med 2022; 11:jcm11175116. [PMID: 36079047 PMCID: PMC9456679 DOI: 10.3390/jcm11175116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 08/18/2022] [Accepted: 08/29/2022] [Indexed: 11/18/2022] Open
Abstract
In this study, we aim to elucidate the association between nondiabetic hyperglycemia and the short-term prognosis of critically ill patients with acute ischemic stroke. We extracted data using the Medical Information Mart for Intensive Care IV from 2008 to 2019. The primary outcomes were set as intensive care units (ICU) and in-hospital mortality. We developed a Cox proportional hazards model to determine the nonlinear association between serum glucose levels and primary outcomes. Of the 1086 patients included, 236 patients had hyperglycemia. Patients with hyperglycemia were associated with higher ages, female gender, higher Charlson Comorbidity Index scores, and higher Acute Physiology Score III scores. After propensity score matching, 222 pairs remained. The hyperglycemia group had a significantly higher ICU mortality (17.6% vs. 10.8%; p = 0.041). Meanwhile, no significant differences in ICU length of stay (5.2 vs. 5.2; p = 0.910), in-hospital mortality (26.6% vs. 18.9%, p = 0.054), and hospital length of stay (10.0 vs. 9.1; p = 0.404) were observed between the two groups. The Kaplan–Meier curves for ICU and in-hospital survival before matching suggested significant differences; however, after matching, they failed to prove any disparity. Non-diabetic patients with acute ischemic stroke have poor clinical characteristic while encountering hyperglycemic events; therefore, careful monitoring in the acute phase is still required.
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Russo MP, Fosser SNM, Elizondo CM, Giunta DH, Fuentes NA, Grande-Ratti MF. In-Hospital Mortality and Glycemic Control in Patients with Hospital Hyperglycemia. Rev Diabet Stud 2021; 17:50-56. [PMID: 34852895 PMCID: PMC9380085 DOI: 10.1900/rds.2021.17.50] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
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.
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Affiliation(s)
- María Paula Russo
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Nicolas Marquez Fosser
- Clinical and Health Informatics Research Group, McGill University, Montr??al, Qu??bec, Canada; Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | | | - Diego Hernán Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - María Florencia Grande-Ratti
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
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Logette E, Lorin C, Favreau C, Oshurko E, Coggan JS, Casalegno F, Sy MF, Monney C, Bertschy M, Delattre E, Fonta PA, Krepl J, Schmidt S, Keller D, Kerrien S, Scantamburlo E, Kaufmann AK, Markram H. A Machine-Generated View of the Role of Blood Glucose Levels in the Severity of COVID-19. Front Public Health 2021; 9:695139. [PMID: 34395368 PMCID: PMC8356061 DOI: 10.3389/fpubh.2021.695139] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/30/2021] [Indexed: 01/08/2023] Open
Abstract
SARS-CoV-2 started spreading toward the end of 2019 causing COVID-19, a disease that reached pandemic proportions among the human population within months. The reasons for the spectrum of differences in the severity of the disease across the population, and in particular why the disease affects more severely the aging population and those with specific preconditions are unclear. We developed machine learning models to mine 240,000 scientific articles openly accessible in the CORD-19 database, and constructed knowledge graphs to synthesize the extracted information and navigate the collective knowledge in an attempt to search for a potential common underlying reason for disease severity. The machine-driven framework we developed repeatedly pointed to elevated blood glucose as a key facilitator in the progression of COVID-19. Indeed, when we systematically retraced the steps of the SARS-CoV-2 infection, we found evidence linking elevated glucose to each major step of the life-cycle of the virus, progression of the disease, and presentation of symptoms. Specifically, elevations of glucose provide ideal conditions for the virus to evade and weaken the first level of the immune defense system in the lungs, gain access to deep alveolar cells, bind to the ACE2 receptor and enter the pulmonary cells, accelerate replication of the virus within cells increasing cell death and inducing an pulmonary inflammatory response, which overwhelms an already weakened innate immune system to trigger an avalanche of systemic infections, inflammation and cell damage, a cytokine storm and thrombotic events. We tested the feasibility of the hypothesis by manually reviewing the literature referenced by the machine-generated synthesis, reconstructing atomistically the virus at the surface of the pulmonary airways, and performing quantitative computational modeling of the effects of glucose levels on the infection process. We conclude that elevation in glucose levels can facilitate the progression of the disease through multiple mechanisms and can explain much of the differences in disease severity seen across the population. The study provides diagnostic considerations, new areas of research and potential treatments, and cautions on treatment strategies and critical care conditions that induce elevations in blood glucose levels.
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Affiliation(s)
- Emmanuelle Logette
- Blue Brain Project, École polytechnique fédérale de Lausanne (EPFL), Geneva, Switzerland
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Henry Markram
- Blue Brain Project, École polytechnique fédérale de Lausanne (EPFL), Geneva, Switzerland
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Kesavadev J, Misra A, Saboo B, Aravind SR, Hussain A, Czupryniak L, Raz I. Blood glucose levels should be considered as a new vital sign indicative of prognosis during hospitalization. Diabetes Metab Syndr 2021; 15:221-227. [PMID: 33450531 PMCID: PMC8049470 DOI: 10.1016/j.dsx.2020.12.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 12/17/2020] [Accepted: 12/17/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS The measurement of vital signs is an important part of clinical work up. Presently, measurement of blood glucose is a factor for concern mostly when treating individuals with diabetes. Significance of blood glucose measurement in prognosis of non-diabetic and hospitalized patients is not clear. METHODS A systematic search of literature published in the Electronic databases, PubMed and Google Scholar was performed using following keywords; blood glucose, hospital admissions, critical illness, hospitalizations, cardiovascular disease (CVD), morbidity, and mortality. This literature search was largely restricted to non-diabetic individuals. RESULTS Blood glucose level, even when in high normal range, or in slightly high range, is an important determinant of morbidity and mortality, especially in hospitalized patients. Further, even slight elevation of blood glucose may increase mortality in patients with COVID-19. Finally, blood glucose variability and hypoglycemia in critically ill individuals without diabetes causes excess in-hospital complications and mortality. CONCLUSION In view of these data, we emphasize the significance of blood glucose measurement in all patients admitted to the hospital regardless of presence of diabetes. We propose that blood glucose be included as the "fifth vital sign" for any hospitalized patient.
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Affiliation(s)
| | - Anoop Misra
- Fortis-C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, India; National Diabetes, Obesity and Cholesterol Foundation (N-DOC), India; Diabetes Foundation (India) (DFI), India.
| | - Banshi Saboo
- Diacare, Diabetes Care & Hormone Clinic, Ahmedabad, India.
| | | | - Akhtar Hussain
- Faculty of Health Sciences, Chronic Disease-Diabetes, NORD University, Stjørdal, Norway; Faculty of Medicine, Federal University of Ceara, Brazil.
| | - Leszek Czupryniak
- Medical University of Warsaw, Department of Diabetology and Internal Medicine, Warsaw, Poland.
| | - Itamar Raz
- Internal Medicine, and Head of the Diabetes Unit at Hadassah University Hospital, Israel.
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Russo MP, Grande Ratti MF, Giunta DH, Elizondo CM. Hospitalized patients with stress hyperglycemia: incidence of diabetes and mortality on follow-up. ACTA ACUST UNITED AC 2018; 65:571-576. [PMID: 30293899 DOI: 10.1016/j.endinu.2018.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 07/10/2018] [Accepted: 07/12/2018] [Indexed: 10/28/2022]
Abstract
INTRODUCTION The study objective was to estimate during post-discharge follow-up the incidence of diabetes and to ascertain mortality in hospitalized patients, classified during follow-up as having stress hyperglycemia (SH) or normoglycemia (NG) based on blood glucose levels. MATERIAL AND METHODS A retrospective cohort of non-diabetic adults with SH (> 140mg/dl and HbA1c <6.5%) or NG (all blood glucose values ≤ 140mg/dl) was used. RESULTS There were 3981 patients with NG and 884 with SH. During the observation period (median follow-up of 1.83 years), there were 255 cases of diabetes and 831 deaths. The cumulative incidence of diabetes per year was 1.59% (95% CI: 1.23-2.06) in patients with NG and 7.39% (95% CI: 5.70-9.56) in those with SH. SH was significantly associated to diabetes (crude HR 1.33, 95% CI: 1.13-1.73, p .025), even after adjusting for age and sex (adjusted HR 1.38, 95% CI 1.06-1.78, p .014). The mortality rate at one year was 10.07% (95% CI: 9.18-11.05) in NG patients and 13.24% (95% CI: 11.17-15.65) in SH patients. The sub-hazard ratio of developing diabetes considering death as a competitive event was 1.41 (95% CI 1.29-1.53, p <.001). CONCLUSIONS SH is a risk factor for diabetes. There were no differences in mortality during follow-up, but death appears to be a competitive event in development of diabetes in this population.
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Affiliation(s)
- María Paula Russo
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - María Florencia Grande Ratti
- Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Servicio Medicina Familiar y Comunitaria, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Área Epidemiológica de Dirección de Promoción de la Salud y Control de Enfermedades No Transmisibles, Ministerio de Salud de Nación, Argentina
| | - Diego Hernán Giunta
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Departamento de Investigación, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Cristina María Elizondo
- Servicio de Clínica Médica, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Área de Investigación en Medicina Interna, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Olariu E, Pooley N, Danel A, Miret M, Preiser JC. A systematic scoping review on the consequences of stress-related hyperglycaemia. PLoS One 2018; 13:e0194952. [PMID: 29624594 PMCID: PMC5889160 DOI: 10.1371/journal.pone.0194952] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 03/13/2018] [Indexed: 01/04/2023] Open
Abstract
Background Stress-related hyperglycaemia (SHG) is commonly seen in acutely ill patients and has been associated with poor outcomes in many studies performed in different acute care settings. We aimed to review the available evidence describing the associations between SHG and different outcomes in acutely ill patients admitted to an ICU. Study designs, populations, and outcome measures used in observational studies were analysed. Methods We conducted a systematic scoping review of observational studies following the Joanna Briggs methodology. Medline, Embase, and the Cochrane Library were searched for publications between January 2000 and December 2015 that reported on SHG and mortality, infection rate, length of stay, time on ventilation, blood transfusions, renal replacement therapy, or acquired weakness. Results The search yielded 3,063 articles, of which 43 articles were included (totalling 536,476 patients). Overall, the identified studies were heterogeneous in study conduct, SHG definition, blood glucose measurements and monitoring, treatment protocol, and outcome reporting. The most frequently reported outcomes were mortality (38 studies), ICU and hospital length of stay (23 and 18 studies, respectively), and duration of mechanical ventilation (13 studies). The majority of these studies (40 studies) compared the reported outcomes in patients who experienced SHG with those who did not. Fourteen studies (35.9%) identified an association between hyperglycaemia and increased mortality (odds ratios ranging from 1.13 to 2.76). Five studies identified hyperglycaemia as an independent risk factor for increased infection rates, and one identified it as an independent predictor of increased ICU length of stay. Discussion SHG was consistently associated with poor outcomes. However, the wide divergences in the literature mandate standardisation of measuring and monitoring SHG and the creation of a consensus on SHG definition. A better comparability between practices will improve our knowledge on SHG consequences and management.
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Affiliation(s)
| | | | | | | | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
- * E-mail:
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Short term outcome of patients with hyperglycemia and acute stroke. THE EGYPTIAN JOURNAL OF CRITICAL CARE MEDICINE 2017. [DOI: 10.1016/j.ejccm.2017.11.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Sharma J, Chittawar S, Maniram RS, Dubey TN, Singh A. Clinical and epidemiological study of stress hyperglycemia among medical intensive care unit patients in Central India. Indian J Endocrinol Metab 2017; 21:137-141. [PMID: 28217513 PMCID: PMC5240055 DOI: 10.4103/2230-8210.196011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Stress hyperglycemia is common in patients presenting at the emergency medical ward and is associated with poor prognosis and increased risk of mortality. AIMS AND OBJECTIVE To study and determine the prevalence and factors associated with stress hyperglycemia. MATERIALS AND METHODS A cross-sectional observational study was performed on 536 nondiabetic patients presented to the Intensive Care Unit (ICU) at Gandhi Medical College and allied Hamidia Hospital, Bhopal, between March 31, 2015, and May 28, 2015. A detailed history including demographic profile, presence of chronic disease, history of hospitalization and ICU admission, surgical status, and major reason for ICU admission (i.e., predominant diagnostic category) was collected. Hematological and other parameters based on profile of study population were also analyzed. RESULTS Out of 536 patients, 109 (20.33%) had stress hyperglycemia. Out of 109 patients with stress hyperglycemia, 87 (16.23%) patients had glycated hemoglobin (HbA1c) <5.7% and 22 (4.10%) patients had HbA1c between 5.7% and 6.4%. Mean age of the study population was 40.27 ± 1.44 years, with male dominance. Mean random blood glucose level was 181.46 ± 3.80 mg/dl. Frequency of stress hyperglycemia was 24.13% in stroke, 19.54% in multiple organ dysfunction syndrome (MODS), 17.24% in chronic kidney disease (CKD), 12.64% in central nervous system (CNS) infection, 8.05% in chronic liver disease (CLD), and 8.05% in seizure patients. Association between stroke and stress hyperglycemia was significant (P = 0.036). Association between hospital stay more than 7 days and stress hyperglycemia was significant in stroke patients (P = 0.0029), CKD patients (P = 0.0036), CLD (P = 0.0099), and MODS patients (P = 0.0328). CONCLUSIONS The factors associated with stress hyperglycemia were stroke, MODS, CKD, CNS infection, CLD, seizure patients, with prolonged hospital stay and expected proportion.
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Affiliation(s)
- Jitendra Sharma
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - Sachin Chittawar
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - Ram Singh Maniram
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - T. N. Dubey
- Department of Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India
| | - Ambrish Singh
- Independent Statistician and Medical Writer, MS Pharmacology and Toxicology, Bhopal, Madhya Pradesh, India
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Sandoval-Pinto E, Padilla-Gutiérrez JR, Valdés-Alvarado E, García-González IJ, Valdez-Haro A, Muñoz-Valle JF, Flores-Salinas HE, Brennan-Bourdon LM, Valle Y. Association of the -1031T>C polymorphism and soluble TNF-α levels with Acute Coronary Syndrome. Cytokine 2015; 78:37-43. [PMID: 26618233 DOI: 10.1016/j.cyto.2015.11.014] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 10/10/2015] [Accepted: 11/12/2015] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Inflammation has gained a pivotal role in the pathophysiology of Acute Coronary Syndrome (ACS). TNF-α is a pro-inflammatory cytokine that could be a potential biomarker in ACS due to its multiple functions. The rs1799964 TNFA polymorphism (-1031T>C) has been associated with a decrease in gene transcription and cytokine levels. OBJECTIVE To determine the association of rs1799964 TNFA polymorphism and TNF-α soluble levels in ACS. METHODS A total of 251 patients diagnosed with ACS and 164 individuals without cardiovascular diseases classified as the reference group (RG), were included. The rs1799964 polymorphism was genotyped by PCR-RFLP. Soluble protein levels were determined by ELISA. Statistical analyses were performed using chi square and U-Mann Whitney tests. RESULTS The genotype and allele frequencies were different between ACS and RG (OR=0.317, p=0.01; OR=0.688, p=0.03 respectively). ACS patients had higher soluble TNF-α levels compared with the RG (31.08 vs 23.00pg/mL, p<0.001); according genotype significant differences were observed (T/T: 24.06 vs T/C: 34.95pg/mL, p=0.0001) in patients. In the RG, T/T carriers showed discrete lower levels than C/C genotype (22.14 vs 27.83pg/mL, p=0.04). CONCLUSIONS The -1031C allele of the TNFA polymorphism confers protection for the development of ACS. The T/C genotype carriers had higher TNF-α serum levels compared to the T/T genotype in ACS. In addition, the -1031T>C TNFA polymorphism was associated with dyslipidemia in ACS in a Western Mexican population.
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Affiliation(s)
- Elena Sandoval-Pinto
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Jorge Ramón Padilla-Gutiérrez
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Emmanuel Valdés-Alvarado
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Ilian Janet García-González
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Genética Humana, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Angélica Valdez-Haro
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico; Doctorado en Genética Humana, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - José Francisco Muñoz-Valle
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Hector Enrique Flores-Salinas
- Hospital de Especialidades del Centro Médico Nacional de Occidente, Instituto Mexicano del Seguro Social, Guadalajara, Jalisco, Mexico
| | - Lorena Michele Brennan-Bourdon
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico
| | - Yeminia Valle
- Instituto de Investigación en Ciencias Biomédicas, Centro Universitario de Ciencias de la Salud, Universidad de Guadalajara, Guadalajara, Jalisco, Mexico.
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Mesejo A, Montejo-González JC, Vaquerizo-Alonso C, Lobo-Tamer G, Zabarte-Martinez M, Herrero-Meseguer JI, Acosta-Escribano J, Blesa-Malpica A, Martinez-Lozano F. Diabetes-specific enteral nutrition formula in hyperglycemic, mechanically ventilated, critically ill patients: a prospective, open-label, blind-randomized, multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:390. [PMID: 26549276 PMCID: PMC4638090 DOI: 10.1186/s13054-015-1108-1] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 10/19/2015] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Although standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial. This study examines whether a high-protein diabetes-specific formula reduces insulin needs, improves glycemic control and reduces ICU-acquired infection in critically ill, hyperglycemic patients on mechanical ventilation (MV). METHODS This was a prospective, open-label, randomized (web-based, blinded) study conducted at nine Spanish ICUs. The patient groups established according to the high-protein formula received were: group A, new-generation diabetes-specific formula; group B, standard control formula; group C, control diabetes-specific formula. Inclusion criteria were: expected enteral nutrition ≥5 days, MV, baseline glucose >126 mg/dL on admission or >200 mg/dL in the first 48 h. Exclusion criteria were: APACHE II ≤10, insulin-dependent diabetes, renal or hepatic failure, treatment with corticosteroids, immunosuppressants or lipid-lowering drugs and body mass index ≥40 kg/m(2). The targeted glucose level was 110-150 mg/dL. Glycemic variability was calculated as the standard deviation, glycemic lability index and coefficient of variation. Acquired infections were recorded using published consensus criteria for critically ill patients. Data analysis was on an intention-to-treat basis. RESULTS Over a 2-year period, 157 patients were consecutively enrolled (A 52, B 53 and C 52). Compared with the standard control formula, the new formula gave rise to lower insulin requirement (19.1 ± 13.1 vs. 23.7 ± 40.1 IU/day, p <0.05), plasma glucose (138.6 ± 39.1 vs. 146.1 ± 49.9 mg/dL, p <0.01) and capillary blood glucose (146.1 ± 45.8 vs. 155.3 ± 63.6 mg/dL, p <0.001). Compared with the control diabetes-specific formula, only capillary glucose levels were significantly reduced (146.1 ± 45.8 vs. 150.1 ± 41.9, p <0.01). Both specific formulas reduced capillary glucose on ICU day 1 (p <0.01), glucose variability in the first week (p <0.05), and incidences of ventilator-associated tracheobronchitis (p <0.01) or pneumonia (p <0.05) compared with the standard formula. No effects of the nutrition formula were produced on hospital stay or mortality. CONCLUSIONS In these high-risk ICU patients, both diabetes-specific formulas lowered insulin requirements, improved glycemic control and reduced the risk of acquired infections relative to the standard formula. Compared with the control-specific formula, the new-generation formula also improved capillary glycemia. TRIAL REGISTRATION Clinicaltrials.gov NCT1233726 .
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Affiliation(s)
- Alfonso Mesejo
- Intensive Care Unit, Hospital Clínico Universitario, Avda Blasco Ibáñez 17, 46010, Valencia, Spain.
| | | | - Clara Vaquerizo-Alonso
- Intensive Care Unit, Hospital Universitario de Fuenlabrada, Camino del Molino 2, 28942, Fuenlabrada, Madrid, Spain.
| | - Gabriela Lobo-Tamer
- Clinic and Dietetics Nutrition Unit, Hospital Virgen de las Nieves, Avda Fuerzas Armadas 2, 18014, Granada, Spain.
| | - Mercedes Zabarte-Martinez
- Intensive Care Unit, Hospital Universitario de Donostia, Paseo Dr. Beguiristain s/n, 20080, Donostia, Spain.
| | - Jose Ignacio Herrero-Meseguer
- Intensive Care Unit, Hospital Universitario de Bellvitge, C/ Feixa Llarga 1, 08907L'Hospitalet de Llobregat, Barcelona, Spain.
| | - Jose Acosta-Escribano
- Intensive Care Unit, Hospital General Universitario, C/ Pintor Baeza s/n, 03005, Alicante, Spain.
| | - Antonio Blesa-Malpica
- Intensive Care Unit, Hospital Clínico San Carlos, C/ Prof. Martín Lagos s/n, 28040, Madrid, Spain.
| | - Fátima Martinez-Lozano
- Intensive Care Unit, Hospital General Universitario Reina Sofía, Avda Intendente Jorge Palacios 1, 30003, Murcia, Spain.
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14
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Marics G, Koncz L, Eitler K, Vatai B, Szénási B, Zakariás D, Mikos B, Körner A, Tóth-Heyn P. Effects of pH, lactate, hematocrit and potassium level on the accuracy of continuous glucose monitoring (CGM) in pediatric intensive care unit. Ital J Pediatr 2015; 41:17. [PMID: 25888142 PMCID: PMC4372234 DOI: 10.1186/s13052-015-0122-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 03/04/2015] [Indexed: 11/10/2022] Open
Abstract
Background Continuous glucose monitoring (CGM) originally was developed for diabetic patients and it may be a useful tool for monitoring glucose changes in pediatric intensive care unit (PICU). Its use is, however, limited by the lack of sufficient data on its reliability at insufficient peripheral perfusion. We aimed to correlate the accuracy of CGM with laboratory markers relevant to disturbed tissue perfusion. Patients and Methods In 38 pediatric patients (age range, 0–18 years) requiring intensive care we tested the effect of pH, lactate, hematocrit and serum potassium on the difference between CGM and meter glucose measurements. Guardian® (Medtronic®) CGM results were compared to GEM 3000 (Instrumentation laboratory®) and point-of-care measurements. The clinical accuracy of CGM was evaluated by Clarke Error Grid -, Bland-Altman analysis and Pearson’s correlation. We used Friedman test for statistical analysis (statistical significance was established as a p < 0.05). Results CGM values exhibited a considerable variability without any correlation with the examined laboratory parameters. Clarke, Bland-Altman analysis and Pearson’s correlation coefficient demonstrated a good clinical accuracy of CGM (zone A and B = 96%; the mean difference between reference and CGM glucose was 1,3 mg/dL, 48 from the 780 calibration pairs overrunning the 2 standard deviation; Pearson’s correlation coefficient: 0.83). Conclusions The accuracy of CGM measurements is independent of laboratory parameters relevant to tissue hypoperfusion. CGM may prove a reliable tool for continuous monitoring of glucose changes in PICUs, not much influenced by tissue perfusion, but still not appropriate for being the base for clinical decisions.
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Affiliation(s)
- Gábor Marics
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
| | | | - Katalin Eitler
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
| | - Barbara Vatai
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
| | - Boglárka Szénási
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary. .,Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary.
| | - David Zakariás
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
| | | | - Anna Körner
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
| | - Péter Tóth-Heyn
- First Department of Pediatrics, Semmelweis University, Budapest, Hungary.
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15
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Ceriotti F, Kaczmarek E, Guerra E, Mastrantonio F, Lucarelli F, Valgimigli F, Mosca A. Comparative performance assessment of point-of-care testing devices for measuring glucose and ketones at the patient bedside. J Diabetes Sci Technol 2015; 9:268-77. [PMID: 25519295 PMCID: PMC4604596 DOI: 10.1177/1932296814563351] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Point-of-care (POC) testing devices for monitoring glucose and ketones can play a key role in the management of dysglycemia in hospitalized diabetes patients. The accuracy of glucose devices can be influenced by biochemical changes that commonly occur in critically ill hospital patients and by the medication prescribed. Little is known about the influence of these factors on ketone POC measurements. The aim of this study was to assess the analytical performance of POC hospital whole-blood glucose and ketone meters and the extent of glucose interference factors on the design and accuracy of ketone results. StatStrip glucose/ketone, Optium FreeStyle glucose/ketone, and Accu-Chek Performa glucose were also assessed and results compared to a central laboratory reference method. The analytical evaluation was performed according to Clinical and Laboratory Standards Institute (CLSI) protocols for precision, linearity, method comparison, and interference. The interferences assessed included acetoacetate, acetaminophen, ascorbic acid, galactose, maltose, uric acid, and sodium. The accuracies of both Optium ketone and glucose measurements were significantly influenced by varying levels of hematocrit and ascorbic acid. StatStrip ketone and glucose measurements were unaffected by the interferences tested with exception of ascorbic acid, which reduced the higher level ketone value. The accuracy of Accu-Chek glucose measurements was affected by hematocrit, by ascorbic acid, and significantly by galactose. The method correlation assessment indicated differences between the meters in compliance to ISO 15197 and CLSI 12-A3 performance criteria. Combined POC glucose/ketone methods are now available. The use of these devices in a hospital setting requires careful consideration with regard to the selection of instruments not sensitive to hematocrit variation and presence of interfering substances.
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Affiliation(s)
- Ferruccio Ceriotti
- Istituto Scientifico Ospedale San Raffaele, Servizio di Medicina di Laboratorio, Milan, Italy
| | - Ewa Kaczmarek
- Istituto Scientifico Ospedale San Raffaele, Servizio di Medicina di Laboratorio, Milan, Italy
| | - Elena Guerra
- Istituto Scientifico Ospedale San Raffaele, Servizio di Medicina di Laboratorio, Milan, Italy
| | | | | | | | - Andrea Mosca
- Dip. di Fisiopatologia Medico-Chirurgica e dei Trapianti, Centro per la Riferibilità Metrologica in Medicina di Laboratorio (CIRME), Università degli Studi di Milano, Milan, Italy
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16
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Yuan Q, Liu H, Xu Y, Wu X, Sun Y, Hu J. Continuous measurement of the cumulative amplitude and duration of hyperglycemia best predicts outcome after traumatic brain injury. Neurocrit Care 2015; 20:69-76. [PMID: 22810485 DOI: 10.1007/s12028-012-9730-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND This study aimed to assess the accuracy and utility of high-resolution continuous glucose recording in patients with traumatic brain injury (TBI) and to establish whether a relationship exists between the cumulative amplitude and duration of hyperglycemia and outcome after TBI. METHODS Glucose data for 56 TBI patients were collected continuously at 5-min intervals. The degree and duration of hyperglycemia above treatment thresholds were calculated as "glucose times time dose" (GTD; mg/dL d) using continuous recordings (GTD) for early stage (first 3 days). Long-term neurological functional outcome was assessed using the extended Glasgow Outcome Scale (GOSE). Receiver operating characteristic (ROC) curves were constructed to determine the predictive values of GTD, percentage readings, mean, and range of glucose for in-hospital mortality and GOSE. RESULTS All measurements of GTD were statistically significantly higher in the group that died. GTD of glucose >150 and glucose >180 had a high-predictive power for in-hospital mortality (areas under the ROC curve [AUC] = 0.917; 95 % CI, 0.837-0.998 and 0.876; 95 % CI, 0.784-0.967, respectively) and demonstrated significantly higher predictive power for mortality when compared with %reading >150 and %reading >180, respectively (p < 0.05). GTD of glucose >150 also had a significantly higher predictive power for mortality than mean glucose and range of glucose. GTD of glucose >150 and glucose >180 also had a high-predictive power for poor outcome (areas under the ROC curve [AUC] = 0.913; 95 % CI, 0.843-0.983 and 0.858; 95 % CI, 0.760-0.956, respectively). CONCLUSIONS Continuous collection of glucose recordings is more reliable and accurate than routine discontinuous recordings. Assessing both the duration and the amplitude of the episodes using continuous collection of glucose data helps in better predicting outcomes than the total duration of episodes.
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Affiliation(s)
- Qiang Yuan
- Department of Neurosurgery, The Sixth People's Hospital Affiliated to Shanghai Jiao Tong University, Shanghai, China
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Ligtenberg JJM, ter Maaten JC, Zijlstra JG. Back to basics in sepsis treatment: critically ill patients need intensive care. Crit Care 2014; 18:405. [PMID: 24485066 PMCID: PMC4057168 DOI: 10.1186/cc13714] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Jack JM Ligtenberg
- Emergency Department, University Medical Center Groningen (UMCG), NL-9700 RB, Groningen, the Netherlands
| | - Jaan C ter Maaten
- Emergency Department, University Medical Center Groningen (UMCG), NL-9700 RB, Groningen, the Netherlands
| | - Jan G Zijlstra
- Critical Care Department, University Medical Center Groningen (UMCG), NL-9700 RB, Groningen, the Netherlands
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18
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Gillani S, Rahmatillah D, Sari Y, Baig MR, Syed Sulaiman S. Monitoring of Hypocalcaemia & Hyperglycemia predictive consequences of Thyroidectomy. Int Arch Med 2014; 7:13. [PMID: 24684723 PMCID: PMC3984019 DOI: 10.1186/1755-7682-7-13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Accepted: 03/17/2014] [Indexed: 11/10/2022] Open
Abstract
Background Hyperglycemia and hypocalcaemia have separately been attributed to adverse outcomes in critically ill patients. The study was aim determine whether hyperglycemia and hypocalcaemia together post-operative effect of thyroidectomy and evaluate the gender & age impact on the extend of clinical condition. Methods All the patients underwent thyroidectomy in the duration of 1st Jan 2012 till 30th June, 2013 in HPP and HUSM Kelantan, Malaysia. Serum evaluation has been made on 4 consecutive reading with duration of 6 hours. The predictive trend has been established to identify the hypokalemic and hyperglycemic condition. Ethical approvals & Patients’ consent forms have been made prior to conduct this study. Results The incidence of hyperglycemia [≥ 150 mg/dl(8.3 mmol/L)] and hypocalcaemia (serum calcium < 8.5 mg/dl (2.2 mmol/L)] were 39.4% and 43.9% respectively. Hyperglycemia and hypocalcaemia associated with age and length of stay, significant association has been found among pre-operative diagnosis as well. The interaction of hyperglycemia and hypocalcaemia did not separate effects on mortality. Conclusion As demonstrated, the prevalence of hyperglycemia and hypocalcaemia in post-thyroidectomy patients is considerable high. Also, the linear association pattern has been shown. However, considering the disease severity, the association of hyperglycemia and hypocalcaemia with surgical ward indicators of morbidity could not be verified.
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Diabetes and hemoglobin a1c as risk factors for nosocomial infections in critically ill patients. Crit Care Res Pract 2013; 2013:279479. [PMID: 24459586 PMCID: PMC3891611 DOI: 10.1155/2013/279479] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Revised: 07/17/2013] [Accepted: 10/09/2013] [Indexed: 12/13/2022] Open
Abstract
UNLABELLED Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012. INCLUSION CRITERIA ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20 (1.91-20.17; P = 0.002) and blood transfusion 3.33 (1.23-9.02; P = 0.018) were independent risk factors for VAP. BSI in ICU (P = 0.044) and ICU mortality (P = 0.038) were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45 (1.14-5.29; P = 0.022) and stroke on admission2.77 (1.12-6.88; P = 0.029). Sepsis 3.34 (1.47-7.58; P = 0.004) and parenteral feeding 6.29 (1.59-24.83; P = 0.009) were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU.
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Jiménez-Ibáñez EO, Castillejos-López M, Hernández A, Gorocica P, Alvarado-Vásquez N. High mortality associated with hyperglycemia, neutrophilia, and lymphopenia in critically ill patients. TOHOKU J EXP MED 2012; 226:213-20. [PMID: 22353790 DOI: 10.1620/tjem.226.213] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
A common finding in patients admitted to an Intensive Care Unit (ICU) is hyperglycemia without prior history of diabetes. This increase in blood glucose is considered a negative prognostic factor for patients in the ICU. Hence, we performed a retrospective cohort study in patients admitted at the ICU of the National Institute of Respiratory Diseases (INER) in a 7-month period; we collected data about their blood glucose concentration during their stay at the ICU. We gathered the available medical records of 30 patients out of 58 admitted to the ICU. Among the 30 patients, 21 patients survived (70%) and 9 patients with community-acquired pneumonia (CAP) died (30%). The 21 surviving patients included 17 patients with acute respiratory distress secondary to CAP and 4 patients with asthmatic crisis upon admission to the ICU. After admission, all patients progressed to sepsis and showed an increase in blood glucose. We detected higher glucose concentrations in deceased patients (147 mg/dl ± 4.23), as compared to surviving patients (129 mg/dl ± 2.17) (P < 0.001). In addition, the percentage of lymphocytes was lower in deceased patients than that in surviving patients (5.7 vs. 11.8%, P < 0.001), whereas percentage of neutrophils was elevated in the deceased patients (90.7 vs. 80.9%, P < 0.001). It is therefore important to measure continuously glucose concentrations, as well as the numbers of neutrophils and lymphocytes in critically ill patients with hyperglycemia. Such a simple monitoring plan may prevent fatal complications in patients admitted to ICU.
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Affiliation(s)
- Enrique O Jiménez-Ibáñez
- Graduate and Research Section, Higher School of Medicine of the National Polytechnical Institute, México City, México
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21
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Hyperglycemia in patients with hypertensive crisis: Response to ?Hypertensive crisis: Comparison between diabetics and non-diabetics? Int J Cardiol 2012; 154:378. [DOI: 10.1016/j.ijcard.2011.11.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2011] [Accepted: 11/26/2011] [Indexed: 11/19/2022]
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Abstract
UNLABELLED NEED AND PURPOSE OF REVIEW: Hyperglycemia is prevalent among critically ill pediatric patients. Previously thought to be an adaptive response to stress, hyperglycemia is now recognized to be associated with an adverse outcome. Correction of such hyperglycemia with insulin infusion has been shown to improve outcome but carries risk of hypoglycemia. This review addresses these issues related to treatment of hyperglycemia. METHODS A Pubmed search was performed using the search strategy: (hyperglycemia OR blood glucose OR insulin therapy) AND (critical illness OR critical care OR intensive care unit). Randomized controlled trials, clinical trials, meta-analysis and observational studies (adult and pediatric) published in the last 10 years were included. CONCLUSION Blood sugar monitoring and correction of hyperglycemia while caring for critically ill children is crucial. A modest blood glucose target of <150 mg/dL is appropriate. Providing adequate nutrition along with training of the nursing personnel would prevent any adverse effect such as hypoglycemia.
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Ricci Z, Cruz DN, Ronco C. Intensive care. Nephrol Dial Transplant 2010; 25:678-83. [PMID: 20185413 DOI: 10.1093/ndt/gfq005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Zaccaria Ricci
- Department of Pediatric Cardiosurgery, Bambino Gesù Hospital, Rome, Italy.
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A literature review of intensive insulin therapy and mortality in critically ill patients. CLIN NURSE SPEC 2010; 24:80-6. [PMID: 20168143 DOI: 10.1097/nur.0b013e3181cf55af] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Since Van den Berghe et al published their study on tight glucose control in 2001, intensive insulin therapy (IIT) has been increasingly used for critically ill patients worldwide. However, recent studies reported a significantly increased risk of hypoglycemia without a significant reduction in mortality. OBJECTIVE The purpose of this article was to evaluate the effect of IIT with a target glucose of 110 mg/dL or less on mortality in adult critically ill patients and to determine whether it is appropriate to generalize IIT for all critically ill patients. METHODS Ovid, MEDLINE, and PubMed databases were searched for studies that compared "conventional" vs "intensive" insulin therapy in adult critically ill patients. RESULTS Eleven articles were included for this review. There was no significant difference in intensive care unit mortality between tight glucose control group and conventional glucose control group in 5 of 6 studies. Only 1 study showed a significant difference in hospital mortality between the 2 groups. Seven studies showed a significant increase in the incidence of hypoglycemia. CONCLUSIONS Intensive insulin therapy was not associated with significant reduction in mortality in adult critically ill patients but was related to a significant increase in the incidence of hypoglycemia. Therefore, it is inappropriate to generalize IIT for all critically ill patients, even though it significantly improved blood glucose control.
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Hiperglucemia de estrés y su control con insulina en el paciente crítico: evidencia actual. Med Intensiva 2010; 34:273-81. [DOI: 10.1016/j.medin.2009.10.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/04/2009] [Accepted: 10/06/2009] [Indexed: 01/12/2023]
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Preiser JC, Devos P, Chiolero R. Which factors influence glycemic control in the intensive care unit? Curr Opin Clin Nutr Metab Care 2010; 13:205-10. [PMID: 20010097 DOI: 10.1097/mco.0b013e328335720b] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Intensive insulin therapy titrated to restore and maintain blood glucose between 80 and 110 mg/dl (4.4-6.1 mmol/l) was found to improve survival of critically ill patients in one pioneering proof-of-concept study performed in a surgical intensive care unit. The external validity of these findings was investigated. RECENT FINDINGS Six independent prospective randomized controlled trials, involving 9877 patients in total, were unable to confirm the survival benefit reported in the pioneering trial. Several hypotheses were proposed to explain this discrepancy, including the case-mix, the features of the usual care, the quality of glucose control and the risks associated with hypoglycemia. SUMMARY Before a better understanding and delineation of the conditions associated with and improved outcome by tight glycemic control, the choice of an intermediate glycemic target appears as a safe and effective solution.
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Affiliation(s)
- Jean-Charles Preiser
- Department of General Intensive Care, University Hospital Centre of Liege, Liege, Belgium.
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Lazzeri C, Tarquini R, Giunta F, Gensini GF. Glucose dysmetabolism and prognosis in critical illness. Intern Emerg Med 2009; 4:147-56. [PMID: 19030949 DOI: 10.1007/s11739-008-0206-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2008] [Accepted: 10/29/2008] [Indexed: 01/08/2023]
Abstract
Acute hyperglycemia frequently present in stress conditions, has long been generally accepted as normal, and not thought to be a cause for concern since a moderate hyperglycemia in critically ill adult patients has been thought to be beneficial during the "fight or flight" response to ensure a supply of glucose as a source of energy to organs that do not require insulin for glucose uptake (i.e., the brain and the immune system). However, an increasing body of evidence associates the upon-admission degree and duration of hyperglycemia during critical illness with an adverse outcome. Hyperglycemia should be regarded as a part of the systemic and complex metabolic derangements observed in critical illness in response to stress and inflammation, which can lead, independent of initial disease, to multiorgan dysfunction and death. A tight glycemic control should be constantly pursued and achieved by insulin infusion bearing in mind that the therapeutic target is fighting the systemic inflammatory response and not merely the glucose plasma levels.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Cardiac Care Unit, Heart and Vessel Department, Azienda Ospedaliero-Universitaria Careggi, University of Florence, Viale Morgagni 85, Florence, Italy.
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Thomas Z, Kimborowicz K. Highlights from the 2008 Surviving Sepsis Campaign: Part 2. Hosp Pharm 2009. [DOI: 10.1310/hpj4404-298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Previously, 1 key issues surrounding the 2008 Surviving Sepsis Campaign (SSC) were examined, 2 including evidence-based ratings, initial resuscitation, antimicrobial therapy, vasopressor support, and the role of the pharmaceutical industry in the SSC. In part 2 of this series, the recommendations for corticotherapy, intensive insulin therapy, activated protein C, blood transfusions, and selective digestive tract decontamination are discussed.
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Affiliation(s)
- Zachariah Thomas
- Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey; Clinical Pharmacist, Hackensack University Medical Center, Hackensack, New Jersey
| | - Katarzyna Kimborowicz
- Ernest Mario School of Pharmacy, Rutgers, the State University of New Jersey, Piscataway, New Jersey; Clinical Pharmacist, Morristown Memorial Hospital, Morristown, New Jersey
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Is normalized mean blood glucose level good enough for the intensive care unit?--glycemic variability as a new independent predictor of mortality. Crit Care Med 2008; 36:3104-6. [PMID: 18941315 DOI: 10.1097/ccm.0b013e31818c38ab] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Affiliation(s)
- Philippe Devos
- a Department of General Intensive Care, University Hospital Centre of Liege, Domaine universitaire du Sart-Tilman, 4000 Liege, Belgium.
| | - Jean-Charles Preiser
- b Department of General Intensive Care, University Hospital Centre of Liege, Domaine universitaire du Sart-Tilman, 4000 Liege, Belgium.
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Vandijck DM, Oeyen SG, Buyle EM, Claus BO, Blot SI, Decruyenaere JM. Hyperglycaemia upon onset of ICU-acquired bloodstream infection is associated with adverse outcome in a mixed ICU population. Anaesth Intensive Care 2008; 36:25-9. [PMID: 18326128 DOI: 10.1177/0310057x0803600105] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study aimed to assess whether a relationship exists between hyperglycaemia and outcome in a mixed cohort of critically ill patients with nosocomial bloodstream infection (BSI), and to evaluate patterns of blood glucose levels between survivors and non-survivors. A historical observational cohort study was conducted in the intensive care unit (ICU) of a tertiary care referral centre. One-hundred-and-thirty patients with a microbiologically documented ICU-acquired BSI (period 2003 to 2004) were included. For the study, morning blood glucose levels were evaluated from one day prior until five days after onset of BSI. The contribution of hyperglycaemia, divided in three subgroups (> or = 150 mg/dl, > or = 175 mg/dl and > or = 200 mg/dl), to in-hospital mortality was estimated by logistic regression. In-hospital mortality was 36.2%. Over the seven study days, no differences were found in daily morning blood glucose levels between survivors (n = 83) and non-survivors (n = 47). Nevertheless, the trend of blood glucose levels upon onset of BSI showed a remarkable increase in the non-survivors, whereas it decreased in the survivors. Hyperglycaemia (> or = 175 mg/dl and > or = 200 mg/dl) was observed more often among the non-survivors. Multivariate logistic regression showed that APACHE II (P = 0.002), antibiotic resistance (P = 0.004) and hyperglycaemia (> or = 175 mg/dl) upon onset of BSI (P = 0.017) were independently associated with in-hospital mortality, whereas a history of diabetes (P = 0.041) was associated with better outcome. Hyperglycaemia (> or = 175 mg/dl) upon onset of ICU-acquired BSI is associated with worse outcome in a heterogeneous ICU population. Patterns of morning blood glucose levels have only limited value in the prediction of the individual course.
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Affiliation(s)
- D M Vandijck
- Ghent University, Ghent University Hospital, Faculty of Medicine and Health Sciences, Department of Intensive Care Medicine, De Pintelaan 185, 9000 Ghent, Belgium
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Honiden S, Schultz A, Im SA, Nierman DM, Gong MN. Early versus late intravenous insulin administration in critically ill patients. Intensive Care Med 2008; 34:881-7. [PMID: 18180902 DOI: 10.1007/s00134-007-0978-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Accepted: 12/06/2007] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To investigate whether timing of intensive insulin therapy (IIT) after intensive care unit (ICU) admission influences outcome. DESIGN AND SETTING Single-center prospective cohort study in the 14-bed medical ICU of a 1,171-bed tertiary teaching hospital. PATIENTS The study included 127 patients started on ITT within 48 h of ICU admission (early group) and 51 started on ITT thereafter (late group); the groups did not differ in age, gender, race, BMI, APACHE III, ICU steroid use, admission diagnosis, or underlying comorbidities. MEASUREMENTS AND RESULTS The early group had more ventilator-free days in the first 28 days after ICU admission (median 12 days, IQR 0-24, vs. 1 day, 0-11), shorter ICU stay (6 days, IQR 3-11, vs. 11 days, vs. 7-17), shorter hospital stay (15 days, IQR 9-30, vs. 25 days, 13-43), lower ICU mortality (OR 0.48), and lower hospital mortality (OR 0.27). On multivariate analysis, early therapy was still associated with decreased hospital mortality (ORadj 0.29). The strength and direction of association favoring early IIT was consistent after propensity score modeling regardless of method used for analysis. CONCLUSIONS Early IIT was associated with better outcomes. Our results raise questions about the assumption that delayed administration of IIT has the same benefit as early therapy. A randomized study is needed to determine the optimal timing of therapy.
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Affiliation(s)
- Shyoko Honiden
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Yale University School of Medicine, New Haven, CT, USA
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Abstract
OBJECTIVE To describe the current status and the clinical data related to the effects of tight glucose control by intensive insulin therapy in critically ill patients. DESIGN Review article. SETTING University hospital. PATIENTS Medical and surgical critically ill patients in whom a correlation between blood glucose and outcome variables were searched. INTERVENTIONS Tight glucose control by intensive insulin therapy. MEASUREMENTS AND MAIN RESULTS In contrast to the decreases in mortality and to low severity of adverse effects reported when insulin rate was titrated to keep blood glucose between 80 and 110 mg/dL, the benefits were not confirmed in multicenter prospective studies. Retrospective data found an association between a mean blood glucose level of <140-150 mg/dL and improved outcome. Currently unanswered issues include the optimal target for blood glucose, the effects of high blood glucose variability, the risks and hazards of hypoglycemia, and the potential influence of the underlying disorder on the effects of tight glucose control. CONCLUSIONS Recommendations regarding the practical aspects of tight glucose control by intensive insulin therapy cannot be presently issued. An intermediate target level for blood glucose of 140-180 mg/dL seems to be associated with the lowest risk-to-benefit ratio.
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Affiliation(s)
- Jean-Charles Preiser
- Department of General Intensive Care, University Hospital Center, University of Liege, Domaine universitaire du Sart-Tilman, Liege, Belgium.
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Abstract
PURPOSE OF REVIEW The outcomes of intervention studies implementing intensive insulin therapy aimed at tight glucose control (TGC) are yet not conclusive. There is concern about an increasing incidence of hypoglycemic episodes. Normoglycemia is not easy to obtain in a 'real-life' ICU setting. To facilitate the implementation of TGC, we review its practical aspects. RECENT FINDINGS Point-of-care blood gas/glucose analyzers currently present the best trade-off between accuracy and speed. A nurse-driven dynamic scale protocol leads to the most efficacious and safe implementation of TGC. Paper protocols have been published and computerized protocols are a new development. Closed-loop systems are not yet available for clinical use. SUMMARY Clinicians should take care in selecting both the patient group and target blood glucose level. As long as doubts remain about the potential benefits, it is important to perform TGC in a safe way. This can be done with a nurse-driven protocol, using arterial blood samples measured on a point-of-care blood gas analyzer. Insulin administration should be continuous, and guided by a dynamic scale protocol either on paper or on the computer. Periodical monitoring of performance and incremental modification of the protocol leads to best results.
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Affiliation(s)
- Mathijs Vogelzang
- Surgical ICU, Department of Surgery, University Medical Center Groningen, University of Groningen, the Netherlands
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Abstract
PURPOSE OF REVIEW This review updates our knowledge on the benefits and risks of tight glucose control by intensive insulin therapy in critically ill patients, as well as discussing unanswered questions related to the subject. RECENT FINDINGS At the cellular level, the toxic effects of elevated and highly variable glucose concentration are related to an increase in oxidative stress and to several toxic intracellular derivates generated as by-products of the glycolytic pathway. Clinically, several recent studies have suggested that the optimal target for blood glucose may be higher than the 'normal' values of 4.4-6.1 mmol/l for various categories of patients. Also, the variability in glucose level appears to be an important determinant of glucose toxicity. Conflicting data on the hazards of hypoglycaemia are emerging. SUMMARY Practical recommendations for the implementation of tight glucose control using intensive insulin therapy cannot be disseminated until questions relating to optimal blood glucose level and the corresponding categories of patients have been resolved. The issues of glucose variability and the most efficient method of preventing hypoglycaemia will probably represent important parameters for comparing the safety and quality of protocols used for tight glucose control.
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Affiliation(s)
- Philippe Devos
- Department of Intensive Care, Centre Hospitalier, Universitaire du Sart Tilman, Liège, Belgium
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Reply to the comment by Dr. Tayek. Intensive Care Med 2006. [DOI: 10.1007/s00134-006-0282-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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