Insulin-treated diabetes is not associated with increased mortality in critically ill patients

Correlation of hyperglycemia and balthazar classification in patients with acute pancreatitis

Objective

High levels of glucose during acute pancreatitis (AP) progression influence disease progression by promoting the release of inflammatory cytokines. The aim of this study was to evaluate the effects of both the blood glucose level in patients without diabetes mellitus (DM) and the presence of DM on the severity and course of AP in patients presenting with clinical AP.

Methods

The study included 343 patients who were hospitalized at Van Training and Research Hospital, Turkey and followed up with the diagnosis of AP between 2014 and 2018. The patients were separated into two groups as diabetic and non-diabetic. The relationship between DM and the severity and course of AP was examined in the two groups.

Results

The DM group included 52 (15.1%) patients, and the non- DM group included 291 (84.9%) patients. In the non-DM group, the serum glucose level was <125 mg/dl in 160 (54.9 %) patients, and >125 mg/dl in 131 (45.1 %) patients. In the comparison of AP severity in the diabetic and non-diabetic groups, the rate of severe AP was determined to be significantly higher in the diabetic group according to the Modified Balthazar classification, evaluated from tomographies taken on admission and on the 3rd day (p:0.026, p:0.001, respectively).

Conclusion

Elevated blood glucose is relatively common in patients with AP and has a negative impact on the disease process. A high glucose level can increase the severity of AP and slow healing.

Clinical Outcomes of Diabetes Mellitus on Moderately Severe Acute Pancreatitis and Severe Acute Pancreatitis

Objective

To analyze the influence of diabetes mellitus on the clinical outcomes of moderately severe acute pancreatitis (MSAP) and severe acute pancreatitis (SAP).

Methods

This retrospective study included patients diagnosed with MSAP and SAP at Shanxi Bethune Hospital from January 1, 2017, to December 31, 2021. Clinical data were collected, including patient demographics, 24-hour laboratory indicators, and inflammation indices. Propensity score matching (PSM) was used to compare outcomes before and after matching. Patients were randomized into training and validation sets (7:3) to develop and validate a clinical prediction model for infected pancreatic necrosis (IPN).

Results

Among 421 patients, 79 had diabetes at admission. Before PSM, diabetic patients had higher incidences of peripancreatic fluid (71% vs 47%, p<0.001) and IPN (48% vs 10%, p<0.001), higher surgical intervention rates (24% vs 12%, p=0.008), and significant differences in abdominocentesis (22% vs 11%, p=0.014). After PSM, 174 patients were matched, and the diabetes group still showed higher incidences of peripancreatic fluid (69% vs 47%, p=0.008), IPN (48% vs 11%, p<0.001), and surgical intervention rates (27% vs 13%, p=0.037). Diabetes, modified CT severity index (MCTSI), serum calcium, and HDL-c were identified as independent risk factors for IPN. The prediction model demonstrated good predictive value.

Conclusion

In MSAP and SAP patients, diabetes mellitus can exert an influence on their clinical outcome and is an independent risk factor for IPN. The alignment diagram and web calculator constructed on the basis of diabetes mellitus, modified CT severity index (MCTSI), serum calcium and high-density lipoprotein cholesterol (HDL-c) have good predictive value and clinical guidance for the occurrence of IPN in MSAP and SAP.

Persistent Hyperglycemia Worsens the Oleic Acid Induced Acute Lung Injury in Rat Model of Type II Diabetes Mellitus

Aim

This research aimed to study the impacts of persistent hyperglycemia on oleic acid (OA)-induced acute lung injury (ALI) in a rat model of type II diabetes mellitus.

Materials and Methods

Healthy adult male albino rats that weigh 150 to 180 g were divided into four groups (n = 6). Group I-saline (75 μL i.v.) was injected and served as a control; group II-OA (75 μL i.v.) was injected to induce ALI. Group III-pretreated with a high-fat diet and streptozotocin (35 mg/kg), was injected with saline, and served as a control for group IV. Group IV was pretreated with a high-fat diet, and streptozotocin (35 mg/kg) was injected with OA (75 μL i.v). Urethane was used to anesthetize the animal. The jugular venous cannulation was done for drug/saline administration, carotid artery cannulation was done to record blood pressure, and the tracheal cannulation was done to maintain the respiratory tract's patent. Heart rate, mean arterial pressure, and respiratory frequency were recorded on a computerized chart recorder; an arterial blood sample was collected to measure PaO2/FiO2. Additionally, the pulmonary water content and lung histology were examined.

Result

Hyperglycemic rats showed no significant change in the cardio-respiratory parameter. Histology of the lungs shows fibroblastic proliferation; however, rats survived throughout the observation period. There was an early deterioration of all the cardio-respiratory parameters in hyperglycemic rats when induced ALI (OA- induced), and survival time was significantly less compared to nonhyperglycemic rats.

Conclusion

Persistent hyperglycemia may cause morphological changes in the lungs, which worsens the outcome of acute lung injury.

Recent advances in molecular mechanisms of acute kidney injury in patients with diabetes mellitus

Several insults can lead to acute kidney injury (AKI) in native kidney and transplant patients, with diabetes critically contributing as pivotal risk factor. High glucose per se can disrupt several signaling pathways within the kidney that, if not restored, can favor the instauration of mechanisms of maladaptive repair, altering kidney homeostasis and proper function. Diabetic kidneys frequently show reduced oxygenation, vascular damage and enhanced inflammatory response, features that increase the kidney vulnerability to hypoxia. Importantly, epidemiologic data shows that previous episodes of AKI increase susceptibility to diabetic kidney disease (DKD), and that patients with DKD and history of AKI have a generally worse prognosis compared to DKD patients without AKI; it is therefore crucial to monitor diabetic patients for AKI. In the present review, we will describe the causes that contribute to increased susceptibility to AKI in diabetes, with focus on the molecular mechanisms that occur during hyperglycemia and how these mechanisms expose the different types of resident renal cells to be more vulnerable to maladaptive repair during AKI (contrast- and drug-induced AKI). Finally, we will review the list of the existing candidate biomarkers of diagnosis and prognosis of AKI in patients with diabetes.

Critical care for multimorbid patients

Multimorbidity - the simultaneous presence of several chronic diseases - is very common in the critically ill patients. Its prevalence is roughly 40-85 % and continues to increase further. Certain chronic diseases such as diabetes, obesity, chronic heart, pulmonary, liver or kidney disease and malignancy are associated with higher risk of developing serious acute complications and therefore the possible need for intensive care. This review summarizes and discusses selected specifics of critical care for multimorbid patients.

Type 2 diabetes mellitus and sepsis: state of the art, certainties and missing evidence

Diabetes and sepsis are important causes of morbidity and mortality worldwide, and diabetic patients represent the largest population experiencing post-sepsis complications and rising mortality. Dysregulated immune pathways commonly found in both sepsis and diabetes contribute to worsen the host response in diabetic patients with sepsis. The impact of diabetes on mortality from sepsis is still controversial. Whereas a substantial proportion of severe infections can be attributed to poor glycemic control, treatment with insulin, metformin and thiazolidinediones may be associated with lower incidence and mortality for sepsis. It has been suggested that chronic exposure to high glucose might enhance immune adaptation, leading to reduced mortality rate in septic diabetic patients. On the other hand, higher risk of acute kidney injury has been extensively documented and a suggested lower risk of acute respiratory distress syndrome has been recently questioned. Additional investigations are ongoing to confirm the protective role of some anti-diabetic treatments, the occurrence of acute organ dysfunction, and the risk/benefit of less stringent glycemic control in diabetic patients experiencing sepsis. Based on a MEDLINE/PubMed search from inception to December 31, 2020, the aim of this review is therefore to summarize the strengths and weaknesses of current knowledge on the interplay between diabetes and sepsis.

Survivors of Intensive Care With Type 2 Diabetes and the Effect of Shared-Care Follow-Up Clinics: The SWEET-AS Randomized Controlled Pilot Study

BACKGROUND

Follow-up clinics after ICU admission have demonstrated limited benefit. However, existing trials have evaluated heterogeneous cohorts and used physicians who had limited training in outpatient care.

RESEARCH QUESTION

What are the effects of a "shared-care" intensivist-endocrinologist clinic for ICU survivors with type 2 diabetes on process measures and clinical outcomes 6 months after hospital discharge, and is it feasible to conduct a larger trial?

STUDY DESIGN AND METHODS

This was a prospective, randomized, single-center pilot study with blinded outcome assessment. Patients with type 2 diabetes, who required ≥ 5 days of ICU care (mixed medical-surgical ICU) and survived to ICU discharge, were eligible. Participants were randomized to attendance at the shared-care clinic 1 month after hospital discharge or usual care. Six months after hospital discharge, participants were assessed for outcomes including glycated hemoglobin, neuropathy, nephropathy, quality of life, return to employment, frailty, and health-care use. The primary outcome was participant recruitment and retention.

RESULTS

During an 18-month period, 42 of 82 eligible patients (51%) were recruited. Four participants (10%) withdrew before assessment at 6 months and 11 (26%) died. At 6 months, only 18 of 38 participants who did not withdraw (47%) were living independently without support, and 24 (63%) required at least one subsequent hospital admission. In the intervention group (n = 21), 16 (76%) attended the clinic. Point estimates did not indicate that the intervention improved glycated hemoglobin (+5.6 mmol/mol; 95% CI, -6.3 to 17; P = .36) or quality of life (36-Item Short Form Survey physical summary score, 32 [9] vs. 32 [7]; P = 1.0).

INTERPRETATION

Outcomes for ICU survivors with type 2 diabetes are poor. Because of low participation and high mortality, a larger trial of a shared-care follow-up clinic in this cohort, using the present design, does not appear feasible.

TRIAL REGISTRY

Australian New Zealand Clinical Trials Registry (ANZCTR); No.: ACTRN12616000206426; URL: www.anzctr.org.au.

Diabetes on sepsis outcomes in non-ICU patients: A cohort study and review of the literature

AIMS

We sought to determine whether primary outcomes differ between non-ICU septic patients with and without type 2 diabetes (T2D).

METHODS

This study utilized the Hellenic Sepsis Study Group Registry, collecting nationwide data for sepsis patients since 2006, and classified patients upon presence or absence of T2D. Patients were perfectly matched for a) Sepsis 3 definition criteria (including septic shock) b) gender, c) age, d) APACHE II score and e) Charlson's comorbidity index (CCI). Independent sample t-test and chi-square t-test was used to compare prognostic indices and primary outcomes.

RESULTS

Of 4320 initially included non-ICU sepsis patients, 812 were finally analysed, following match on criteria. Baseline characteristics were age 76 [±10.3] years, 46% male, APACHE II 15.5 [±6], CCI 5.1 [±1.8], 24% infection, 63.8% sepsis and 12.2% septic shock. No significant difference was noted between two groups in qSOFA, SOFA, or suPAR1 levels (p = 0.7, 0.1 & 0.3) respectively. Primary sepsis syndrome resolved in 70.9% of cases (p = 0.9), while mortality was 24% in 28-days time. Cause of death was similar between patients with and without T2D (sepsis 17.8% vs 15.8%, heart event 3.7% vs 3.2%, CNS event 0.5% vs 0.5%, malignancy 0.7% vs 2% respectively, p = 0.6).

CONCLUSIONS

DM does not appear to negatively affect outcomes in septic patients not requiring ICU.

Prevalence and impact of chronic dysglycemia in intensive care unit patients-A retrospective cohort study

BACKGROUND

The prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to Swedish intensive care units (ICUs) is unknown. We aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centered outcomes in critically ill patients.

METHODS

In this retrospective observational cohort study, we obtained glycated hemoglobin A1c (HbA1c) in patients admitted to four tertiary ICUs in Sweden between March and August 2016. Based on previous diabetes history and HbA1c we determined the prevalence of chronic dysglycemia. We used multivariable regression analyses to study the association of chronic dysglycemia with the time-weighted average blood glucose concentration, glycemic lability index (GLI), and development of hypoglycemia (co-primary outcomes), and with ICU length of stay, mechanical ventilation duration, renal replacement therapy (RRT) use, vasopressor use, ICU-acquired infections, and mortality (exploratory clinical outcomes).

RESULTS

Of 943 patients, 312 (33%) had chronic dysglycemia. Of these 312 patients, 84 (27%) had prediabetes, 43 (14%) had undiagnosed diabetes and 185 (59%) had known diabetes. Chronic dysglycemia was independently associated with higher time-weighted average blood glucose concentration (P < .001), higher GLI (P < .001), and hypoglycemia (P < .001). Chronic dysglycemia was independently associated with RRT use (adjusted odds ratio 1.97, 95% CI 1.24-3.13, P = .004) but not with other exploratory clinical outcomes.

CONCLUSIONS

In four tertiary Swedish ICUs, measurement of HbA1c showed that one-third of patients had chronic dysglycemia. Chronic dysglycemia was associated with marked derangements in glycemic control, and a greater need for renal replacement therapy.

Association of Diabetes and Admission Blood Glucose Levels with Short-Term Outcomes in Patients with Critical Illnesses

BACKGROUND

Association of diabetes and admission glucose on the short-term prognosis in patients with critical illnesses are currently ambiguous. We aimed to determine whether diabetes and admission glucose affects short-term prognosis of critically ill patients.

METHODS

We performed a retrospective analysis of data on 46,476 critically ill patients from the critical care database. Association of diabetes with 28-day mortality was assessed by inverse probability weighting based on the propensity score. Smoothing splines and threshold effect analysis were applied to explore the relationship between admission glucose and clinical outcomes.

RESULTS

Of the 33,680 patients enrolled in the study, 8,701 (25.83%) had diabetes. In the main analysis, the 28-day mortality was reduced by 29% (hazard ratio (HR)=0.71, 95% confidence interval (CI) 0.67-0.76) in patients with diabetes compared to those without diabetes. The E-value of 2.17 indicated robustness to unmeasured confounders. Significant interactions were observed for glucose at ICU admission, admission type, and insulin use (Interaction P <0.05). A V-shaped relationship was observed between admission glucose and 28-day mortality in non-diabetic patients, with the lowest 28-day mortality corresponding to a glucose level of 101.75 mg/dl (95% CI 94.64-105.80 mg/dl), and admission hypoglycemia or hyperglycemia should be avoided, especially in patients admitted to the surgical intensive care unit (SICU), cardiac surgery recovery unit (CSRU), and coronary care unit (CCU); for diabetic patients, elevated admission glucose does not appear to be associated with a poor prognosis and perhaps may be beneficial except for CCU and CSRU.

CONCLUSION

The non-detrimental effect of diabetes on the short-term prognosis of critically ill patients was further confirmed, which would reduce 28-day mortality by approximately 29%. For non-diabetic patients, the admission glucose level corresponding to the lowest 28-day mortality was 101.75 mg/dl (95% CI 94.64-105.80 mg/dl); however, for diabetics, the appropriate admission glucose threshold remains unresolved.

Titin and CK2α are New Intracellular Targets in Acute Insulin Application-Associated Benefits on Electrophysiological Parameters of Left Ventricular Cardiomyocytes From Insulin-Resistant Metabolic Syndrome Rats

BACKGROUND

Previous studies have demonstrated that a high-carbohydrate intake could induce metabolic syndrome (MetS) in male rats with marked cardiac functional abnormalities. In addition, studies mentioned some benefits of insulin application on these complications, but there are considerable disagreements among their findings. Therefore, we aimed to extend our knowledge on the in-vitro influence of insulin on left ventricular dysfunction and also in the isolated cardiomyocytes from MetS rats.

RESULTS

At the organ function level, an acute insulin application (100-nM) provided an important beneficial effect on the left ventricular developed pressure in MetS rats. Furthermore, to treat the freshly isolated cardiomyocytes from MetS rats with insulin provided marked recoveries in elevated resting intracellular Ca²⁺-level, as well as significant prevention of prolonged action potential through an augmentation in depressed K⁺-channel currents. Insulin also normalized the cellular levels of increased ROS and phosphorylation of PKCα, together with normalizations of apoptotic markers in MetS cardiomyocytes through the insulin-mediated regulation of phospho-Akt. Since not only elevated PKCα-activity but also reductions in phospho-Akt are key modulators of titin-based cardiomyocyte stiffening in hyperglycemia, insulin treatment of the cardiomyocytes prevented the activation of titin via the above pathways. Furthermore, CK2α-activation and NOS-phosphorylation could be prevented with insulin treatment. Mechanistically, we found that impaired insulin signaling and elevated PKCα and CK2α activities, as well as depressed Akt phosphorylation, are key modulators of titin-based cardiomyocyte stiffening in MetS rats.

CONCLUSION

We propose that restoring normal kinase activities and also increases in phospho-Akt by insulin can contribute marked recoveries in MetS heart function, indicating a promising approach to modulate titin-associated factors in heart dysfunction associated with type-2 diabetes mellitus. Graphical Abstract.

Inpatient Kidney Function Recovery among Septic Shock Patients Who Initiated Kidney Replacement Therapy in the Hospital

BACKGROUND

Sepsis and septic shock are life-threatening causes of acute kidney injury (AKI) frequently seen and managed in intensive care units (ICUs). Sepsis-associated AKI (SA-AKI) independently contributes to the mortality of sepsis. Understanding the potential factors involved in kidney function recovery may further aid in the prevention and management of SA-AKI. This study aimed to describe the clinical characteristics of septic shock patients who required kidney replacement therapy and factors associated with kidney function recovery.

METHODS

We conducted a retrospective cohort study of adult septic shock patients who received in-hospital kidney replacement therapy at medical intensive care unit (MICU) at the Mayo Clinic, Rochester, from January 1, 2006, to May 31, 2018. Kidney function recovery was defined as liberation from kidney replacement therapy before hospital discharge. Associations between clinical features and kidney recovery were analyzed using multivariable Fine and Gray regression accounting for death as a competing event.

RESULTS

Our retrospective cohort consisted of 229 patients with a median (interquartile range [IQR]) age of 64 (52-74) years: 55% were men, 89% were Caucasians, 39% had diabetes mellitus (DM), 16% had heart failure, APACHE (Acute Physiology and Chronic Health Evaluation) III score was 105 (84-123), and SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score was 12 (9-14). The patients received 1,567 (524-4,108) mL of intravenous fluids in the first 3 h, 92% required vasopressor support, and 83% required mechanical ventilation. The median MICU and hospital stays were 7 (4-13) and 19 (10-31) days, respectively. Median (IQR) kidney replacement therapy duration was 7 (3.5-17.1) days. Among 158 ICU survivors, 73 (46%) patients were weaned from RRT in ICU and 85 (54%) were transitioned to intermittent RRT. A higher volume of fluid resuscitation in the first 3 h (hazard ratio [HR] = 1.07 per 1 L, CI: 1.01-1.14, p = 0.04) and a history of DM (HR = 1.70, CI: 1.14-2.54, p = 0.009) were associated with kidney function recovery.

CONCLUSION

Among septic shock patients who initiated kidney replacement therapy in the MICU, 41% recovered kidney function before discharge. A higher initial fluid resuscitation volume was associated with recovery, and interestingly, patients with DM had a higher chance of recovery.

Is intensive glucose control bad for critically ill patients? A systematic review and meta-analysis

Background: The monitoring and management of blood glucose concentration are standard practices in critical settings as hyperglycaemia has been shown close association with poorer outcomes. Several meta-analyses have revealed that intensive glucose control has no benefit in decreasing short-term mortality among critically ill patients, while the studies these meta-analyses have incorporated have been largely divergent. We aim to perform a more comprehensive meta-analysis addressing this problem to provide stronger evidence. Methods: We conducted comprehensive searches for relevant randomized controlled studies in online databases, including the Cochrane Library, EMBASE, and PubMed databases, up to September 1, 2018. The clinical data, which included all-cause mortality, severe hypoglycemia, need for RRT, infection resulting in sepsis, ICU mortality, 90-day mortality, 180-day mortality, and hospital and ICU lengths of stay, were screened and analyzed after data extraction. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences for continuous outcomes with a random effects model. Results: A total of 57 RCTs involving a total of 21840 patients were finally included. Patients admitted to the ICU who underwent intensive glucose control showed significantly reduced all-cause mortality (OR: 0.89; 95% CI: 0.80-1.00; P=0.04; I2=32%), reduced infection rate (OR: 0.65, 95% CI: 0.51-0.82, P=0.0002; I2=47%), a lower occurrence of acquired sepsis (OR: 0.80, 95% CI: 0.65-0.99, P=0.04; I2=0%) and shortened length of ICU stay (MD: -0.70, 95% CI: -1.21--0.19, P=0.007, I2=70%) when compared to the same parameters as those treated with the usual care strategy. However, patients in the intensive glucose control group presented with a significantly higher risk of severe hypoglycemia (OR: 5.63, 95% CI: 4.02-7.87, P<0.00001; I2=67%). Conclusions: Critically ill patients undergoing intensive glucose control showed significantly reduced all-cause mortality, length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy, while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events.

Routine HbA1c among hematology and oncology inpatients: Diabetes-status and hospital-outcomes

AIMS

Using routine HbA1c measurement to determine the prevalence of diabetes mellitus (known and previously unrecognized) and their hospital outcomes among hematology and oncology inpatients.

METHODS

This was a prospective, observational study. Routine automated HbA1c testing was performed in all hematology and oncology inpatients aged ≥54 years at a tertiary hospital, July 2013-January 2015. The outcome measures were: (i) prevalence of known and previously unrecognized diabetes, and (ii) hospital outcomes: length-of-stay (LOS), intensive-care-unit (ICU) admission, 30-day/18-month readmission, and 18-month mortality.

RESULTS

Over the 18-month study period, 1076 inpatients aged ≥54 years were admitted to hematology (n = 298) and oncology (n = 778) units: 21% had known diabetes and 7% had previously unrecognized diabetes. Patients with known diabetes had a longer LOS (IRR: 1.18, 95%CI: 1.02-1.37, p = 0.03), compared to those without diabetes, adjusting for age, hemoglobin level, estimated-glomerular-filtration-rate, admission specialty unit, Charlson's comorbidity index score, and glucocorticoid exposure. No significant differences were observed in ICU admission, 30-day/18-month readmission, and 18-month mortality among patients with known, previously unrecognized and no diabetes (p ≥ 0.05).

CONCLUSIONS

Approximately one in five hematology or oncology inpatients aged ≥54 years had known diabetes, and one in fourteen had previously unrecognized diabetes. Those with known diabetes had a longer hospital stay. Routine HbA1c measurement is can be useful for identifying previously unrecognized diabetes, particularly among patients with high glucocorticoid exposure. Further study is required to determine cost-effectiveness in screening for unrecognized diabetes and optimal management of these patients.

Characteristics and Outcomes of Patients With and Without Type 2 Diabetes Mellitus and Pulmonary Sepsis

PURPOSE

To date, studies have provided conflicting results regarding the impact of type 2 diabetes mellitus (DM) on sepsis-related outcomes. Our objective is to understand the impact of type 2 DM in bacterial pneumonia and sepsis-related intensive care unit (ICU) outcomes.

METHODS

Retrospective study using Multiparameter Intelligent Monitoring in Intensive Care III database. We included 1698 unique patients admitted with sepsis secondary to bacterial pneumonia to the ICU within the time period of 2001 to 2012.

RESULTS

The type 2 DM group had an increased incidence of acute kidney injury (67.9% vs 58.1%, P < .01) and need for dialysis compared to the non-DM group. There was no difference in mortality, microbiology, other organ failure, or hospital length of stay between the type 2 DM and non-DM group. Lower admission blood glucose was associated with increased mortality in patients with type 2 DM (49% at ≤120 mg/dL, 35.1% at 121-180 mg/dL, and 32.1% at >180 mg/dL) but not in non-DM patients. Conversely, higher mean glucose during the hospital stay was associated with increased mortality in non-DM patients (24.7% at ≤120 mg/dL, 45.1% at 121-180 mg/dL, and 73.0% at >180 mg/dL) but not in patients with type 2 DM.

CONCLUSIONS

Our findings demonstrated that type 2 DM does not increase the overall mortality. Our findings of increased mortality in both type 2 DM patients with lower admission glucose, and non-DM patients with higher mean glucose during the hospital stay needs to be further evaluated. Future studies in regards to this could lead to personalized glucose treatment goals for patients.

Hospital outcomes and cumulative burden from complications in type 2 diabetic sepsis patients: a cohort study using administrative and hospital-based databases

BACKGROUND

The association between type 2 diabetes and hospital outcomes of sepsis remains controversial when severity of diabetes is not taken into consideration. We examined this association using nationwide and hospital-based databases.

METHODS

The first part of this study was mainly conducted using a nationwide database, which included 1.6 million type 2 diabetic patients. The diabetic complication burden was evaluated using the adapted Diabetes Complications Severity Index score (aDCSI score). In the second part, we used laboratory data from a distinct hospital-based database to make comparisons using regression analyses.

RESULTS

The nationwide study included 19,719 type 2 diabetic sepsis patients and an equal number of nondiabetic sepsis patients. The diabetic sepsis patients had an increased odds ratio (OR) of 1.14 (95% confidence interval 1.1-1.19) for hospital mortality. The OR for mortality increased as the complication burden increased [aDCSI scores of 0, 1, 2, 3, 4, and ⩾5 with ORs of 0.91, 0.87, 1.14, 1.25, 1.56, and 1.77 for mortality, respectively (all p < 0.001)].The hospital-based database included 1054 diabetic sepsis patients. Initial blood glucose levels did not differ significantly between the surviving and deceased diabetic sepsis patients: 273.9 ± 180.3 versus 266.1 ± 200.2 mg/dl (p = 0.095). Moreover, the surviving diabetic sepsis patients did not have lower glycated hemoglobin (HbA1c; %) values than the deceased patients: 8.4 ± 2.6 versus 8.0 ± 2.5 (p = 0.078).

CONCLUSIONS

For type 2 diabetic sepsis patients, the diabetes-related complication burden was the major determinant of hospital mortality rather than diabetes per se, HbA1c level, or initial blood glucose level.

Linagliptin Attenuates the Cardiac Dysfunction Associated With Experimental Sepsis in Mice With Pre-existing Type 2 Diabetes by Inhibiting NF-κB

The mortality rate of patients who develop sepsis-related cardiac dysfunction is high. Many disease conditions (e.g., diabetes) increase the susceptibility to infections and subsequently sepsis. Activation of the NF-κB pathway plays a crucial role in the pathophysiology of sepsis-associated cardiac dysfunction and diabetic cardiomyopathy. The effect of diabetes on outcomes in patients with sepsis is still highly controversial. We here hypothesized that type 2 diabetes (T2DM) augments the cardiac (organ) dysfunction associated with sepsis, and that inhibition of the NF-κB pathway with linagliptin attenuates the cardiac (organ) dysfunction in mice with T2DM/sepsis. To investigate this, 10-week old male C57BL/6 mice were randomized to receive normal chow or high fat diet (HFD), 60% of calories derived from fat). After 12 weeks, mice were subjected to sham surgery or cecal ligation and puncture (CLP) for 24 h. At 1 hour after surgery, mice were treated with linagliptin (10 mg/kg, i.v.), IKK-16 (1 mg/kg, i.v.), or vehicle (2% DMSO, 3 ml/kg, i.v.). Mice also received analgesia, fluids and antibiotics at 6 and 18 h after surgery. Mice that received HFD showed a significant increase in body weight, impairment in glucose tolerance, reduction in ejection fraction (%EF), and increase in alanine aminotransferase (ALT). Mice on HFD subjected to CLP showed further reduction in %EF, increase in ALT, developed acute kidney dysfunction and lung injury. They also showed significant increase in NF-κB pathway, iNOS expression, and serum inflammatory cytokines compared to sham surgery group. Treatment of HFD-CLP mice with linagliptin or IKK-16 resulted in significant reductions in (i) cardiac, liver, kidney, and lung injury associated with CLP-sepsis, (ii) NF-κB activation and iNOS expression in the heart, and (iii) serum inflammatory cytokine levels compared to HFD-CLP mice treated with vehicle. Our data show that pre-existing type 2 diabetes phenotype worsens the organ dysfunction/injury associated with CLP-sepsis in mice. Most notably, inhibition of NF-κB reduces the organ dysfunction/injury associated with sepsis in mice with pre-existing T2DM.

Identifying associations between diabetes and acute respiratory distress syndrome in patients with acute hypoxemic respiratory failure: an analysis of the LUNG SAFE database

BACKGROUND

Diabetes mellitus is a common co-existing disease in the critically ill. Diabetes mellitus may reduce the risk of acute respiratory distress syndrome (ARDS), but data from previous studies are conflicting. The objective of this study was to evaluate associations between pre-existing diabetes mellitus and ARDS in critically ill patients with acute hypoxemic respiratory failure (AHRF).

METHODS

An ancillary analysis of a global, multi-centre prospective observational study (LUNG SAFE) was undertaken. LUNG SAFE evaluated all patients admitted to an intensive care unit (ICU) over a 4-week period, that required mechanical ventilation and met AHRF criteria. Patients who had their AHRF fully explained by cardiac failure were excluded. Important clinical characteristics were included in a stepwise selection approach (forward and backward selection combined with a significance level of 0.05) to identify a set of independent variables associated with having ARDS at any time, developing ARDS (defined as ARDS occurring after day 2 from meeting AHRF criteria) and with hospital mortality. Furthermore, propensity score analysis was undertaken to account for the differences in baseline characteristics between patients with and without diabetes mellitus, and the association between diabetes mellitus and outcomes of interest was assessed on matched samples.

RESULTS

Of the 4107 patients with AHRF included in this study, 3022 (73.6%) patients fulfilled ARDS criteria at admission or developed ARDS during their ICU stay. Diabetes mellitus was a pre-existing co-morbidity in 913 patients (22.2% of patients with AHRF). In multivariable analysis, there was no association between diabetes mellitus and having ARDS (OR 0.93 (0.78-1.11); p = 0.39), developing ARDS late (OR 0.79 (0.54-1.15); p = 0.22), or hospital mortality in patients with ARDS (1.15 (0.93-1.42); p = 0.19). In a matched sample of patients, there was no association between diabetes mellitus and outcomes of interest.

CONCLUSIONS

In a large, global observational study of patients with AHRF, no association was found between diabetes mellitus and having ARDS, developing ARDS, or outcomes from ARDS.

TRIAL REGISTRATION

NCT02010073 . Registered on 12 December 2013.

Dysglycemia in the critically ill patient: current evidence and future perspectives

Dysglycemia in critically ill patients (hyperglycemia, hypoglycemia, glycemic variability and time in range) is a biomarker of disease severity and is associated with higher mortality. However, this impact appears to be weakened in patients with previous diabetes mellitus, particularly in those with poor premorbid glycemic control; this phenomenon has been called "diabetes paradox". This phenomenon determines that glycated hemoglobin (HbA1c) values should be considered in choosing glycemic control protocols on admission to an intensive care unit and that patients' target blood glucose ranges should be adjusted according to their HbA1c values. Therefore, HbA1c emerges as a simple tool that allows information that has therapeutic utility and prognostic value to be obtained in the intensive care unit.

Predicting Mortality in Diabetic ICU Patients Using Machine Learning and Severity Indices

Diabetes constitutes a significant health problem that leads to many long term health issues including renal, cardiovascular, and neuropathic complications. Many of these problems can result in increased health care costs, as well risk of ICU stay and mortality. To date, no published study has used predictive modeling to examine the relative influence of diabetes, diabetic health maintenance, and comorbidities on outcomes in ICU patients. Using the MIMIC-III database, machine learning and binomial logistic regression modeling were applied to predict risk of mortality. The final models achieved good fit with AUC values of 0.787 and 0.785 respectively. Additionally, this study demonstrated that robust classification can be done as a combination of five variables (HbA1c, mean glucose during stay, diagnoses upon admission, age, and type of admission) to predict risk as compared with other machine learning models that require nearly 35 variables for similar risk assessment and prediction.

Pathophysiological changes after lipopolysaccharide-induced acute inflammation in a type 2 diabetic rat model versus normal controls

AIMS

The present study aimed to explore the mechanism of a potential beneficial effect of pre-existing diabetes in acute hyperglycemia during critical illness.

METHODS

Pathophysiological changes including blood glucose variability, changes of inflammatory and oxidative stress responses after lipopolysaccharide (LPS)-induced acute infection were compared between type 2 diabetic rat model (GK rats) and normal controls (Wistar rats).

RESULTS

After LPS injection, Wistar rats showed serious infective symptoms while GK rats did not. Blood glucose (BG) levels were significantly elevated in both GK and Wistar rats; however, compared to Wistar rats, GK rats had lower BG variability, smaller increases in the serum tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels, a larger increase in the serum IL-10 level, and a smaller decrease in the IκB-α protein level of lung tissue. Serum malondialdehyde (MDA) levels increased and serum total antioxidant capacity (T-AOC) levels decreased for both GK and Wistar rats.

CONCLUSIONS

We found diabetes was associated with adaptive changes at the cellular level that might actually be protective in acute hyperglycemia-mediated damage during sepsis. Chronic exposure to hyperglycemia potentially reduced the acute deleterious effects of acute hyperglycemia on septic mortality by decreasing BG variability, blunting the pro-inflammatory response and elevating the anti-inflammatory response.

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

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

Association of Diabetes and Insulin Therapy With Risk of Hospitalization for Infection and 28-Day Mortality Risk

Background

Epidemiologic and experimental evidence suggests that individuals with diabetes are at increased risk of infection. We sought to examine the association of diabetes and insulin therapy with hospitalization for infection and 28-day mortality.

Methods

We performed a prospective cohort study using data from 30 239 community-dwelling participants aged ≥45 years enrolled in the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. We defined diabetes as a fasting glucose level ≥126 mg/L (or ≥200 mg/L for those not fasting), the use of insulin or oral hypoglycemic agents, or self-reported history. We identified infection-related hospitalizations over the years 2003–2012. We fit Cox proportional hazards models to assess the association of diabetes with hazard rates of infection and logistic regression models for 28-day mortality.

Results

Among 29 683 patients from the REGARDS study with complete follow-up, 7375 had diabetes. Over a median follow-up period of 6.5 years, we identified 2593 first and 3411 total infection hospitalizations. In adjusted analyses, participants with diabetes had an increased hazard of infection (hazard ratio, 1.50; 95% confidence interval [CI], 1.37–1.64) compared with those without diabetes. Participants with diabetes hospitalized for infection did not have an increased odds of death within 28 days (odds ratio, 0.94; 95% CI, .67–1.32). Participants receiving insulin therapy had greater hazard of infection (hazard ratio, 2.18; 95% CI, 1.90–2.51) but no increased odds of mortality (odd ratio, 1.07; 95% CI, .67–1.71).

Conclusions

Diabetes is associated with increased risk of hospitalization for infection. However, we did not find an association with 28-day mortality. Insulin therapy conferred an even greater risk of hospitalization, without increased mortality.

Long-term mortality of critically ill patients with diabetes who survive admission to the intensive care unit

OBJECTIVE

Long-term outcomes of critically ill patients with diabetes are unknown. Our objectives were to evaluate the effect of diabetes on both long-term survival rates and the average number of years of life lost for patients admitted to an intensive care unit who survived to hospital discharge.

DESIGN AND PARTICIPANTS

A data linkage study evaluating all adult patients in South Australia between 2004 and 2011 who survived hospitalisation that required admission to a public hospital ICU.

MAIN OUTCOME MEASURES

All patients were evaluated using hospital coding for diabetes, which was crossreferenced with registration with the Australian National Diabetes Services Scheme for a diagnosis of diabetes. This dataset was then linked to the Australian National Death Index. Longitudinal survival was assessed using Cox proportional hazards regression. Life-years lost were calculated using age- and sex-specific life-tables from the Australian Bureau of Statistics.

RESULTS

5450 patients with diabetes and 17 023 patients without diabetes were included. Crude mortality rates were 105.5 per 1000 person-years (95% CI, 101.6-109.6 per 1000 person-years) for patients with diabetes, and 67.6 per 1000 person-years (95% CI, 65.9-69.3 per 1000 personyears) for patients without diabetes. Patients with diabetes were older and had higher illness severity scores on admission to the ICU, were more likely to die after hospital discharge (unadjusted hazard ratio [HR], 1.52 [95% CI, 1.45-1.59]; adjusted HR, 1.16 [95% CI, 1.10-1.21]; P < 0.0001) and suffered a greater number of average lifeyears lost.

CONCLUSIONS

Our study indicates that crude mortality for ICU survivors with pre-existing diabetes is considerable after hospital discharge, and the risk of mortality is greater than for survivors without diabetes.

Diabetes Is Not Associated With Increased 90-Day Mortality Risk in Critically Ill Patients With Sepsis

OBJECTIVES

To determine the association of pre-existing diabetes, hyperglycemia, and hypoglycemia during the first 24 hours of ICU admissions with 90-day mortality in patients with sepsis admitted to the ICU.

DESIGN

We used mixed effects logistic regression to analyze the association of diabetes, hyperglycemia, and hypoglycemia with 90-day mortality (n = 128,222).

SETTING

All ICUs in the Netherlands between January 2009 and 2014 that participated in the Dutch National Intensive Care Evaluation registry.

PATIENTS

All unplanned ICU admissions in patients with sepsis.

INTERVENTIONS

The association between 90-day mortality and pre-existing diabetes, hyperglycemia, and hypoglycemia, corrected for other factors, was analyzed using a generalized linear mixed effect model.

MEASUREMENTS AND MAIN RESULTS

In a multivariable analysis, diabetes was not associated with increased 90-day mortality. In diabetes patients, only severe hypoglycemia in the absence of hyperglycemia was associated with increased 90-day mortality (odds ratio, 2.95; 95% CI, 1.19-7.32), whereas in patients without pre-existing diabetes, several combinations of abnormal glucose levels were associated with increased 90-day mortality.

CONCLUSIONS

In the current retrospective large database review, diabetes was not associated with adjusted 90-day mortality risk in critically ill patients admitted with sepsis.

Incidence, characteristic and outcomes of ventilator-associated pneumonia among type 2 diabetes patients: An observational population-based study in Spain

BACKGROUND

To describe incidence, characteristics and outcomes of ventilator-associated pneumonia (VAP) during hospitalization among patients with or without type 2 diabetes (T2DM).

METHODS

We used the Spanish national hospital discharge database to select all hospitalization with VAP in subjects aged 40years or more from 2010 to 2014. We analyzed incidence, patient comorbidities, procedures, pneumonia pathogens and in-hospital outcomes according to diabetes status (T2DM and no-diabetes). We used propensity score analysis to estimate the effect of T2DM on in-hospital mortality RESULTS: In 7952 admissions, the patient developed a VAP (13.6% with T2DM). Adjusted incidence rate of VAP was slightly, but significantly, higher in T2DM than in non-diabetic patients (36.46[95% CI 34.41-38.51] vs. 32.57[95% CI 31.40-33.74] cases per 100,000/inhabitants). T2DM people were older and had higher Charlson comorbidity index than non-diabetic people. T2DM patients had a lower mean number of failing organs than non-diabetic patients (1.20 SD 1.17 vs. 1.45 SD 1.44, p<0.001). Pseudomonas was the most frequently isolated agent in both groups. IHM was 41.92% for T2DM patients and 37.91% for non-diabetic patients (p<0.05). Factors associated with a higher mortality in both groups included: older age, more comorbidities and primary diagnoses of vein or artery occlusion, pulmonary disease and cancer. T2DM was not associated with a higher in-hospital mortality after adjustment using a propensity score (OR 0.88; 95% CI 0.76-1.35).

CONCLUSIONS

VAP incidence rates were higher among T2DM patients. In-hospital mortality was higher among the older patients and those with more co-morbid conditions. T2DM does not predict higher mortality in VAP during hospitalization.

Glycaemic variability in patients with severe sepsis or septic shock admitted to an Intensive Care Unit

BACKGROUND

Sepsis is associated with morbidity and mortality, which implies high costs to the global health system. Metabolic alterations that increase glycaemia and glycaemic variability occur during sepsis.

OBJECTIVE

To verify mean body glucose levels and glycaemic variability in Intensive Care Unit (ICU) patients with severe sepsis or septic shock.

METHOD

Retrospective and exploratory study that involved collection of patients' sociodemographic and clinical data and calculation of severity scores. Glycaemia measurements helped to determine glycaemic variability through standard deviation and mean amplitude of glycaemic excursions.

RESULTS

Analysis of 116 medical charts and 6730 glycaemia measurements revealed that the majority of patients were male and aged over 60 years. Surgical treatment was the main reason for ICU admission. High blood pressure and diabetes mellitus were the most usual comorbidities. Patients that died during the ICU stay presented the highest SOFA scores and mean glycaemia; they also experienced more hypoglycaemia events. Patients with diabetes had higher mean glycaemia, evaluated through standard deviation and mean amplitude of glycaemia excursions.

CONCLUSION

Organic impairment at ICU admission may underlie glycaemic variability and lead to a less favourable outcome. High glycaemic variability in patients with diabetes indicates that monitoring of these individuals is crucial to ensure better outcomes.

Elevated Omentin Serum Levels Predict Long-Term Survival in Critically Ill Patients

Introduction. Omentin, a recently described adipokine, was shown to be involved in the pathophysiology of inflammatory and infectious diseases. However, its role in critical illness and sepsis is currently unknown. Materials and Methods. Omentin serum concentrations were measured in 117 ICU-patients (84 with septic and 33 with nonseptic disease etiology) admitted to the medical ICU. Results were compared with 50 healthy controls. Results. Omentin serum levels of critically ill patients at admission to the ICU or after 72 hours of ICU treatment were similar compared to healthy controls. Moreover, circulating omentin levels were independent of sepsis and etiology of critical illness. Notably, serum concentrations of omentin could not be linked to concentrations of inflammatory cytokines or routinely used sepsis markers. While serum levels of omentin were not predictive for short term survival during ICU treatment, low omentin concentrations were an independent predictor of patients' overall survival. Omentin levels strongly correlated with that of other adipokines (e.g., leptin receptor or adiponectin), which have also been identified as prognostic markers in critical illness. Conclusions. Although circulating omentin levels did not differ between ICU-patients and controls, elevated omentin levels were predictive for an impaired patients' long term survival.

Survivors of intensive care with type 2 diabetes and the effect of shared care follow-up clinics: study protocol for the SWEET-AS randomised controlled feasibility study

BACKGROUND

Many patients who survive the intensive care unit (ICU) experience long-term complications such as peripheral neuropathy and nephropathy which represent a major source of morbidity and affect quality of life adversely. Similar pathophysiological processes occur frequently in ambulant patients with diabetes mellitus who have never been critically ill. Some 25 % of all adult ICU patients have diabetes, and it is plausible that ICU survivors with co-existing diabetes are at heightened risk of sequelae from their critical illness. ICU follow-up clinics are being progressively implemented based on the concept that interventions provided in these clinics will alleviate the burdens of survivorship. However, there is only limited information about their outcomes. The few existing studies have utilised the expertise of healthcare professionals primarily trained in intensive care and evaluated heterogenous cohorts. A shared care model with an intensivist- and diabetologist-led clinic for ICU survivors with type 2 diabetes represents a novel targeted approach that has not been evaluated previously. Prior to undertaking any definitive study, it is essential to establish the feasibility of this intervention.

METHODS

This will be a prospective, randomised, parallel, open-label feasibility study. Eligible patients will be approached before ICU discharge and randomised to the intervention (attending a shared care follow-up clinic 1 month after hospital discharge) or standard care. At each clinic visit, patients will be assessed independently by both an intensivist and a diabetologist who will provide screening and targeted interventions. Six months after discharge, all patients will be assessed by blinded assessors for glycated haemoglobin, peripheral neuropathy, cardiovascular autonomic neuropathy, nephropathy, quality of life, frailty, employment and healthcare utilisation. The primary outcome of this study will be the recruitment and retention at 6 months of all eligible patients.

DISCUSSION

This study will provide preliminary data about the potential effects of critical illness on chronic glucose metabolism, the prevalence of microvascular complications, and the impact on healthcare utilisation and quality of life in intensive care survivors with type 2 diabetes. If feasibility is established and point estimates are indicative of benefit, funding will be sought for a larger, multi-centre study.

TRIAL REGISTRATION

ANZCTR ACTRN12616000206426.

Association of diabetes and diabetes treatment with the host response in critically ill sepsis patients

Background

Diabetes is associated with chronic inflammation and activation of the vascular endothelium and the coagulation system, which in a more acute manner are also observed in sepsis. Insulin and metformin exert immune modulatory effects. In this study, we aimed to determine the association of diabetes and preadmission insulin and metformin use with sepsis outcome and host response.

Methods

We evaluated 1104 patients with sepsis, admitted to the intensive care unit and stratified according to the presence or absence of diabetes mellitus. The host response was examined by a targeted approach (by measuring 15 plasma biomarkers reflective of pathways implicated in sepsis pathogenesis) and an unbiased approach (by analyzing whole genome expression profiles in blood leukocytes).

Results

Diabetes mellitus was not associated with differences in sepsis presentation or mortality up to 90 days after admission. Plasma biomarker measurements revealed signs of systemic inflammation, and strong endothelial and coagulation activation in patients with sepsis, none of which were altered in those with diabetes. Patients with and without diabetes mellitus, who had sepsis demonstrated similar transcriptional alterations, comprising 74 % of the expressed gene content and involving over-expression of genes associated with pro-inflammatory, anti-inflammatory, Toll-like receptor and metabolic signaling pathways and under-expression of genes associated with T cell signaling pathways. Amongst patients with diabetes mellitus and sepsis, preadmission treatment with insulin or metformin was not associated with an altered sepsis outcome or host response.

Conclusions

Neither diabetes mellitus nor preadmission insulin or metformin use are associated with altered disease presentation, outcome or host response in patients with sepsis requiring intensive care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1429-8) contains supplementary material, which is available to authorized users.

An Application of Bayesian Approach in Modeling Risk of Death in an Intensive Care Unit

Background and Objectives

There are not many studies that attempt to model intensive care unit (ICU) risk of death in developing countries, especially in South East Asia. The aim of this study was to propose and describe application of a Bayesian approach in modeling in-ICU deaths in a Malaysian ICU.

Methods

This was a prospective study in a mixed medical-surgery ICU in a multidisciplinary tertiary referral hospital in Malaysia. Data collection included variables that were defined in Acute Physiology and Chronic Health Evaluation IV (APACHE IV) model. Bayesian Markov Chain Monte Carlo (MCMC) simulation approach was applied in the development of four multivariate logistic regression predictive models for the ICU, where the main outcome measure was in-ICU mortality risk. The performance of the models were assessed through overall model fit, discrimination and calibration measures. Results from the Bayesian models were also compared against results obtained using frequentist maximum likelihood method.

Results

The study involved 1,286 consecutive ICU admissions between January 1, 2009 and June 30, 2010, of which 1,111 met the inclusion criteria. Patients who were admitted to the ICU were generally younger, predominantly male, with low co-morbidity load and mostly under mechanical ventilation. The overall in-ICU mortality rate was 18.5% and the overall mean Acute Physiology Score (APS) was 68.5. All four models exhibited good discrimination, with area under receiver operating characteristic curve (AUC) values approximately 0.8. Calibration was acceptable (Hosmer-Lemeshow p-values > 0.05) for all models, except for model M3. Model M1 was identified as the model with the best overall performance in this study.

Conclusion

Four prediction models were proposed, where the best model was chosen based on its overall performance in this study. This study has also demonstrated the promising potential of the Bayesian MCMC approach as an alternative in the analysis and modeling of in-ICU mortality outcomes.

Dysglycemia and Glucose Control During Sepsis

Sepsis predisposes to disordered metabolism and dysglycemia; the latter is a broad term that includes hyperglycemia, hypoglycemia, and glycemic variability. Dysglycemia is a marker of illness severity. Large randomized controlled trials have provided considerable insight into the optimal blood glucose targets for critically ill patients with sepsis. However, it may be that the pathophysiologic consequences of dysglycemia are dynamic throughout the course of a septic insult and also altered by premorbid glycemia. This review highlights the relevance of hyperglycemia, hypoglycemia, and glycemic variability in patients with sepsis with an emphasis on a rational approach to management.

Effect of D-glucose feeding on mortality induced by sepsis

Sepsis is the life-threatening response to infection which can lead to tissue damage, organ failure, and death. In the current study, the effect of orally administered D-glucose on the mortality and the blood glucose level induced by D-Galactosamine (GaLN)/lipopolysaccharide (LPS)-induced sepsis was examined in ICR mice. After various amounts of D-glucose (from 1 to 8 g/kg) were orally fed, sepsis was induced by injecting intraperitoneally (i.p.) the mixture of GaLN /LPS. Oral pre-treatment with D-glucose dose-dependently increased the blood glucose level and caused a reduction of sepsis-induced mortality. The oral post-treatment with D-glucose (8 g/kg) up to 3 h caused an elevation of the blood glucose level and protected the mortality observed in sepsis model. However, D-glucose post-treated at 6, 9, or 12 h after sepsis induction did not affect the mortality and the blood glucose level induced by sepsis. Furthermore, the intrathecal (i.t.) pretreatment once with pertussis toxin (PTX; 0.1 µg/5 ml) for 6 days caused a reduction of D-glucose-induced protection of mortality and hyperglycemia. Furthermore, once the hypoglycemic state is continued up to 6 h after sepsis initiated, sepsis-induced mortality could not be reversed by D-glucose fed orally. Based on these findings, it is assumed that the hypoglycemic duration between 3 and 6 h after the sepsis induction may be a critical time of period for the survival. D-glucose-induced protective effect against sepsis-induced mortality appears to be mediated via activating PTX-sensitive G-proteins in the spinal cord. Finally, the production of hyperglycemic state may be critical for the survival against the sepsis-induced mortality.

Impact of diabetes mellitus and its complications: survival and quality-of-life in critically ill patients

PURPOSE

Diabetes mellitus represents an increasing problem for patients and health care systems worldwide. We sought to investigate the effect of diabetes and its associated comorbidities on long-term survival and quality of life following an admission to a medical intensive care unit (ICU).

METHODS

A total of 6662 consecutive patients admitted to ICU between 2004 and 2009 were included (patients with diabetes n=796, non-diabetic patients n=5866). The primary endpoint of the study was death of any cause. Data on mortality was collected upon review of medical records or phone interviews. Moreover, a questionnaire was sent to 500 randomly selected patients addressing Health related Quality of Life (HrQoL) after ICU treatment.

RESULTS

Overall mortality did not differ significantly between diabetic and non-diabetic patients after ICU treatment (mean follow-up time: 490 days). For a subgroup of patients already exhibiting comorbidities associated with diabetes, the mortality rate was significantly higher (p=0.022). Regarding quality of life, no differences were found between groups.

CONCLUSIONS

Diabetes was not associated with increased mortality or reduced quality of life in a general population of medical ICU patients. However, once comorbidities associated with diabetes occurred, the survival rate of patients with comorbidities associated with hyperglycemia was significantly reduced.

The outcome of acute respiratory distress syndrome in relation to body mass index and diabetes mellitus

OBJECTIVE

To determine the 28 day mortality of patients with ARDS in relation to body mass index (BMI) and presence diabetes mellitus (DM).

DESIGN

Retrospective cohort study of patients enrolled in the ARDS Network randomized controlled trials.

RESULTS

2914 patients were enrolled in these trials. 112 patients were underweight (BMI < 18.5), 948 patients were normal range (18.5 ≤ BMI < 25.0), 801 patients were overweight (25.0 ≤ BMI < 30.0), 687 patients were obese (30.0 ≤ BMI < 40.0), and 175 patients were severely obese (BMI ≥ 40.0). 469 patients had DM. There was no significant difference in the 28 day mortality in relation to BMI or presence of DM (underweight adjusted OR, 1.217; 95% CI, 0.749-1.979; overweight adjusted OR, 0.887; 95% CI, 0.696-1.131; obese adjusted OR, 0.812; 95% CI, 0.624-1.056; severely obese adjusted OR, 1.102; 95% CI, 0.716-1.695; and DM adjusted OR, 0.938; 95% CI, 0.728-1.208).

CONCLUSIONS

The short term mortality in patients with ARDS is not affected by BMI or the presence of DM.

Acute Kidney Injury in Severe Sepsis and Septic Shock in Patients with and without Diabetes Mellitus: A Multicenter Study

Introduction

Whether diabetes mellitus increases the risk of acute kidney injury (AKI) during sepsis is controversial.

Materials and Methods

We used a case-control design to compare the frequency of AKI, use of renal replacement therapy (RRT), and renal recovery in patients who had severe sepsis or septic shock with or without diabetes. The data were from the Outcomerea prospective multicenter database, in which 12 French ICUs enrolled patients admitted between January 1997 and June 2009.

Results

First, we compared 451 patients with severe sepsis or septic shock and diabetes to 3,277 controls with severe sepsis or septic shock and without diabetes. Then, we compared 318 cases (with diabetes) to 746 matched controls (without diabetes). Diabetic patients did not have a higher frequency of AKI (hazard ratio [HR], 1.18; P = 0.05]) or RRT (HR, 1.09; P = 0.6). However, at discharge, diabetic patients with severe sepsis or septic shock who experienced acute kidney injury during the ICU stay and were discharged alive more often required RRT (9.5% vs. 4.8%; P = 0.02), had higher serum creatinine values (134 vs. 103 µmoL/L; P<0.001) and had less often recovered a creatinine level less than 1.25 fold the basal creatinine (41.1% vs. 60.5%; P<0.001).

Conclusions

In patients with severe sepsis or septic shock, diabetes is not associated with occurrence of AKI or need for RRT but is an independent risk factor for persistent renal dysfunction in patients who experience AKI during their ICU stay.

Hyper/hypoglycemia and acute kidney injury in critically ill patients

BACKGROUND & AIMS

Abnormalities of blood glucose (BG) concentration (hyper- and hypoglycemia), now referred to with the cumulative term of dysglycemia, are frequently observed in critically ill patients, and significantly affect their clinical outcome. Acute kidney injury (AKI) may further complicate glycemic control in the same clinical setting. This narrative review was aimed at describing the pathogenesis of hyper- and hypoglycemia in the intensive care unit (ICU), with special regard to patients with AKI. Moreover, the complex relationship between AKI, glycemic control, hypoglycemic risk, and outcomes was analyzed.

METHODS

An extensive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, treatment and outcome of hypo- and hyperglycemia in critically ill patients with AKI.

RESULTS AND CONCLUSION

Patients with AKI are at increased risk of both hyper-and hypoglycemia. The available evidence does not support a protective effect on the kidney by glycemic control protocols employing Intensive Insulin Treatment (IIT), i.e. those aimed at maintaining normal BG concentrations (80-110 mg/dl). Recent guidelines taking into account the high risk for hypoglycemia associated with IIT protocols in critically ill patients, now suggest higher BG concentration targets (<180 mg/dl or 140-180 mg/dl) than those previously recommended (80-110 mg/dl). Notwithstanding the limited evidence available, it seems reasonable to extend these indications also to ICU patients with AKI.

Inpatient HbA1c testing: a prospective observational study

OBJECTIVE

To use admission inpatient glycated hemoglobin (HbA1c) testing to help investigate the prevalence of unrecognized diabetes, the cumulative prevalence of unrecognized and known diabetes, and the prevalence of poor glycemic control in both. Moreover, we aimed to determine the 6-month outcomes for these patients. Finally, we aimed to assess the independent association of diabetes with these outcomes.

RESEARCH DESIGN AND METHODS

Prospective observational cohort study conducted in a tertiary hospital in Melbourne, Australia.

PATIENTS

A cohort of 5082 inpatients ≥54 years admitted between July 2013 and January 2014 underwent HbA1c measurement. A previous diagnosis of diabetes was obtained from the hospital medical record. Patient follow-up was extended to 6 months.

RESULTS

The prevalence of diabetes (known and unrecognized) was 34%. In particular, we identified that unrecognized but HbA1c-confirmed diabetes in 271 (5%, 95% CI 4.7% to 6.0%) patients, previously known diabetes in 1452 (29%, 95% CI 27.3% to 29.8%) patients; no diabetes in 3359 (66%, 95% CI 64.8-67.4%) patients. Overall 17% (95% CI 15.3% to 18.9%) of patients with an HbA1c of >6.5% had an HbA1c ≥8.5%. After adjusting for age, gender, Charlson Index score, estimated glomerular filtration rate, and hemoglobin levels, with admission unit treated as a random effect, patients with previously known diabetes had lower 6-month mortality (OR 0.69, 95% CI 0.56 to 0.87, p=0.001). However, there were no significant differences in proportions of intensive care unit admission, mechanical ventilation or readmission within 6 months between the 3 groups.

CONCLUSIONS

Approximately one-third of all inpatients ≥54 years of age admitted to hospital have diabetes of which about 1 in 6 was previously unrecognized. Moreover, poor glycemic control was common. Proportions of intensive care unit admission, mechanical ventilation, or readmission were similar between the groups. Finally, diabetes was independently associated with lower 6-month mortality.

A comparison of all-cause mortality with pioglitazone and insulin in type 2 diabetes: an expanded analysis from a retrospective cohort study

OBJECTIVES

The objectives of this study were to assess and compare all-cause mortality rates between pioglitazone (PIO) and insulin (INS).

RESEARCH DESIGN

The study population included 56,536 patients with type 2 diabetes aged ≥45 years who were first-time users of PIO or INS. Data from 1 May 2000 until 30 June 2010 from the i3 InVision Data Mart database were linked to death records of the US Social Security Administration obtained in March 2012, with approval from the Institutional Review Board and in full compliance with the Health Insurance Portability and Accountability Act of 1996.

MAIN OUTCOME MEASURES

Kaplan-Meier curves were generated and hazard ratios (HRs) were estimated for the occurrence of deaths in the PIO and INS cohorts using Cox proportional hazards models adjusted with inverse probability weights derived from propensity scores.

RESULTS

After adjustment for >40 covariates through inverse probability weights derived from propensity scores, the PIO group showed a significantly lower risk of all-cause mortality (HR 0.33; 95% confidence interval, 0.31, 0.36). The risk of all-cause mortality was also significantly lower in the PIO cohort than the INS cohort among subgroups based on baseline variables such as sex, age (<55 years, ≥55 years), antidiabetic medication use (sulfonylureas or metformin), lipid-altering medication use, and congestive heart failure status. The study has some limitations. Use of a claims database means a potential bias toward a younger cohort. Disease-specific mortality was not identified because of no recorded cause of death. Reliable information regarding the differences in disease deterioration rate and some clinical and lab results were not available, which limits the statistical adjustment of baseline variables.

CONCLUSION

PIO was associated with a lower risk of all-cause mortality than INS.

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

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Glycemic control in critically ill: A moving target

Glycemic control targets in intensive care units (ICUs) have three distinct domains. Firstly, excessive hyperglycemia needs to be avoided. The upper limit of this varies depending on the patient population studied and diabetic status of the patients. Surgical patients particularly cardiac surgery patients tend to benefit from a lower upper limit of glycemic control, which is not evident in medically ill patient. Patient with premorbid diabetic status tends to tolerate higher blood sugar level better than normoglycemics. Secondly, hypoglycemia is clearly detrimental in all groups of critically ill patient and all measures to avoid this catastrophe need to be a part of any glycemic control protocol. Thirdly, glycemic variability has increasingly been shown to be detrimental in this patient population. Glycemic control protocols need to take this into consideration and target to reduce any of the available metrics of glycemic variability. Newer technologies including continuous glucose monitoring techniques will help in titrating all these three domains within a desirable range.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Risk of acute lung injury/acute respiratory distress syndrome in critically ill adult patients with pre-existing diabetes: a meta-analysis

Background

The impact of pre-existing diabetes on the development of acute lung injury/acute respiratory distress syndrome (ALI/ARDS) in critically ill patients remains unclear. We performed a meta-analysis of cohort studies to evaluate the risk of ALI/ARDS in critically ill patients with and without pre-existing diabetes.

Materials and Methods

We searched PubMed and Embase from the inception to September 2013 for cohort studies assessing the effect of pre-existing diabetes on ALI/ARDS occurrence. Pooled odds ratio (OR) with 95% confidence interval (CI) was calculated using random- or fixed-effect models when appropriate.

Results

Seven cohort studies with a total of 12,794 participants and 2,937 cases of pre-existing diabetes, and 2,457 cases of ALI/ARDS were included in the meta-analysis. A fixed-effects model meta-analysis showed that pre-existing diabetes was associated with a reduced risk of ALI/ARDS (OR 0.66; 95% CI, 0.55–0.80; p<0.001), with low heterogeneity among the studies (I² = 18.9%; p = 0.286). However, the asymmetric funnel plot and Egger's test (p = 0.007) suggested publication bias may exist.

Conclusions

Our meta-analysis suggests that pre-existing diabetes was associated with a decreased risk of ALI/ARDS in critically ill adult patients. However, the result should be interpreted with caution because of the potential bias and confounding in the included studies.

Outcomes of diabetic and nondiabetic patients undergoing general and vascular surgery

Aims. Preoperative diabetic and glycemic screening may or may not be cost effective. Although hyperglycemia is known to compromise surgical outcomes, the effect of a diabetic diagnosis on outcomes is poorly known. We examine the effect of diabetes on outcomes for general and vascular surgery patients. Methods. Data were collected from the Michigan Surgical Quality Collaborative for general or vascular surgery patients who had diabetes. Primary and secondary outcomes were 30-day mortality and 30-day overall morbidity, respectively. Binary logistic regression analysis was used to identify risk factors. Results. We identified 177,430 (89.9%) general surgery and 34,006 (16.1%) vascular surgery patients. Insulin and noninsulin diabetics accounted for 7.1% and 9.8%, respectively. Insulin and noninsulin dependent diabetics were not at increased risk for mortality. Diabetics are at a slight increased odds than non-diabetics for overall morbidity, and insulin dependent diabetics more so than non-insulin dependent. Ventilator dependence, 10% weight loss, emergent case, and ASA class were most predictive. Conclusions. Diabetics were not at increased risk for postoperative mortality. Insulin-dependent diabetics undergoing general or vascular surgery were at increased risk of overall 30-day morbidity. These data provide insight towards mitigating poor surgical outcomes in diabetic patients and the cost effectiveness of preoperative diabetic screening.

Dysglycaemia in the critically ill - significance and management

Hyperglycaemia frequently occurs in the critically ill, in patients with diabetes, as well as those who were previously glucose-tolerant. The terminology 'stress hyperglycaemia' reflects the pathogenesis of the latter group, which may comprise up to 40% of critically ill patients. For comparable glucose concentrations during acute illness outcomes in stress hyperglycaemia appear to be worse than those in patients with type 2 diabetes. While several studies have evaluated the optimum glycaemic range in the critically ill, their interpretation in relation to clinical recommendations is somewhat limited, at least in part because patients with stress hyperglycaemia and known diabetes were grouped together, and the optimum glycaemic range was regarded as static, rather than dynamic, phenomenon. In addition to hyperglycaemia, there is increasing evidence that hypoglycaemia and glycaemic variability influence outcomes in the critically ill adversely. These three categories of disordered glucose metabolism can be referred to as dysglycaemia. While stress hyperglycaemia is most frequently managed by administration of short-acting insulin, guided by simple algorithms, this does not treat all dysglycaemic categories; rather the use of insulin increases the risk of hypoglycaemia and may exacerbate variability. The pathogenesis of stress hyperglycaemia is complex, but hyperglucagonaemia, relative insulin deficiency and insulin resistance appear to be important. Accordingly, novel agents that have a pathophysiological rationale and treat hyperglycaemia, but do not cause hypoglycaemia and limit glycaemic variability, are appealing. The potential use of glucagon-like peptide-1 (or its agonists) and dipeptyl-peptidase-4 inhibitors is reviewed.

The impact of obesity on sepsis mortality: a retrospective review

Background

Recent sepsis guidelines have focused on the early identification and risk stratification of patients on presentation. Obesity is associated with alterations in multiple inflammatory regulators similar to changes seen in sepsis, suggesting a potential interaction between the presence of obesity and the severity of illness in sepsis.

Methods

We performed a retrospective chart review of patients admitted with a primary billing diagnosis of sepsis at a single United States university hospital from 2007 to 2010. Seven hundred and ninety-two charts were identified meeting inclusion criteria. Obesity was defined as a body mass index (BMI) ≥ 30 kg/m². The data recorded included age, race, sex, vital signs, laboratory values, length of stay, comorbidities, weight, height, and survival to discharge. A modified APACHE II score was calculated to estimate disease severity. The primary outcome variable was inpatient mortality.

Results

Survivors had higher average BMI than nonsurvivors (27.6 vs. 26.3 kg/m2, p = 0.03) in unadjusted analysis. Severity of illness and comorbid conditions including cancer were similar across BMI categories. Increased incidence of diabetes mellitus type 2 was associated with increasing BMI (p < 0.01) and was associated with decreased mortality, with an odds ratio of 0.53 compared with nondiabetic patients. After adjusting for age, gender, race, severity of illness, length of stay, and comorbid conditions, the trend of decreased mortality for increased BMI was no longer statistically significant, however diabetes continued to be strongly protective (odds ratio 0.52, p = 0.03).

Conclusions

This retrospective analysis suggests obesity may be protective against mortality in septic inpatients. The protective effect of obesity may be dependent on diabetes, possibly through an unidentified hormonal intermediary. Further prospective studies are necessary to elaborate the specific mechanism of this protective effect.