Stress-Induced Hyperglycemia in Diabetes: A Cross-Sectional Analysis to Explore the Definition Based on the Trauma Registry Data

Evaluating the prognostic value of the stress index in trauma patients

Background

The stress index (SI), defined as the serum glucose to potassium ratio, has emerged as a potential prognostic indicator in some patient populations. This study aims to evaluate the predictive value of SI on the trauma patients sustained by all trauma causes.

Methods

A retrospective analysis was conducted on 20,040 adult trauma patients admitted to a single trauma center from January 1, 2009, to December 31, 2022. The SI was calculated according to the serum levels of glucose (mg/dL) and potassium (mEq/L) upon patients' arrival to emergency room. The enrolled patients were stratified into two groups based on an optimal SI cutoff value determined by receiver operating characteristic (ROC) curve analysis. The association between SI and in-hospital mortality, as well as other clinical outcomes, was assessed using multivariate logistic regression, adjusting for potential confounders.

Results

The mortality patients had a significantly higher SI (59.7 ± 30.6 vs. 39.5 ± 17.5, p < 0.001) than those who survived. The SI was identified as a significant independent predictor of mortality (odds ratio [OR] 4.65, 95 % confidence interval [CI]: 2.61-8.27, p < 0.001) in the multivariate analysis. In addition, patients in the high SI group (≥42.7) demonstrated significantly worse outcomes, including higher in-hospital mortality (7.5 % vs. 1.4 %, p < 0.001), longer hospital stays compared to the low SI group (<42.7).

Conclusion

The SI serves as a simple and valuable prognostic tool in risk stratification of the trauma patients.

Stress hyperglycemia is associated with poor prognosis in critically ill patients with cardiogenic shock

Background

Stress hyperglycemia is now more common in intensive care unit (ICU) patients and is strongly associated with poor prognosis. Whether this association exists in critically ill patients with cardiogenic shock (CS) is unknown. This study investigated the prognostic relationship of stress hyperglycemia on critically ill patients with CS.

Methods

We included 393 critically ill patients with CS from the MIMIC IV database in this study and categorized the patients into four groups based on quartiles of Stress hyperglycemia ratio (SHR). We assessed the correlation between SHR and mortality using restricted cubic spline analysis and Cox proportional hazards models. The primary outcomes observed were ICU mortality and hospitalization mortality.

Results

The mean age of the entire study population was 68 years, of which 30% were male (118 cases). There was no significant difference between the four groups in terms of age, gender, BMI, and vital signs (P>0.05). There was an increasing trend in the levels of lactate (lac), white blood cell count (WBC), glutamic oxaloacetic transaminase (AST), glucose and Hemoglobin A1C (HbA1c) from group Q1 to group Q2, with the greatest change in patients in group Q4 (P<0.05) and the patients in group Q4 had the highest use of mechanical ventilation, the longest duration of mechanical ventilation, ICU stay and hospital stay. After adjusting for confounders, SHR was found to be strongly associated with patient ICU mortality, showing a U-shaped relationship.

Conclusion

In critically ill patients with CS, stress hyperglycemia assessed by SHR was significantly associated with patient ICU mortality.

Elevation of White Blood Cell Subtypes in Adult Trauma Patients with Stress-Induced Hyperglycemia

BACKGROUND

Blood immune cell subset alterations following trauma can indicate a patient's immune-inflammatory status. This research explored the influence of stress-induced hyperglycemia (SIH) on platelet counts and white blood cell (WBC) subtypes, including the derived indices of the monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), in trauma patients.

METHODS

We studied 15,480 adult trauma patients admitted from 1 January 1998 to 31 December 2022. They were categorized into four groups: nondiabetic normoglycemia (NDN, n = 11,602), diabetic normoglycemia (DN, n = 1750), SIH (n = 716), and diabetic hyperglycemia (DH, n = 1412). A propensity score-matched cohort was formed after adjusting for age, sex, and comorbidities, allowing for comparing the WBC subtypes and platelet counts.

RESULTS

Patients with SIH exhibited significantly increased counts of monocytes, neutrophils, and lymphocytes in contrast to NDN patients. However, no significant rise in platelet counts was noted in the SIH group. There were no observed increases in these cell counts in either the DN or DH groups.

CONCLUSIONS

Our results demonstrated that trauma patients with SIH showed significantly higher counts of monocytes, neutrophils, and lymphocytes when compared to NDN patients, whereas the DN and DH groups remained unaffected. This underscores the profound association between SIH and elevated levels of specific WBC subtypes.

Fasting Plasma Glucose Levels at the Time of Admission Predict 90-Day Mortality in Patients with Viral Pneumonia. A Prospective Study

PURPOSE

To determine the effect of fasting plasma glucose (FPG) level at admission affects the 90-day mortality rate in patients with viral pneumonia.

METHODS

Two hundred fifty viral pneumonia patients were stratified into normal FPG (FPG<7.0 mmol/L), moderately-elevated FPG (FPG=7.0-14.0 mmol/L), and highly-elevated FPG groups (FPG≥14.0 mmol/L) according to the FPG level at the time of admission. The clinical characteristics, etiologies, and prognosis of different groups of patients were compared. Kaplan-Meier survival and Cox regression analyses were used to determine the relationship between the FPG level and 90-day all-cause mortality rate in patients with viral pneumonia.

RESULTS

Patients in the moderately- and highly-elevated FPG groups had a higher proportion of severe disease and mortality compared with the normal FPG group (P<0.001). Kaplan-Meier survival analysis showed a significant trend toward higher mortality and increased cumulative risk at 30, 60, and 90 d in patients with an FPG=7.0-14.0 mmol/L and an FPG≥14 mmol/L (χ²=51. 77, P<0.001). Multivariate Cox regression analysis revealed that compared with an FPG<7.0 mmol/L, FPG=7.0 and 14.0 mmol/L (HR: 9.236, 95% CI: 1.106-77.119, P=0.040) and FPG≥14.0 mmol/L (HR: 25.935, 95% CI: 2.586-246.213, P=0.005) were independent risk factors for predicting the 90-day mortality rate in viral pneumonia patients.

CONCLUSIONS

The higher the FPG level at admission in a patient with viral pneumonia, the higher the risk of all-cause mortality within 90 d.

Admission Blood Glucose Level as a Predictor of Outcome in Intensive Care Patients: A Cross-Sectional Study

INTRODUCTION

In the Intensive care unit (ICU), hyperglycemia is often observed; commonly associated with pre-existing diabetes or pre-diabetes or in nondiabetic patients. This study aimed to assess the role of admission blood sugar levels with outcomes in ICU patients.

METHODS

A total of 100 patients above 18 years of age were included in the study. A detailed history regarding the patient's age, sex, and any chronic illness were taken. Heart rate, systolic blood pressure, and Glasgow coma scale (GCS) scores were recorded. Admission blood glucose level, blood urea, total leucocyte count, and serum electrolytes were measured; and the outcome was noted.

RESULTS

The number of diabetics was significantly higher (65.5%) in the random blood sugar (RBS) ≥180 group. Hyponatremia was significantly associated with hyperglycemia. Patients with hyperglycemia had serum bicarbonate <18. A significantly greater number of patients with hyperglycemia had GCS scores of <8, and required mechanical ventilation. The duration of ICU stay and non-survivors were significantly higher in the hyperglycemia group. Random blood sugar at admission as a factor to assess outcome showed a sensitivity of 68.4 and specificity of 59.3 with a cut-off value of 197.

CONCLUSION

Admission of random blood sugar was significantly associated with poor outcomes. More stringent surveillance as well as routine blood glucose checks at the time of hospital admission should be emphasized.

Conventional Glycaemic Control May Not Be Beneficial in Diabetic Patients Following Cardiac Surgery

INTRODUCTION

Stress hyperglycaemia is common following cardiac surgery. Its optimal management is uncertain and emerging literature suggests that flexible glycaemic control in diabetic patients may be preferable. This study aims to assess the relationship between maximal postoperative in-hospital blood glucose levels (BSL) and the morbidity and mortality outcomes of diabetic and non-diabetic cardiac surgery patients.

METHODS

A retrospective cohort analysis of all patients undergoing cardiac surgery at a tertiary single centre institution from 2015 to 2019 was undertaken. Early management and outcomes of hyperglycaemia following cardiac surgery were assessed via multivariable regression modelling. Follow-up was assessed to 1 year postoperatively.

RESULTS

Consecutive non-diabetic patients (n=1,050) and diabetic patients (n=689) post cardiac surgery were included. Diabetics with peak BSL ≤13.9 mmol/L did not have an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L was associated with overall wound complications (5.7% vs 8.8%, OR 1.64 [1.00-2.69], p=0.049) and postoperative pneumonia (2.7% vs 7.3%, OR 2.35 [1.26-4.38], p=0.007). Diabetic patients with postoperative peak BSL >13.9 mmol/L were at an increased risk of overall wound complication (7.4% vs 14.8%, OR 2.47 [1.46-4.16], p<0.001), graft harvest site infection (3.7% vs 11.8%, OR 3.75 [1.92-7.30], p<0.001), and wound-related readmission (3.1% vs 8.8%, OR 3.11 [1.49-6.47], p=0.002) when compared to diabetics with peak BSL ≤13.9 mmol/L.

CONCLUSION

In non-diabetics, stress hyperglycaemia with peak BSL >10.0 mmol/L is associated with morbidity. In diabetic patients, hyperglycaemia with peak BSL ≤13.9 mmol/L was not associated with an increased risk of morbidity or mortality compared to non-diabetics with peak BSL ≤10.0 mmol/L. Further investigation of flexible glycaemic targets (target BSL ≤13.9 mmol/L) in diabetic patients is warranted.

Stress Hyperglycemia Is Independently Associated with Persistent Organ Failure in Acute Pancreatitis

BACKGROUND/AIMS

Stress hyperglycemia is common in critical illness but it has not been clearly studied in patients with acute pancreatitis (AP). This study aimed to investigate the specific blood glucose (BG) level that defines stress hyperglycemia and to determine the impact of stress hyperglycemia on clinical outcomes in AP patients.

METHODS

AP patients admitted ≤ 48 h after abdominal pain onset were retrospectively analyzed. Patients were stratified by pre-existing diabetes and stress hyperglycemia was defined using stratified BG levels for non-diabetes and diabetes with clinical outcomes compared.

RESULTS

There were 967 non-diabetic and 114 diabetic (10.5%) patients met the inclusion criteria and the clinical outcomes between these two groups were not significantly different. In non-diabetes, the cut-off BG level of ≥ 180 mg/dl was selected to define stress hyperglycemia with an 8.8-fold higher odds ratio for persistent organ failure (POF) (95% CI 5.4-14.3; P < 0.001). For diabetes, ≥ 300 mg/dl was selected with a 7.5-fold higher odds ratio for POF (95% CI 1.7-34.3; P = 0.009). In multivariable logistic regression, stress hyperglycemia was independently associated with POF, acute necrotic collection, major infection and mortality. The combination of BG and systemic inflammatory response syndrome (SIRS) score in predicting POF was better than SIRS or Glasgow score alone.

CONCLUSIONS

This study identifies a cut-off BG level of ≥ 180 mg/dl and ≥ 300 mg/dl was optimal to define stress hyperglycemia for non-diabetic and diabetic AP patients, respectively. There was a significant relationship between stress hyperglycemia and adverse clinical outcomes.

Birkenfeld A, Sponholz C, A. Müller U, von Loeffelholz C. Blood Sugar Targets in Surgical Intensive Care—Management and Special Considerations in Patients With Diabetes

BACKGROUND

30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar.

RESULTS

Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions.

CONCLUSION

Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.

Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma

Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage trigger hepatic gluconeogenesis, glycogenolysis, peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage. Methods: All patients with documented liver, kidney or spleen injuries, treated at a university hospital between 2000 and 2020 were charted. Demographic, laboratory, radiological, surgical and other data were analyzed. Results: A total of 772 patients were included. In liver (n = 456), spleen (n = 375) and kidney (n = 152) trauma, an increase in injury severity past moderate to severe (according to the American Association for the Surgery of Trauma, AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While stress-induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p < 0.0001) and kidney injuries (median 10.6 mmol/L, p = 0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p < 0.0001). Conclusions: Absence of stress hyperglycemia on hospital admission could be a sign of most severe liver injury (AAST V). Blood glucose should be considered an additional diagnostic criterion for grading liver injury.

Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia

Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.

Impact of stress hyperglycemia on myocardial salvage in patients with ST-Elevation myocardial infarction: Cardiac magnetic resonance study

Cardiovascular complications in ST-segment–elevation myocardial infarction survivors remain substantial despite advances in the management of STEMI. We aimed to determine effect of AH on the area at risk (AAR), final infarct size (FIS), and salvage index (SI) in STEMI patients using cardiac magnetic resonance (CMR). 43 successfully reperfused STEMI patients were recruited. CMR was utilized to estimate AAR and FIS, SI was calculated: SI = AAR- FIS/AAR. AH showed significant positive correlations to FIS (r-value = 0.538, P = < 0.001), and AAR (r-value = 0.435, P = 0.002), and a negative correlation with SI (r-value = −0.378, P = 0.006).

Stress Hyperglycemia and Mortality in Subjects With Diabetes and Sepsis

Objectives:

Poor glycemic control is associated with mortality in critical patients with diabetes. The aim of the study was to assess the predicting value of stress hyperglycemia in patients with diabetes following hospital admission for sepsis.

Design:

Retrospective observational study.

Setting:

Adult, emergency department, and critical care in a district hospital.

Patients:

In a 10-year retrospective analysis of sepsis-related hospitalizations in the emergency department, we carried out a secondary analysis of 915 patients with diabetes (males, 54.0%) in whom both fasting glucose at entry and glycosylated hemoglobin were available.

Interventions:

None.

Measurements and Main Results:

Patients’ mean age was 79.0 (sd 11.0), glucose at admission was 174.0 mg/dL (74.3 mg/dL), and glycosylated hemoglobin was 7.7% (1.7%). Stress hyperglycemia was defined by the stress hyperglycemia ratio, that is, fasting glucose concentration at admission divided by the estimated average glucose derived from glycosylated hemoglobin. A total of 305 patients died (33.3%) in hospital. Factors associated with in-hospital case fatality rate were tested by multivariable logistic model. Ten variables predicting outcomes in the general population were confirmed in the presence of diabetes (male sex, older age, number of organ dysfunction diagnoses, in particular cardiovascular dysfunction, infection/parasitic, circulatory, respiratory, digestive diseases diagnosis, and Charlson Comorbidity Index). In addition, also glycemic control (glycosylated hemoglobin: odds ratio, 1.17; 95% CI, 1.15–1.40) and stress hyperglycemia (stress hyperglycemia ratio: 5.25; 3.62–7.63) were significant case fatality rate predictors. High stress hyperglycemia ratio (≥ 1.14) significantly increased the discriminant capacity (area under the receiver operating characteristic curve, 0.864; se, 0.013; p < 0.001).

Conclusions:

Stress hyperglycemia, even in the presence of diabetes, is predictive of mortality following admission for sepsis. Stress hyperglycemia ratio may be used to refine prediction of an unfavorable outcome.

An elevated glycemic gap predicts adverse outcomes in diabetic patients with necrotizing fasciitis

Background

Diabetes is the most common comorbidity of necrotizing fasciitis (NF), but the effect of stress-induced hyperglycemia (SIH) on diabetic patients with NF has never been investigated. The aim of this study was to assess whether SIH, as determined by the glycemic gap between admission glucose levels and A_1C-derived average glucose levels, predicts adverse outcomes in diabetic patients hospitalized with NF.

Methods

We retrospectively reviewed the glycemic gap and clinical outcomes in 252 diabetic patients hospitalized due to NF from 2011 to 2018 in a single medical center in Taiwan. A receiver operating characteristic (ROC) curve was used to analyze the optimal cutoff values for predicting adverse outcomes. Univariate and multivariate logistic regression analyses were employed to identify significant predictors of adverse outcomes.

Results

In total, 194 diabetic NF patients were enrolled. Compared with patients without adverse outcomes, patients with adverse outcomes had significantly higher glycemic gaps, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and C-reactive protein (CRP) levels; lower albumin and hemoglobin levels; greater incidence of limb loss; and longer hospital and intensive care unit stays. The glycemic gap positively correlates with the laboratory risk indicator for NF scores, APACHE II scores and CRP levels. A glycemic gap of 146 mg/dL was the optimal cutoff value for predicting adverse outcomes using the ROC curve. Compared with patients with glycemic gaps ≤146 mg/dL, those with glycemic gaps >146 mg/dL had higher APACHE II scores and incidence rates of adverse outcomes, especially bacteremia and acute kidney injury. Multivariate analysis revealed that a glycemic gap >146 mg/dL and APACHE II score >15 were independent predictors of adverse outcomes, while the presence of hyperglycemia at admission was not.

Conclusions

An elevated glycemic gap was significantly independently associated with adverse outcomes in diabetic NF patients. Further prospective studies are warranted to validate the role of the glycemic gap in NF patients with diabetes.

Stress-induced hyperglycaemia

Stress-induced hyperglycaemia is an important clinical entity. It is an adaptive immune-neurohormonal response to physiological stress in an attempt to increase metabolic substrates to struggling organs during a time of crisis. However, this acute hyperglycaemia is also responsible for a number of detrimental effects implying that treatment is necessary. Hence, admission hyperglycaemia is not necessarily equivalent to a diagnosis of diabetes mellitus but the blood glucose level needs to be interpreted in context of the patient's presenting complaint and previous glycaemic status. Stress-induced hyperglycaemia is associated with increased morbidity and short-term mortality. Thus prompt recognition of stress-induced hyperglycaemia and high risk hyperglycaemic patients with the stress hyperglycaemia ratio can help improve inpatient management. Patients with stress-induced hyperglycaemia who have recovered from their acute illness should be followed up as they remain at risk for incident diabetes. This review focuses on the definition, pathophysiology, targets, management and significance of stress-induced hyperglycaemia.

The influence of ageing on the incidence and site of trauma femoral fractures: a cross-sectional analysis

BACKGROUND

This study aimed to determine the influence of ageing on the incidence and site of femoral fractures in trauma patients, by taking the sex, body weight, and trauma mechanisms into account.

METHODS

This retrospective study reviewed data from adult trauma patients aged ≥20 years who were admitted into a Level I trauma center, between January 1, 2009 and December 31, 2016. According to the femoral fracture locations, 3859 adult patients with 4011 fracture sites were grouped into five subgroups: proximal type A (n = 1359), proximal type B (n = 1487), proximal type C (n = 59), femoral shaft (n = 640), and distal femur (n = 466) groups. A multivariate logistic regression analysis was applied to identify independent effects of the univariate predictive variables on the occurrence of fracture at a specific site. A two-dimensional plot was presented visually with age and the propensity score accounts for the risk of a fracture at a specific femoral site.

RESULTS

This analysis revealed that older age was an independent variable that could positively predict the occurrence of proximal type A (OR [95%CI]: 1.03 [1.03-1.04], p < 0.001) and B fractures (1.02 [1.01-1.02], p < 0.001), and negatively predict the occurrence of proximal type C (0.96 [0.94-0.98], p < 0.001), shaft (0.95 [0.95-0.96], p < 0.001), and distal fractures (0.98 [0.98-0.99], p < 0.001).

DISCUSSION

Using the propensity scores which account for the risk of a fracture in a specific femoral site, this study revealed that the older patients were at a higher risk of developing proximal type A and type B fractures, while a lower risk of developing fractures in the shaft and distal femur. This incidence of fracture site can largely be explained by age-related factors, including a decrease in bone strength and falling being the most common mechanism of trauma in older patients.

CONCLUSIONS

This study revealed a difference in the involvement of age in the incidence of femoral fracture sites in the trauma patients.

Trauma in the Diabetic Limb

Poorly controlled diabetes with comorbid manifestations negatively affects outcomes in lower extremity trauma, increasing the risk of short-term and long-term complications. Management strategies of patients with diabetes that experience lower extremity trauma should also include perioperative management of hyperglycemia to reduce adverse and serious adverse events.

Stress-Induced and Diabetic Hyperglycemia Associated with Higher Mortality among Intensive Care Unit Trauma Patients: Cross-Sectional Analysis of the Propensity Score-Matched Population

Background: This study was designed to measure the effect of stress-induced hyperglycemia (SIH) and diabetic hyperglycemia (DH) versus non-diabetic normoglycemia (NDN) on the outcomes of trauma patients in the intensive care unit (ICU). Methods: Diabetes mellitus (DM) was determined based on patient history and/or a hemoglobin A1c (HbA1c) level of ≥6.5% at admission. The patients who had serum glucose levels of ≥200 mg/dL in the absence or presence of DM were assigned into the groups SIH and DH, respectively. Diabetic normoglycemia (DN) and NDN were determined based on serum glucose levels of <200 mg/dL in patients with and without DM, respectively. Patients with burn injury or incomplete data were excluded. Detailed data of trauma patients in the ICU of a Level-I trauma center from 1 January 2009 to 31 December 2016 were retrieved from the database of the Trauma Registry System. These patients were classified into four exclusive groups, including NDN (n = 1745), DN (n = 306), SIH (n = 225) and DH (n = 206). The Pearson chi-square test was used to compare categorical data between groups. Continuous variables were compared using one-way analysis of variance along with the Games–Howell post hoc test. To decrease the confounding effect of the differences in sex and age, preexisting comorbidities and injury severity score (ISS) among different groups of patients, 1:1 ratio propensity score-matched cohorts were assigned using the NCSS software. The effect of hyperglycemia on the outcomes of patients with and without DM was assessed with a logistic regression analysis. Results: Among those selected propensity score-matched patient cohorts, the patients with SIH and DH had a 3.88-fold (95% CI, 2.13–7.06; p < 0.001) and 1.83-fold (95% CI, 1.00–3.34; p = 0.048) higher mortality, respectively, than those with NDN. Moreover, the patients in the SIH group (10.0 vs. 7.4 days; p = 0.005) and those in the DH group (10.1 vs. 7.4 days; p = 0.006) who were admitted to the ICU had a significantly longer length of stay than those in the NDN group. In addition, the SIH group had a 2.13-fold (95% CI, 1.04–4.36; p = 0.038) higher adjusted odds ratio for mortality than the DH group. Conclusions: This study revealed significantly worse outcomes in terms of mortality among patients with SIH and DH who were admitted to the ICU after controlling for sex and age, preexisting comorbidities and ISS. In addition, patients who had SIH presented significantly higher adjusted odds for mortality than those DH patients. These results suggest that hyperglycemia is detrimental in patients with or without DM who were admitted to the ICU, and there is a different pathophysiological mechanisms behind the SIH and DH.

Stress-induced hyperglycemia on complications in non-critically elderly hospitalized patients

AIMS

Hospital complications and hyperglycemia are common in elderly patients during hospitalization. Our aim was to analyze the relationship between hyperglycemia and hospital complications in an ageing population.

METHODS

We conducted an observational study to evaluate the association between maximum blood glucose (MBG) levels and hospital complications. Patients were stratified according to the quartiles of MBG levels. Diabetes mellitus (DM) was determined by patient history and/or admission glycated hemoglobin (HbA1c) level ≥6.5%. Hyperglycemia in patients without DM was defined as stress-induced hyperglycemia (SH). The composite primary end-point included frequent complications and/or all-cause hospital mortality.

RESULTS

Among 461 patients, mean age 80±7.5years, 238 (51.6%) patients had DM, 20 had undiagnosed DM, and 162 (35.1%) developed hospital complications. Patients with complications had higher mean daily BG levels (215±84 vs 195±85mg/dl, P<.01). The incidence of complications was directly associated with severity of hyperglycemia according to the quartiles of MBG levels in patients without DM, namely SH (<140 mg/dl, 22.2%; 140-185mg/dl, 40%; 186-250mg/dl, 47%; >250mg/dl, 60%; P=.002), but not in patients with DM (<140mg/dl, 26.3%; 140-185mg/dl, 40.4%; 186-250mg/dl, 35.6%; >250mg/dl, 37.4%; P=.748). In the multivariate analyses, SH was independently associated with complications: OR 2.60 (CI95%: 1.2-5.6), 2.82 (CI95%: 1.2-6.5), 5.50 (CI95%: 1.4-20.8) for the second, third and fourth quartile respectively (P=.01), as compared to the first quartile. We found no association with readmissions and all-cause mortality.

CONCLUSIONS

SH in elderly patients is associated with hospital complications, but not with all-cause mortality, compared to patients with diabetes or normoglycemia.