101
|
Krinsley JS, Maurer P, Holewinski S, Hayes R, McComsey D, Umpierrez GE, Nasraway SA. Glucose Control, Diabetes Status, and Mortality in Critically Ill Patients: The Continuum From Intensive Care Unit Admission to Hospital Discharge. Mayo Clin Proc 2017. [PMID: 28645517 DOI: 10.1016/j.mayocp.2017.04.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe the relationships among glycemic control, diabetes mellitus (DM) status, and mortality in critically ill patients from intensive care unit (ICU) admission to hospital discharge. PATIENTS AND METHODS This is a retrospective investigation of 6387 ICU patients with 5 or more blood glucose (BG) tests and 4462 ICU survivors admitted to 2 academic medical centers from July 1, 2010, through December 31, 2014. We studied the relationships among mean BG level, hypoglycemia (BG level <70 mg/dL [to convert to mmol/L, multiply by 0.0555]), high glucose variability (coefficient of variation ≥20%), DM status, and mortality. RESULTS The ICU mortality for patients without DM with ICU mean BG levels of 80 to less than 110, 110 to less than 140, 140 to less than 180, and at least 180 mg/dL was 4.50%, 7.30%, 12.16%, and 32.82%, respectively. Floor mortality for patients without DM with these BG ranges was 2.74%, 2.64%, 7.88%, and 5.66%, respectively. The ICU and floor mean BG levels of 80 to less than 110 and 110 to less than 140 mg/dL were independently associated with reduced ICU and floor mortality compared with mean BG levels of 140 to less than 180 mg/dL in patients without DM (odds ratio [OR] [95% CI]: 0.43 (0.28-0.66), 0.62 (0.45-0.85), 0.41 (0.23-0.75), and 0.40 (0.25-0.63), respectively) but not in patients with DM. Both ICU and floor hypoglycemia and increased glucose variability were strongly associated with ICU and floor mortality in patients without DM, and less so in those with DM. The independent association of dysglycemia occurring in either setting with mortality was cumulative in patients without DM. CONCLUSION These findings support the importance of glucose control across the entire trajectory of hospitalization in critically ill patients and suggest that the BG target of 140 to less than 180 mg/dL is not appropriate for patients without DM. The optimal BG target for patients with DM remains uncertain.
Collapse
Affiliation(s)
- James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT.
| | | | - Sharon Holewinski
- Department of Nursing, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| | - Roy Hayes
- Department of System Engineering, University of Virginia, Charlottesville, VA
| | | | | | - Stanley A Nasraway
- Department of Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, MA
| |
Collapse
|
102
|
Kutz A, Struja T, Hausfater P, Amin D, Amin A, Haubitz S, Bernard M, Huber A, Mueller B, Schuetz P. The association of admission hyperglycaemia and adverse clinical outcome in medical emergencies: the multinational, prospective, observational TRIAGE study. Diabet Med 2017; 34:973-982. [PMID: 28164367 DOI: 10.1111/dme.13325] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/31/2017] [Indexed: 01/04/2023]
Abstract
AIMS The clinical relevance of hyperglycaemia in an emergency department population remains incompletely understood. We investigated the association between admission blood glucose levels and adverse clinical outcomes in a large emergency department cohort. METHODS We prospectively enrolled 7132 adult medical patients seeking emergency department care in three tertiary care hospitals in Switzerland, France and the USA. We used adjusted multivariable logistic regression models to examine the association between admission blood glucose levels and 30-day mortality, as well as adverse clinical course stratified by pre-existing diabetes and principal medical diagnoses. RESULTS In 6044 people without diabetes (84.7%), severe hyperglycaemia, defined as a glucose level of > 11.1 mmol/l (200 mg/dl), was associated with a doubling in the risk of 30-day mortality [adjusted odds ratio (OR) 1.9; 95% confidence interval (95% CI), 1.1 to 3.3; P = 0.018] and a three-fold increase in the risk of intensive care unit admission (adjusted OR 3.0; 95% CI, 1.9 to 4.9; P < 0.001). These associations were similar among different diagnoses. In the population with diabetes (n = 1088), no association with 30-day mortality was found (adjusted OR 1.0; 95% CI, 0.6 to 1.8; P for interaction = 0.001), whereas the association with intensive care unit admission was weaker (adjusted OR 2.4; 95% CI, 1.5 to 4.1; P for interaction = 0.011). Overall 30-day mortality was higher in those with diabetes than in those without (6.1 vs. 4.4%, P = 0.015). CONCLUSIONS In this large medical emergency department patient cohort, admission hyperglycaemia was strongly associated with adverse clinical course in people without diabetes. (Clinical Trial Registry No: NCT01768494).
Collapse
Affiliation(s)
- A Kutz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - T Struja
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - P Hausfater
- Emergency Department, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP), Paris, France
- Sorbonne Universités UPMC-Univ Paris 06, UMRS INSERM 1166, IHUC ICAN, Paris, France
| | - D Amin
- Morton Plant Hospital, Clearwater, Florida, USA
| | - A Amin
- Morton Plant Hospital, Clearwater, Florida, USA
| | - S Haubitz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - M Bernard
- Biochemistry Department, Hôpital Pitié-Salpêtrière and Univ-Paris Descartes, Paris, France
| | - A Huber
- Department of Laboratory Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - B Mueller
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| | - P Schuetz
- Division of General Internal and Emergency Medicine, University Department of Medicine, Kantonsspital Aarau, Aarau, Switzerland
| |
Collapse
|
103
|
Jensen AV, Egelund GB, Andersen SB, Trier Petersen P, Benfield T, Faurholt-Jepsen D, Rohde G, Ravn P. The impact of blood glucose on community-acquired pneumonia: a retrospective cohort study. ERJ Open Res 2017; 3:00114-2016. [PMID: 28656133 PMCID: PMC5478863 DOI: 10.1183/23120541.00114-2016] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2016] [Accepted: 04/21/2017] [Indexed: 01/08/2023] Open
Abstract
Hyperglycaemia is common in patients with community-acquired pneumonia (CAP) and is a predictor of severe outcomes. Data are scarce regarding whether this association is affected by diabetes mellitus (DM) and also regarding its importance for severe outcomes in hospital. We determined the impact of blood glucose on severe outcomes of CAP in hospital. We studied 1318 adult CAP patients hospitalised at three Danish hospitals. The association between blood glucose and DM status and severe clinical outcome (admission to an intensive care unit (ICU) and/or in-hospital mortality) was assessed by logistic regression. Models were adjusted for CURB-65 score and comorbidities. 12% of patients had DM. In patients without DM an increase in admission blood glucose was associated with risk for ICU admittance (OR 1.25, 95% CI 1.13-1.39), but not significantly associated with in-hospital mortality (OR 1.10, 95% CI 0.99-1.23). In patients with DM an increase in admission blood glucose was not associated with ICU admittance (OR 1.05, 95% CI 1.00-1.12) or in-hospital mortality (OR 1.05, 95% CI 0.99-1.12). An increase in admission blood glucose (only in patients without DM) was associated with a higher risk for ICU admittance and a trend towards higher in-hospital mortality. DM was not associated with a more severe outcome of CAP.
Collapse
Affiliation(s)
- Andreas Vestergaard Jensen
- Dept of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Gertrud Baunbæk Egelund
- Dept of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Stine Bang Andersen
- Dept of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Pelle Trier Petersen
- Dept of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| | - Thomas Benfield
- University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark.,Dept of Infectious Diseases, Hvidovre Hospital, Hvidrove, Denmark
| | - Daniel Faurholt-Jepsen
- Dept of Infectious Diseases, Rigshospitalet, Copenhagen, Denmark.,University of Copenhagen, Dept of Nutrition, Exercise and Sports, Copenhagen, Denmark
| | - Gernot Rohde
- Dept of Respiratory Medicine, Maastricht University Medical Center, Maastricht, The Netherlands.,CAPNETZ-Stiftung, Hannover, Germany
| | - Pernille Ravn
- Dept of Pulmonary and Infectious Diseases, Nordsjællands Hospital, Hillerød, Denmark.,University of Copenhagen, Faculty of Health and Medical Sciences, Copenhagen, Denmark
| |
Collapse
|
104
|
Silva-Perez LJ, Benitez-Lopez MA, Varon J, Surani S. Management of critically ill patients with diabetes. World J Diabetes 2017; 8:89-96. [PMID: 28344751 PMCID: PMC5348624 DOI: 10.4239/wjd.v8.i3.89] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Revised: 11/30/2016] [Accepted: 12/28/2016] [Indexed: 02/05/2023] Open
Abstract
Disorders of glucose homeostasis, such as stress-induced hypoglycemia and hyperglycemia, are common complications in patients in the intensive care unit. Patients with preexisting diabetes mellitus (DM) are more susceptible to hyperglycemia, as well as a higher risk from glucose overcorrection, that may results in severe hypoglycemia. In critically ill patients with DM, it is recommended to maintain a blood glucose range between 140-180 mg/dL. In neurological patients and surgical patients, tighter glycemic control (i.e., 110-140 mg/d) is recommended if hypoglycemia can be properly avoided. There is limited evidence that shows that critically ill diabetic patients with a glycosylated hemoglobin levels above 7% may benefit from looser glycemic control, in order to reduce the risk of hypoglycemia and significant glycemic variability.
Collapse
|
105
|
Sepsis: frontiers in supportive care, organisation and research. Intensive Care Med 2017; 43:496-508. [DOI: 10.1007/s00134-017-4677-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/03/2017] [Indexed: 01/05/2023]
|
106
|
Sechterberger MK, van Steen SCJ, Boerboom EMN, van der Voort PHJ, Bosman RJ, Hoekstra JBL, DeVries JH. Higher glucose variability in type 1 than in type 2 diabetes patients admitted to the intensive care unit: A retrospective cohort study. J Crit Care 2016; 38:300-303. [PMID: 28063297 DOI: 10.1016/j.jcrc.2016.12.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 12/22/2016] [Indexed: 01/09/2023]
Abstract
PURPOSE Although the course of disease of type 1 and type 2 diabetes differs, the distinction is rarely made when patients are admitted to the intensive care unit (ICU). Here, we report patient- and admission-related characteristics in relation to glycemic measures of patients with type 1 and type 2 diabetes admitted to the ICU. MATERIALS AND METHODS A retrospective chart review was performed of 1574 patients with diabetes admitted between 2004 and 2011 to our ICU. Glycemic measures included mean glucose, the incidence of hypoglycemia and hyperglycemia, percentage of glucose values in/below/above target, and glucose variability. The ICU and hospital mortality were secondary outcomes. RESULTS We classified 2% (n=27) of patients as having type 1 diabetes and 98% (n=1547) as having type 2 diabetes. Patients with type 1 diabetes were significantly younger, had a lower body mass index, and were more frequently admitted to the ICU for medical diagnoses. No differences in glycemic measures were found, apart from a 20% higher glucose variability in the type 1 diabetes group. CONCLUSIONS Patients with type 1 diabetes showed a higher glucose variability, but overall glycemic control was not different between patients with type 1 and type 2 diabetes. Very few diabetes patients admitted to the ICU have type 1 diabetes.
Collapse
Affiliation(s)
- Marjolein K Sechterberger
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Sigrid C J van Steen
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Esther M N Boerboom
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - Peter H J van der Voort
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands; TIAS School for Business and Society, Tilburg University, Tilburg, The Netherlands.
| | - Rob J Bosman
- Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands.
| | - Joost B L Hoekstra
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| | - J Hans DeVries
- Department of Endocrinology, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands.
| |
Collapse
|
107
|
Gunst J, Van den Berghe G. Acute severe illness in diabetes patients: is tolerating hyperglycemia beneficial? J Thorac Dis 2016; 8:3012-3015. [PMID: 28066571 DOI: 10.21037/jtd.2016.11.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| |
Collapse
|
108
|
Preiser JC, Chase JG, Hovorka R, Joseph JI, Krinsley JS, De Block C, Desaive T, Foubert L, Kalfon P, Pielmeier U, Van Herpe T, Wernerman J. Glucose Control in the ICU: A Continuing Story. J Diabetes Sci Technol 2016; 10:1372-1381. [PMID: 27170632 PMCID: PMC5094326 DOI: 10.1177/1932296816648713] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
In the present era of near-continuous glucose monitoring (CGM) and automated therapeutic closed-loop systems, measures of accuracy and of quality of glucose control need to be standardized for licensing authorities and to enable comparisons across studies and devices. Adequately powered, good quality, randomized, controlled studies are needed to assess the impact of different CGM devices on the quality of glucose control, workload, and costs. The additional effects of continuing glucose control on the general floor after the ICU stay also need to be investigated. Current algorithms need to be adapted and validated for CGM, including effects on glucose variability and workload. Improved collaboration within the industry needs to be encouraged because no single company produces all the necessary components for an automated closed-loop system. Combining glucose measurement with measurement of other variables in 1 sensor may help make this approach more financially viable.
Collapse
Affiliation(s)
- Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, New Zealand
| | - Roman Hovorka
- University of Cambridge Metabolic Research Laboratories, Level 4, Wellcome Trust-MRC Institute of Metabolic Science, Addenbrooke's Hospital, Cambridge, UK
| | - Jeffrey I Joseph
- Department of Anesthesiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, USA
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, Edegem, Belgium
| | - Thomas Desaive
- GIGA-Cardiovascular Sciences, Université de Liège, Liège, Belgium
| | - Luc Foubert
- Department of Anesthesia and Intensive Care Medicine, OLV Clinic, Aalst, Belgium
| | - Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, Chartres, France
| | - Ulrike Pielmeier
- Department of Health Science and Technology, Aalborg University, Aalborg Øst, Denmark
| | - Tom Van Herpe
- Department of Intensive Care Medicine-Department of Electrical Engineering (STADIUS), Katholieke Universiteit Leuven, Leuven, Belgium
| | - Jan Wernerman
- Karolinska University Hospital Huddinge and Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
109
|
Hyperglycemia and outcomes of medical intensive care unit patients with and without a history of diabetes mellitus in a Chinese population. Intensive Care Med 2016; 43:144-145. [PMID: 27761592 DOI: 10.1007/s00134-016-4598-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Accepted: 10/14/2016] [Indexed: 10/20/2022]
|
110
|
Gunst J, Van den Berghe G. A liberal glycemic target in critically ill patients with poorly controlled diabetes? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:S15. [PMID: 27867983 PMCID: PMC5104654 DOI: 10.21037/atm.2016.10.28] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Accepted: 09/01/2016] [Indexed: 03/18/2024]
Affiliation(s)
- Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, B-3000 Leuven, Belgium
| |
Collapse
|
111
|
Ali Abdelhamid Y, Kar P, Finnis ME, Phillips LK, Plummer MP, Shaw JE, Horowitz M, Deane AM. Stress hyperglycaemia in critically ill patients and the subsequent risk of diabetes: a systematic review and meta-analysis. Crit Care 2016; 20:301. [PMID: 27677709 PMCID: PMC5039881 DOI: 10.1186/s13054-016-1471-6] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Accepted: 08/26/2016] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Hyperglycaemia occurs frequently in critically ill patients without diabetes. We conducted a systematic review and meta-analysis to evaluate whether this 'stress hyperglycaemia' identifies survivors of critical illness at increased risk of subsequently developing diabetes. METHODS We searched the MEDLINE and Embase databases from their inception to February 2016. We included observational studies evaluating adults admitted to the intensive care unit (ICU) who developed stress hyperglycaemia if the researchers reported incident diabetes or prediabetes diagnosed ≥3 months after hospital discharge. Two reviewers independently screened the titles and abstracts of identified studies and evaluated the full text of relevant studies. Data were extracted using pre-defined data fields, and risk of bias was assessed using the Newcastle-Ottawa Scale. Pooled ORs with 95 % CIs for the occurrence of diabetes were calculated using a random-effects model. RESULTS Four cohort studies provided 2923 participants, including 698 with stress hyperglycaemia and 131 cases of newly diagnosed diabetes. Stress hyperglycaemia was associated with increased risk of incident diabetes (OR 3.48; 95 % CI 2.02-5.98; I 2 = 36.5 %). Studies differed with regard to definitions of stress hyperglycaemia, follow-up and cohorts studied. CONCLUSIONS Stress hyperglycaemia during ICU admission is associated with increased risk of incident diabetes. The strength of this association remains uncertain because of statistical and clinical heterogeneity among the included studies.
Collapse
Affiliation(s)
- Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005 Australia
| | - Palash Kar
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005 Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005 Australia
| | - Liza K. Phillips
- Discipline of Medicine, The University of Adelaide, Adelaide, SA 5005 Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 Australia
| | - Mark P. Plummer
- Intensive Care Unit, Addenbrooke’s Hospital, Hills Road, Cambridge, CB2 0QQ UK
| | - Jonathan E. Shaw
- Clinical Diabetes Laboratory, Baker IDI, 75 Commercial Road, Melbourne, VIC 3004 Australia
| | - Michael Horowitz
- Discipline of Medicine, The University of Adelaide, Adelaide, SA 5005 Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, SA 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5005 Australia
| |
Collapse
|
112
|
Su YW, Hsu CY, Guo YW, Chen HS. Usefulness of the plasma glucose concentration-to-HbA 1c ratio in predicting clinical outcomes during acute illness with extreme hyperglycaemia. DIABETES & METABOLISM 2016; 43:40-47. [PMID: 27663631 DOI: 10.1016/j.diabet.2016.07.036] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 07/30/2016] [Accepted: 07/31/2016] [Indexed: 10/21/2022]
Abstract
AIMS To evaluate the correlation between the plasma glucose-to-glycated haemoglobin ratio (GAR) and clinical outcome during acute illness. METHODS This retrospective observational cohort study enrolled 661 patients who visited the emergency department of our hospital between 1 July 2008 and 30 September 2010 with plasma glucose concentrations>500mg/dL. Systolic blood pressure, heart rate, white blood cells, neutrophils, haematocrit, blood urea nitrogen, serum creatinine, liver function and plasma glucose concentration were recorded at the initial presentation to the emergency department. Data on glycated haemoglobin over the preceding 6 months were reviewed from our hospital database. The glucose-to-HbA1c ratio (GAR) was calculated as the plasma glucose concentration divided by glycated haemoglobin. RESULTS The GAR of those who died was significantly higher than that of the survivors (81.0±25.9 vs 67.6±25.0; P<0.001). There was a trend towards a higher 90-day mortality rate in patients with higher GARs (log-rank test P<0.0001 for trend). On multivariate Cox regression analysis, the GAR was significantly related to 90-day mortality (hazard ratio [HR] for 1 standard deviation [SD] change: 1.41, 95% confidence interval [CI]: 1.22-1.63; P<0.001), but not to plasma glucose (HR: 0.89, 95% CI: 0.70-1.13; P=0.328). Rates of intensive care unit (ICU) admission and mechanical ventilator use were also higher in those with higher GARs. CONCLUSION GAR independently predicted 90-day mortality, ICU admission and use of mechanical ventilation. It was also a better predictor of patient outcomes than plasma glucose alone in patients with extremely high glucose levels.
Collapse
Affiliation(s)
- Y-W Su
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan
| | - C-Y Hsu
- Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan; Cardiovascular Research Center, National Yang-Ming University, Taipei, Taiwan; Institute of Clinical Medicine, National Yang-Ming University, Taipei, Taiwan; Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan; Division of Cardiology and Cardiovascular Research Center, Department of Internal Medicine, Taipei Medical University Hospital, Taipei, Taiwan
| | - Y-W Guo
- Department of Medicine, Taipei City Hospital, Zhongxing Branch, Taipei, Taiwan
| | - H-S Chen
- Division of Endocrinology and Metabolism, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; Department of Medicine, National Yang-Ming University School of Medicine, Taipei, Taiwan.
| |
Collapse
|
113
|
Jacobi J. Liberal glucose targets for critically ill diabetic patients: is it time for large clinical trials with more personalized endpoints? ANNALS OF TRANSLATIONAL MEDICINE 2016; 4:358. [PMID: 27761462 DOI: 10.21037/atm.2016.08.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Judith Jacobi
- Critical Care Pharmacist, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| |
Collapse
|
114
|
|
115
|
Plummer MP, Kar P, Cousins CE, Hausken T, Lange K, Chapman MJ, Jones KL, Horowitz M, Deane AM. Critical Illness Is Associated With Impaired Gallbladder Emptying as Assessed by 3D Ultrasound. Crit Care Med 2016; 44:e790-6. [PMID: 27071067 DOI: 10.1097/ccm.0000000000001715] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To quantify gallbladder dysfunction during critical illness. DESIGN Prospective observational comparison study of nutrient-stimulated gallbladder emptying in health and critical illness. SETTING Single-centre mixed medical/surgical ICU. PATIENTS Twenty-four mechanically ventilated critically ill patients suitable to receive enteral nutrition were compared with 12 healthy subjects. INTERVENTIONS Participants were studied after an 8-hour fast. Between 0 and 120 minutes, high-fat nutrient (20% intralipid) was infused via a postpyloric catheter into the duodenum at 2 kcal/min. MEASUREMENTS AND MAIN RESULTS Three-dimensional images of the gallbladder were acquired at 30-minute intervals from -30 to 180 minutes. Ejection fraction (%) was calculated as changes between 0 and 120 minutes. Blood samples were obtained at 30-minute intervals for plasma cholecystokinin. Data are mean (SD) or median [interquartile range]. In the critically ill, fasting gallbladder volumes (critically ill, 61 mL [36-100 mL] vs healthy, 22 mL [15-25] mL; p < 0.001] and wall thickness (0.45 mm [0.15 mm] vs 0.26 mm [0.08 mm]; p < 0.001] were substantially greater, and sludge was evident in the majority of patients (71% vs 0%). Nutrient-stimulated emptying was incomplete in the critically ill after 120 minutes but was essentially complete in the healthy individuals (22 mL [9-66 mL] vs 4 mL [3-5 mL]; p < 0.01]. In five critically ill patients (21%), there was no change in gallbladder volume in response to nutrient, and overall ejection fraction was reduced in the critically ill (50% [8-83%] vs 77 [72-84%]; p = 0.01]. There were no differences in fasting or incremental cholecystokinin concentrations. CONCLUSIONS Fasted critically ill patients have larger, thicker-walled gallbladders than healthy subjects and nutrient-stimulated gallbladder emptying is impaired with "gallbladder paresis" occurring in approximately 20%.
Collapse
Affiliation(s)
- Mark P Plummer
- 1Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.2Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia.3Department of Medicine, Haukeland University Hospital, Bergen, Norway.4Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | | | | | | | | | | | | | | | | |
Collapse
|
116
|
|
117
|
Kar P, Plummer MP, Bellomo R, Jenkins AJ, Januszewski AS, Chapman MJ, Jones KL, Horowitz M, Deane AM. Liberal Glycemic Control in Critically Ill Patients With Type 2 Diabetes: An Exploratory Study. Crit Care Med 2016; 44:1695-703. [PMID: 27315191 DOI: 10.1097/ccm.0000000000001815] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES The optimal blood glucose target in critically ill patients with preexisting diabetes and chronic hyperglycemia is unknown. In such patients, we aimed to determine whether a " liberal" approach to glycemic control would reduce hypoglycemia and glycemic variability and appear safe. DESIGN Prospective, open-label, sequential-period exploratory study. SETTING Medical-surgical ICU. PATIENTS During sequential 6-month periods, we studied 83 patients with preexisting type 2 diabetes and chronic hyperglycemia (glycated hemoglobin, ≥ 7.0% at ICU admission). INTERVENTION During the "standard care" period, 52 patients received insulin to treat blood glucose concentrations greater than 10 mmol/L whereas during the "liberal" period, 31 patients received insulin to treat blood glucose concentrations greater than 14 mmol/L. MEASUREMENTS AND MAIN RESULTS Time-weighted mean glucose concentrations and the number and duration of moderate (< 4.0 mmol/L) and severe (≤ 2.2 mmol/L) hypoglycemic episodes were recorded, with moderate and severe hypoglycemic episodes grouped together. Glycemic variability was assessed by calculating the coefficient of variability for each patient. Safety was evaluated using clinical outcomes and plasma concentrations of markers of inflammation, glucose-turnover, and oxidative stress. Mean glucose (TWglucoseday 0-7, standard care: 9.3 [1.8] vs liberal: 10.3 [2.1] mmol/L; p = 0.02) and nadir blood glucose (4.4 [1.5] vs 5.5 [1.6] mmol/L; p < 0.01) were increased during the liberal period. There was a signal toward reduced risk of moderate-severe hypoglycemia (relative risk: liberal compared with standard care: 0.47 [95% CI, 0.19-1.13]; p = 0.09). Ten patients (19%) during the standard period and one patient (3%) during the liberal period had recurrent episodes of moderate-severe hypoglycemia. Liberal therapy reduced glycemic variability (coefficient of variability, 33.2% [12.9%] vs 23.8% [7.7%]; p < 0.01). Biomarker data and clinical outcomes were similar. CONCLUSIONS In critically ill patients with type 2 diabetes and chronic hyperglycaemia, liberal glycemic control appears to attenuate glycemic variability and may reduce the prevalence of moderate-severe hypoglycemia.
Collapse
Affiliation(s)
- Palash Kar
- 1Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.2Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia.3Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.4School of Medicine, The University of Melbourne, Melbourne, VIC, Australia.5Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.6National Health and Medical Research Council Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia.7National Health and Medical Research Council Centre of Research Excellence (CRE) in the Translation of Nutritional Science into Good Health, University of Adelaide, Adelaide, SA, Australia.8Discipline of Medicine, University of Adelaide, Adelaide, SA, Australia
| | | | | | | | | | | | | | | | | |
Collapse
|
118
|
|
119
|
Harp JB, Yancopoulos GD, Gromada J. Glucagon orchestrates stress-induced hyperglycaemia. Diabetes Obes Metab 2016; 18:648-53. [PMID: 27027662 PMCID: PMC5084782 DOI: 10.1111/dom.12668] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 03/19/2016] [Accepted: 03/24/2016] [Indexed: 01/08/2023]
Abstract
Hyperglycaemia is commonly observed on admission and during hospitalization for medical illness, traumatic injury, burn and surgical intervention. This transient hyperglycaemia is referred to as stress-induced hyperglycaemia (SIH) and frequently occurs in individuals without a history of diabetes. SIH has many of the same underlying hormonal disturbances as diabetes mellitus, specifically absolute or relative insulin deficiency and glucagon excess. SIH has the added features of elevated blood levels of catecholamines and cortisol, which are not typically present in people with diabetes who are not acutely ill. The seriousness of SIH is highlighted by its greater morbidity and mortality rates compared with those of hospitalized patients with normal glucose levels, and this increased risk is particularly high in those without pre-existing diabetes. Insulin is the treatment standard for SIH, but new therapies that reduce glucose variability and hypoglycaemia are desired. In the present review, we focus on the key role of glucagon in SIH and discuss the potential use of glucagon receptor blockers and glucagon-like peptide-1 receptor agonists in SIH to achieve target glucose control.
Collapse
Affiliation(s)
- J B Harp
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| | | | - J Gromada
- Regeneron Pharmaceuticals, Inc., Tarrytown, NY, USA
| |
Collapse
|
120
|
Mahmoodpoor A, Hamishehkar H, Shadvar K, Beigmohammadi M, Iranpour A, Sanaie S. Relationship between glycated hemoglobin, Intensive Care Unit admission blood sugar and glucose control with ICU mortality in critically ill patients. Indian J Crit Care Med 2016; 20:67-71. [PMID: 27076705 PMCID: PMC4810935 DOI: 10.4103/0972-5229.175938] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND AND AIMS The association between hyperglycemia and mortality is believed to be influenced by the presence of diabetes mellitus (DM). In this study, we evaluated the effect of preexisting hyperglycemia on the association between acute blood glucose management and mortality in critically ill patients. The primary objective of the study was the relationship between HbA1c and mortality in critically ill patients. Secondary objectives of the study were relationship between Intensive Care Unit (ICU) admission blood glucose and glucose control during ICU stay with mortality in critically ill patients. MATERIALS AND METHODS Five hundred patients admitted to two ICUs were enrolled. Blood sugar and hemoglobin A1c (HbA1c) concentrations on ICU admission were measured. Age, sex, history of DM, comorbidities, Acute Physiology and Chronic Health Evaluation II score, sequential organ failure assessment score, hypoglycemic episodes, drug history, mortality, and development of acute kidney injury and liver failure were noted for all patients. RESULTS Without considering the history of diabetes, nonsurvivors had significantly higher HbA1c values compared to survivors (7.25 ± 1.87 vs. 6.05 ± 1.22, respectively, P < 0.001). Blood glucose levels in ICU admission showed a significant correlation with risk of death (P < 0.006, confidence interval [CI]: 1.004-1.02, relative risk [RR]: 1.01). Logistic regression analysis revealed that HbA1c increased the risk of death; with each increase in HbA1c level, the risk of death doubled. However, this relationship was not statistically significant (P: 0.161, CI: 0.933-1.58, RR: 1.2). CONCLUSIONS Acute hyperglycemia significantly affects mortality in the critically ill patients; this relation is also influenced by chronic hyperglycemia.
Collapse
Affiliation(s)
- Ata Mahmoodpoor
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Hadi Hamishehkar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Department of Anesthesiology, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Afshin Iranpour
- Department of Anesthesiology, Saudi German Hospital, Dubai, UAE
| | - Sarvin Sanaie
- Tuberculosis and Lung Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| |
Collapse
|
121
|
Affiliation(s)
- S K Todi
- Department of Critical Care Medicine, AMRI Hospitals, Kolkata, West Bengal, India
| |
Collapse
|
122
|
Ali Abdelhamid Y, Chapman MJ, Deane AM. Peri-operative nutrition. Anaesthesia 2016; 71 Suppl 1:9-18. [PMID: 26620142 DOI: 10.1111/anae.13310] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2015] [Indexed: 01/04/2023]
Abstract
Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.
Collapse
Affiliation(s)
- Y Ali Abdelhamid
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - M J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia.,Intensive Care, Royal Adelaide Hospital, Adelaide, Australia
| | - A M Deane
- Intensive Care, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| |
Collapse
|
123
|
Abstract
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.
Collapse
Affiliation(s)
- Mark P Plummer
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide 5000, Australia; Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide 5000, Australia.
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide 5000, Australia; Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide 5000, Australia
| |
Collapse
|
124
|
Greco G, Ferket BS, D'Alessandro DA, Shi W, Horvath KA, Rosen A, Welsh S, Bagiella E, Neill AE, Williams DL, Greenberg A, Browndyke JN, Gillinov AM, Mayer ML, Keim-Malpass J, Gupta LS, Hohmann SF, Gelijns AC, O'Gara PT, Moskowitz AJ. Diabetes and the Association of Postoperative Hyperglycemia With Clinical and Economic Outcomes in Cardiac Surgery. Diabetes Care 2016; 39:408-17. [PMID: 26786574 PMCID: PMC4764032 DOI: 10.2337/dc15-1817] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 12/15/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The management of postoperative hyperglycemia is controversial and generally does not take into account pre-existing diabetes. We analyzed clinical and economic outcomes associated with postoperative hyperglycemia in cardiac surgery patients, stratifying by diabetes status. RESEARCH DESIGN AND METHODS Multicenter cohort study in 4,316 cardiac surgery patients operated on in 2010. Glucose was measured at 6-h intervals for 48 h postoperatively. Outcomes included cost, hospital length of stay (LOS), cardiac and respiratory complications, major infections, and death. Associations between maximum glucose levels and outcomes were assessed with multivariable regression and recycled prediction analyses. RESULTS In patients without diabetes, increasing glucose levels were associated with a gradual worsening of outcomes. In these patients, hyperglycemia (≥180 mg/dL) was associated with an additional cost of $3,192 (95% CI 1,972 to 4,456), an additional hospital LOS of 0.8 days (0.4 to 1.3), an increase in infections of 1.6% (0.5 to 2.8), and an increase in respiratory complications of 2.6% (0.0 to 5.3). However, among patients with insulin-treated diabetes, optimal outcomes were associated with glucose levels considered to be hyperglycemic (180 to 240 mg/dL). This level of hyperglycemia was associated with cost reductions of $6,225 (-12,886 to -222), hospital LOS reductions of 1.6 days (-3.7 to 0.4), infection reductions of 4.1% (-9.1 to 0.0), and reductions in respiratory complication of 12.5% (-22.4 to -3.0). In patients with non-insulin-treated diabetes, outcomes did not differ significantly when hyperglycemia was present. CONCLUSIONS Glucose levels <180 mg/dL are associated with better outcomes in most patients, but worse outcomes in patients with diabetes with a history of prior insulin use. These findings support further investigation of a stratified approach to the management of patients with stress-induced postoperative hyperglycemia based on prior diabetes status.
Collapse
Affiliation(s)
- Giampaolo Greco
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Bart S Ferket
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A D'Alessandro
- Department of Cardiothoracic Surgery, Montefiore Medical Center/Albert Einstein College of Medicine, New York, NY
| | - Wei Shi
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Keith A Horvath
- Department of Cardiothoracic Surgery, NIH Heart Center at Suburban Hospital, Bethesda, MD
| | | | - Stacey Welsh
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Emilia Bagiella
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexis E Neill
- Department of Cardiothoracic Surgery, Emory University Hospital Midtown, Atlanta, GA
| | - Deborah L Williams
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ann Greenberg
- Department of Cardiothoracic Surgery, NIH Heart Center at Suburban Hospital, Bethesda, MD
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH
| | - Mary Lou Mayer
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Jessica Keim-Malpass
- Division of Thoracic and Cardiovascular Surgery, University of Virginia School of Medicine, Charlottesville, VA
| | - Lopa S Gupta
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Annetine C Gelijns
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patrick T O'Gara
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Alan J Moskowitz
- International Center for Health Outcomes and Innovation Research (InCHOIR), the Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| |
Collapse
|
125
|
Pre-morbid glycemic control modifies the interaction between acute hypoglycemia and mortality. Intensive Care Med 2016; 42:562-571. [DOI: 10.1007/s00134-016-4216-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2015] [Accepted: 01/08/2016] [Indexed: 01/25/2023]
|
126
|
Lansink M, Hofman Z, Genovese S, Rouws CHFC, Ceriello A. Improved Glucose Profile in Patients With Type 2 Diabetes With a New, High-Protein, Diabetes-Specific Tube Feed During 4 Hours of Continuous Feeding. JPEN J Parenter Enteral Nutr 2016; 41:968-975. [PMID: 26826263 DOI: 10.1177/0148607115625635] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hyperglycemia frequently occurs in hospitalized patients receiving nutrition support. In this study, the effects of a new diabetes-specific formula (DSF) on glucose profile during 4 hours of continuous feeding and 4 hours after stopping feeding were compared with a standard formula (SF). MATERIALS AND METHODS In this randomized, controlled, double-blind, crossover study, ambulant, nonhospitalized patients with type 2 diabetes received the DSF or an isocaloric, fiber-containing SF via a nasogastric tube. After overnight fasting, the formula was continuously administered to the patients during 4 hours. Plasma glucose and insulin concentrations were determined during the 4-hour period and in the subsequent 4 hours during which no formula was provided. RESULTS During the 4-hour feeding period, DSF compared with SF resulted in a lower mean delta glucose concentration in the 3- to 4-hour period (0.3 ± 1.0 and 2.4 ± 1.5 mmol/L; P < .001). Also, the (delta) peak concentrations, (delta) mean concentrations, and incremental area under the curve (iAUC) for glucose and insulin were significantly lower during DSF compared with SF feeding (all comparisons: P < .001). Furthermore, fewer patients experienced hyperglycemia (>10 mmol/L) on DSF compared with SF (2 vs 11, P = .003, respectively). No differences in number of patients with hypoglycemia (<3.9 mmol/L) were observed. No significant differences in tolerance were observed. CONCLUSION Administration of a new, high-protein DSF during 4 hours of continuous feeding resulted in lower glucose and insulin levels compared with a fiber-containing SF in ambulant, nonhospitalized patients with type 2 diabetes. These data suggest that a DSF may contribute to lower glucose levels in these patients.
Collapse
Affiliation(s)
- Mirian Lansink
- 1 Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, the Netherlands
| | - Zandrie Hofman
- 1 Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, the Netherlands
| | - Stefano Genovese
- 2 Department of Cardiovascular and Metabolic Diseases, IRCCS Gruppo Multimedica, Sesto San Giovanni (MI), Italy
| | - Carlette H F C Rouws
- 1 Nutricia Research, Nutricia Advanced Medical Nutrition, Utrecht, the Netherlands
| | - Antonio Ceriello
- 3 Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,4 Spanish Biomedical Research Centre in Diabetes and Associated Metabolic Disorders (CIBERDEM), Madrid, Spain
| |
Collapse
|
127
|
Plummer MP, Finnis ME, Phillips LK, Kar P, Bihari S, Biradar V, Moodie S, Horowitz M, Shaw JE, Deane AM. Stress Induced Hyperglycemia and the Subsequent Risk of Type 2 Diabetes in Survivors of Critical Illness. PLoS One 2016; 11:e0165923. [PMID: 27824898 PMCID: PMC5100960 DOI: 10.1371/journal.pone.0165923] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Stress induced hyperglycemia occurs in critically ill patients who have normal glucose tolerance following resolution of their acute illness. The objective was to evaluate the association between stress induced hyperglycemia and incident diabetes in survivors of critical illness. DESIGN Retrospective cohort study. SETTING All adult patients surviving admission to a public hospital intensive care unit (ICU) in South Australia between 2004 and 2011. PATIENTS Stress induced hyperglycemia was defined as a blood glucose ≥ 11.1 mmol/L (200 mg/dL) within 24 hours of ICU admission. Prevalent diabetes was identified through ICD-10 coding or prior registration with the Australian National Diabetes Service Scheme (NDSS). Incident diabetes was identified as NDSS registration beyond 30 days after hospital discharge until July 2015. The predicted risk of developing diabetes was described as sub-hazard ratios using competing risk regression. Survival was assessed using Cox proportional hazards regression. MAIN RESULTS Stress induced hyperglycemia was identified in 2,883 (17%) of 17,074 patients without diabetes. The incidence of type 2 diabetes following critical illness was 4.8% (821 of 17,074). The risk of diabetes in patients with stress induced hyperglycemia was approximately double that of those without (HR 1.91 (95% CI 1.62, 2.26), p<0.001) and was sustained regardless of age or severity of illness. CONCLUSIONS Stress induced hyperglycemia identifies patients at subsequent risk of incident diabetes.
Collapse
Affiliation(s)
- Mark P. Plummer
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
- * E-mail:
| | - Mark E. Finnis
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
| | - Liza K. Phillips
- Discipline of Medicine, University of Adelaide, Level 6 Eleanor Harrald Building, Adelaide, South Australia, Australia
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Palash Kar
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
| | - Shailesh Bihari
- Department of Critical Care Medicine, Flinders University, Bedford Park, South Australia, Australia
- Department of Intensive Care Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Vishwanath Biradar
- Department of Intensive Care Medicine, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
| | - Stewart Moodie
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Level 6 Eleanor Harrald Building, Adelaide, South Australia, Australia
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan E. Shaw
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Adam M. Deane
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
| |
Collapse
|
128
|
Ali Abdelhamid Y, Phillips L, Horowitz M, Deane A. 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. Pilot Feasibility Stud 2016; 2:62. [PMID: 27965877 PMCID: PMC5153915 DOI: 10.1186/s40814-016-0104-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 10/01/2016] [Indexed: 02/07/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Liza Phillips
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| | - Adam Deane
- Intensive Care Unit, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia 5000 Australia
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia 5000 Australia
| |
Collapse
|
129
|
Mårtensson J, Bellomo R. The Rationale for Permissive Hyperglycemia in Critically Ill Patients with Diabetes. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2016. [DOI: 10.1007/978-3-319-27349-5_29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
|
130
|
Kar P, Plummer MP, Bellomo R, Jenkins AJ, Januszewski AS, Lange K, Chapman MJ, Horowitz M, Deane AM. Personalised glucose therapy: glucose targets in critically ill patients with pre-existing poorly controlled type 2 diabetes. Intensive Care Med Exp 2015. [PMCID: PMC4797823 DOI: 10.1186/2197-425x-3-s1-a290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
|
131
|
Moghissi ES, Inzucchi SE, Mann KV, Byerly B, Ermentrout L, Juchniewicz JJD, Ferareza JH, Kirkwood N. Hyperglycemia grand rounds: descriptive findings of outcomes from a continuing education intervention to improve glycemic control and prevent hypoglycemia in the hospital setting. Hosp Pract (1995) 2015; 43:270-276. [PMID: 26524116 DOI: 10.1080/21548331.2015.1103191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
UNLABELLED Hyperglycemia is common in the hospital in-patient setting and is associated with adverse outcomes. Healthcare professionals (HCPs) often fail to use best practices established to manage this condition or to coordinate care among team members. OBJECTIVES The objective of the Hyperglycemia Grand Rounds (HGR) continuing education initiative was to improve knowledge levels in a team setting, leading to improved clinical competence, evidence-based behaviors, and improved patient care. METHODS To achieve that goal, a four-module seminar series was presented to HCPs on-site in a "Grand Rounds" format at healthcare institutions across the United States. Outcomes data included satisfaction, learning, impact, and intent-to-implement measures at event time and at follow-up. At the site level, detailed questionnaires assessed skill gaps and expected outcomes from administrators at the time the modules were scheduled and the impact after modules were completed. Demographic information allowed identification of HCPs receiving maximum benefits; data on barriers to implementation are reported. RESULTS Seventy-eight percent of participants self-reported a positive impact on competence, performance, or patient outcomes. Forty percent of learners said they intended to make specific changes in practices. Eighty-two percent of administrators confirmed expected changes in their health system. The follow-up study concurred with the initial findings. CONCLUSION The HGR was an effective program in improving self-reported competence amongst attendees that could potentially lead to improved care. This descriptive report summarizes outcomes from 1 year of educational efforts to more than 2000 healthcare professionals.
Collapse
Affiliation(s)
- Etie S Moghissi
- a David Geffen School of Medicine, University of California, Los Angeles , Marina del Rey , CA , USA
| | - Silvio E Inzucchi
- b Section of Endocrinology , Yale School of Medicine , New Haven , CT , USA
| | | | | | | | | | | | | |
Collapse
|
132
|
Mesotten D, Preiser JC, Kosiborod M. Glucose management in critically ill adults and children. Lancet Diabetes Endocrinol 2015; 3:723-33. [PMID: 26071884 DOI: 10.1016/s2213-8587(15)00223-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2014] [Revised: 01/20/2015] [Accepted: 01/28/2015] [Indexed: 02/06/2023]
Abstract
Blood glucose management in people with acute myocardial infarction and critical illness has always attracted controversy. Compared with the era before 2001 when no attention was given to blood glucose management, DIGAMI-1 in 1995 and the first Leuven study in 2001 showed improved outcomes with strict control of blood glucose, thereby suggesting a causal association between hyperglycaemia and mortality risk. These landmark trials have set the standard in clinical practice that excessive hyperglycaemia is not acceptable. Multicentre trials contradicted the benefits of tight control of patients' blood glucose and results showed that different standard operating procedures for blood glucose control (eg, blood glucose meters or algorithms), divergent concomitant feeding strategies, and varying patient populations are important confounders. The general consensus now is that excessive hyperglycaemia (>10 mmol/L) and severe hypoglycaemia (<2·2 mmol/L) should be avoided in critically ill adults. If adequate blood glucose meters and clinically validated protocols for insulin-dosing are available, targeting of blood glucose concentrations to less than 8 mmol/L (moderate glycaemic control), while avoiding mild hypoglycaemia (<3·9 mmol/L), is a reasonable strategy in adult patients who are critically ill. This recommendation is not based on findings from randomised controlled trials, but merely represents a very common, pragmatic approach by physicians at the bedside. As a result of the few properly validated technologies for tighter blood glucose control, targeting blood glucose concentrations to less than 6 mmol/L is not recommended, because its risk-to-benefit ratio becomes questionable. Because blood glucose control in the target of adult ranges does not improve patient outcomes for children in the intensive care unit, glucose management in this patient population should be limited to avoid excessive hyperglycaemia (>10 mmol/L).
Collapse
Affiliation(s)
- Dieter Mesotten
- KU Leuven-University of Leuven, University Hospitals Leuven, Department of Intensive Care Medicine, Leuven, Belgium.
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| |
Collapse
|
133
|
Rafael Machado T, Jean-Charles P. Reporting on Glucose Control Metrics in the Intensive Care Unit. EUROPEAN ENDOCRINOLOGY 2015; 11:75-78. [PMID: 29632573 PMCID: PMC5819070 DOI: 10.17925/ee.2015.11.02.75] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Accepted: 07/16/2015] [Indexed: 12/19/2022]
Abstract
The 'diabetes of injury' typically associated with critical illness has recently been thoroughly revisited and much better characterised following major therapeutic advances. The occurrence of severe hyperglycaemia, moderate hypoglycaemia or high glycaemic variability has been associated with an increased mortality and rate of complications in large independent cohorts of acutely ill patients. Hence, current guidelines advocate the prevention and avoidance of each of these three dysglycaemic domains, and the use of a common metrics for a quantitative description of dysglycaemic events, such as the proportion of time spent in the target glycaemic range as a unifying variable. Using a common language will help to face the future challenges, including the definition of the most appropriate blood glucose (BG) target according to the category of admission, the time interval from the initial injury and the medical history. The clinical testing of technological improvements in the monitoring systems and the therapeutic algorithms should be assessed using the same metrics.
Collapse
Affiliation(s)
| | - Preiser Jean-Charles
- Professor, Department of Intensive Care, Erasme University Hospital, Universite libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
134
|
Braithwaite SS. Process Performance Measures for Inpatient Glucose Management Programs. Jt Comm J Qual Patient Saf 2015; 41:323-4. [DOI: 10.1016/s1553-7250(15)41042-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
135
|
Krinsley JS, Preiser JC. Time in blood glucose range 70 to 140 mg/dl >80% is strongly associated with increased survival in non-diabetic critically ill adults. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:179. [PMID: 25927986 PMCID: PMC4446958 DOI: 10.1186/s13054-015-0908-7] [Citation(s) in RCA: 107] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 04/01/2015] [Indexed: 01/04/2023]
Abstract
Introduction Hyperglycemia, hypoglycemia and increased glucose variability are independently associated with increased risk of death in critically ill adults. The relationship between time in targeted blood glucose range (TIR) and mortality is not well described and may be a factor that has confounded the results of the major interventional trials of intensive insulin therapy. Methods We conducted a retrospective analysis of prospectively collected data involving 3,297 patients with intensive care unit (ICU) lengths of stay (LOS) of ≥1.0 day who were admitted between 1 January 2009 and 31 December 2013 to a single mixed medical-surgical ICU. We investigated the relationship between TIR 70 to 140 mg/dl with mortality and compared outcomes of non-diabetics (NON) and individuals with diabetes mellitus (DM), including stratifying by TIR above (TIR-hi) and below (TIR-lo) the median value for the NON and DM groups. Results There were 85,799 blood glucose (BG) values for the NON group and 32,651 for the DM group, and we found that 75.5% and 54.8%, respectively, were between 70 and 140 (P <0.0001). The median (interquartile range) TIR (%) values for the NON and DM groups were 80.6% (61.4% to 94.0%) and 55.0% (35.5% to 71.1%), respectively (P <0.0001). For the NON group, mortality was 8.47% and 15.71% for TIR-hi and TIR-lo, respectively (P <0.0001). For the DM group, mortality was 16.09% and 14.44% for TIR-hi and TIR-lo, respectively (P = NS). We observed similar relationships for the NON group when we stratified by ICU LOS or severity of illness, especially in the most severely ill patients. There was a cumulative interaction of indices of hypoglycemia, hyperglycemia or glucose variability with TIR. Multivariable analysis demonstrated, for the NON group, that TIR-hi was independently associated with increased survival (P =0.0019). For the NON group, the observed-to-expected mortality ratios for TIR-hi and TIR-lo, based on Acute Physiology and Chronic Health Evaluation IV methodology, were 0.53 and 0.78, respectively. In contrast, among those in the DM group, there was no clear relationship between TIR 70 to 140 mg/dl and survival. Conclusions Independently of ICU LOS and severity of illness, TIR 70 to 140 mg/dl >80% is strongly associated with survival in critically ill patients without diabetes. These findings have implications for the design of clinical protocols for glycemic control in critically ill patients as well for the design of future interventional trials of intensive insulin therapy. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0908-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, 190 West Broad Street, Stamford, CT, 06902, USA.
| | - Jean-Charles Preiser
- Division of Critical Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, 1070, Brussels, Belgium.
| |
Collapse
|
136
|
Fiaccadori E, Sabatino A, Morabito S, Bozzoli L, Donadio C, Maggiore U, Regolisti G. Hyper/hypoglycemia and acute kidney injury in critically ill patients. Clin Nutr 2015; 35:317-321. [PMID: 25912231 DOI: 10.1016/j.clnu.2015.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/30/2015] [Accepted: 04/05/2015] [Indexed: 01/22/2023]
Abstract
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.
Collapse
Affiliation(s)
- E Fiaccadori
- Acute & Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, Parma University Hospital, Parma, Italy.
| | - A Sabatino
- Acute & Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, Parma University Hospital, Parma, Italy
| | - S Morabito
- Hemodialysis Unit, Policlinico Umberto I, Rome University La Sapienza, Rome, Italy
| | - L Bozzoli
- Postgraduate School in Nephrology, Pisa University, Pisa, Italy
| | - C Donadio
- Postgraduate School in Nephrology, Pisa University, Pisa, Italy
| | - U Maggiore
- Kidney-Pancreas Transplant Unit, Parma University Hospital, Parma, Italy
| | - G Regolisti
- Acute & Chronic Renal Failure Unit, Department of Clinical and Experimental Medicine, Parma University Hospital, Parma, Italy
| |
Collapse
|
137
|
Kalfon P, Le Manach Y, Ichai C, Bréchot N, Cinotti R, Dequin PF, Riu-Poulenc B, Montravers P, Annane D, Dupont H, Sorine M, Riou B. Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:153. [PMID: 25888011 PMCID: PMC4470320 DOI: 10.1186/s13054-015-0851-7] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2014] [Accepted: 03/02/2015] [Indexed: 12/18/2022]
Abstract
Introduction In a randomized controlled trial comparing tight glucose control with a computerized decision support system and conventional protocols (post hoc analysis), we tested the hypothesis that hypoglycemia is associated with a poor outcome, even when controlling for initial severity. Methods We looked for moderate (2.2 to 3.3 mmol/L) and severe (<2.2 mmol/L) hypoglycemia, multiple hypoglycemic events (n ≥3) and the other main components of glycemic control (mean blood glucose level and blood glucose coefficient of variation (CV)). The primary endpoint was 90-day mortality. We used both a multivariable analysis taking into account only variables observed at admission and a multivariable matching process (greedy matching algorithm; caliper width of 10−5 digit with no replacement). Results A total of 2,601 patients were analyzed and divided into three groups: no hypoglycemia (n =1,474), moderate hypoglycemia (n =874, 34%) and severe hypoglycemia (n =253, 10%). Patients with moderate or severe hypoglycemia had a poorer prognosis, as shown by a higher mortality rate (36% and 54%, respectively, vs. 28%) and decreased number of treatment-free days. In the multivariable analysis, severe (odds ratio (OR), 1.50; 95% CI, 1.36 to 1.56; P =0.043) and multiple hypoglycemic events (OR, 1.76, 95% CI, 1.31 to 3.37; P <0.001) were significantly associated with mortality, whereas blood glucose CV was not. Using multivariable matching, patients with severe (53% vs. 35%; P <0.001), moderate (33% vs. 27%; P =0.029) and multiple hypoglycemic events (46% vs. 32%, P <0.001) had a higher 90-day mortality. Conclusion In a large cohort of ICU patients, severe hypoglycemia and multiple hypoglycemic events were associated with increased 90-day mortality. Trial registration Clinicaltrials.gov Identifier: NCT01002482. Registered 26 October 2009.
Collapse
Affiliation(s)
- Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, 34 , avenue du Docteur Maunoury, 28000, Chartres, France.
| | - Yannick Le Manach
- Departments of Anesthesia & Clinical Epidemiology and Biostatistics, Michael G DeGroote School of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, ON, Canada.
| | - Carole Ichai
- Service de Réanimation médico-chirurgicale, Hôpital Saint-Roch, CHU de Nice, 5, rue Pierre Dévoluy, CS 91179, 06001 Nice Cedex 1, France and IRCAN Unit, UMR INSERM U1081-CNRS 7284, Nice-Sophia Antipolis University, Nice, France.
| | - Nicolas Bréchot
- Service de Réanimation médicale, Institut de Cardiologie, CHU Pitié-Salpêtrière, Assistance Publique- Hôpitaux de Paris (AP-HP), 47 bd de l'Hôpital, 75651, Paris cedex 13, France.
| | - Raphaël Cinotti
- Service de Réanimation chirurgicale-Brûlés PTMC, Hôtel Dieu, CHU de Nantes, Place Alexis Ricordeau, 44093, Nantes cedex 1, France.
| | - Pierre-François Dequin
- Service de Réanimation médicale, Hôpital Bretonneau, CHRU de Tours, 2, boulevard Tonnellé, 37044, Tours cedex 9, France.
| | - Béatrice Riu-Poulenc
- Service de Réanimation polyvalente, Hôpital Purpan, CHU de Toulouse, Place du Docteur Baylac TSA 40031, 31059, Toulouse cedex 9, France.
| | - Philippe Montravers
- Département d'Anesthésie et Réanimation chirurgicale, CHU Bichat-Claude Bernard, AP-HP, 46 Rue Henri Huchard, 75018, Paris, France.
| | - Djilalli Annane
- Service de Réanimation, CHU Raymond Poincaré, AP-HP, 104 Boulevard Raymond Poincaré, 92380, Garches, France.
| | - Hervé Dupont
- Service d'Anesthésie Réanimation, Hôpital Nord, CHRU Amiens, Place Victor Pauchet, 80054, Amiens Cedex 1, France.
| | - Michel Sorine
- Institut National de Recherche en Informatique et en Automatique (INRIA), Domaine de Voluceau, Rocquencourt, B.P. 105, 78153, Le Chesnay, France.
| | - Bruno Riou
- Service d'accueil des Urgences, CHU Pitié-Salpêtrière AP-HP, 47 bd de l'Hôpital, 75651, Paris cedex 13, France. .,Sorbonne Université, UPMC Univ Paris 6, UMR INSERM 1166, Paris, France.
| | | |
Collapse
|
138
|
Year in review in Intensive Care Medicine 2014: I. Cardiac dysfunction and cardiac arrest, ultrasound, neurocritical care, ICU-acquired weakness, nutrition, acute kidney injury, and miscellaneous. Intensive Care Med 2015. [PMCID: PMC4315874 DOI: 10.1007/s00134-015-3665-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
|
139
|
Kar P, Cousins CE, Annink CE, Jones KL, Chapman MJ, Meier JJ, Nauck MA, Horowitz M, Deane AM. Effects of glucose-dependent insulinotropic polypeptide on gastric emptying, glycaemia and insulinaemia during critical illness: a prospective, double blind, randomised, crossover study. Crit Care 2015; 19:20. [PMID: 25613747 PMCID: PMC4340673 DOI: 10.1186/s13054-014-0718-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2014] [Accepted: 12/11/2014] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Insulin is used to treat hyperglycaemia in critically ill patients but can cause hypoglycaemia, which is associated with poorer outcomes. In health glucose-dependent insulinotropic polypeptide (GIP) is a potent glucose-lowering peptide that does not cause hypoglycaemia. The objectives of this study were to determine the effects of exogenous GIP infusion on blood glucose concentrations, glucose absorption, insulinaemia and gastric emptying in critically ill patients without known diabetes. METHODS A total of 20 ventilated patients (Median age 61 (range: 22 to 79) years, APACHE II 21.5 (17 to 26), BMI 28 (21 to 40) kg/m(2)) without known diabetes were studied on two consecutive days in a randomised, double blind, placebo controlled, cross-over fashion. Intravenous GIP (4 pmol/kg/min) or placebo (0.9% saline) was infused between T = -60 to 300 minutes. At T0, 100 ml of liquid nutrient (2 kcal/ml) containing 3-O-Methylglucose (3-OMG), 100 mcg of Octanoic acid and 20 MBq Tc-99 m Calcium Phytate, was administered via a nasogastric tube. Blood glucose and serum 3-OMG (an index of glucose absorption) concentrations were measured. Gastric emptying, insulin and glucagon levels and plasma GIP concentrations were also measured. RESULTS While administration of GIP increased plasma GIP concentrations three- to four-fold (T = -60 23.9 (16.5 to 36.7) versus T = 0 84.2 (65.3 to 111.1); P <0.001) and plasma glucagon (iAUC300 4217 (1891 to 7715) versus 1232 (293 to 4545) pg/ml.300 minutes; P = 0.04), there were no effects on postprandial blood glucose (AUC300 2843 (2568 to 3338) versus 2819 (2550 to 3497) mmol/L.300 minutes; P = 0.86), gastric emptying (AUC300 15611 (10993 to 18062) versus 15660 (9694 to 22618) %.300 minutes; P = 0.61), glucose absorption (AUC300 50.6 (22.3 to 74.2) versus 64.3 (9.9 to 96.3) mmol/L.300 minutes; P = 0.62) or plasma insulin (AUC300 3945 (2280 to 6731) versus 3479 (2316 to 6081) mU/L.300 minutes; P = 0.76). CONCLUSIONS In contrast to its profound insulinotropic effect in health, the administration of GIP at pharmacological doses does not appear to affect glycaemia, gastric emptying, glucose absorption or insulinaemia in the critically ill patient. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12612000488808. Registered 3 May 2012.
Collapse
Affiliation(s)
- Palash Kar
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Caroline E Cousins
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Christopher E Annink
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Karen L Jones
- Discipline of Medicine, The University of Adelaide, Royal Adelaide Hospital, Level 6 Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia.
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Marianne J Chapman
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Juris J Meier
- Diabetes Division, Department of Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Gudrunstraße 56, Bochum, 44791, Germany.
| | - Michael A Nauck
- Diabetes Centre, Bad Lauterberg, Kirchberg 21, Bad Lauterberg, Harz, 37431, Germany.
| | - Michael Horowitz
- Discipline of Medicine, The University of Adelaide, Royal Adelaide Hospital, Level 6 Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia.
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, 5000, Australia.
| | - Adam M Deane
- Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, 5000, Australia.
- Discipline of Acute Care Medicine, The University of Adelaide, North Terrace, Adelaide, South Australia, 5000, Australia.
| |
Collapse
|
140
|
Abstract
The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters.
Collapse
Affiliation(s)
- Stijn Blot
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium and the Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. Elsa Afonso is a staff nurse in the neonatal intensive care unit, Chelsea and Westminster NHS Trust, London, United Kingdom. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Elsa Afonso
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium and the Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. Elsa Afonso is a staff nurse in the neonatal intensive care unit, Chelsea and Westminster NHS Trust, London, United Kingdom. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| | - Sonia Labeau
- Stijn Blot is a professor in the Department of Internal Medicine, Faculty of Medicine and Health Science, Ghent University, Belgium and the Burns Trauma and Critical Care Research Centre, The University of Queensland, Brisbane, Australia. Elsa Afonso is a staff nurse in the neonatal intensive care unit, Chelsea and Westminster NHS Trust, London, United Kingdom. Sonia Labeau is a lecturer in the Faculty of Education, Health and Social Work, University College Ghent, Belgium
| |
Collapse
|
141
|
Deane AM, Jeppesen PB. Understanding incretins. Intensive Care Med 2014; 40:1751-4. [DOI: 10.1007/s00134-014-3435-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/01/2014] [Indexed: 12/21/2022]
|
142
|
Marik PE, Egi M. Treatment thresholds for hyperglycemia in critically ill patients with and without diabetes. Intensive Care Med 2014; 40:1049-51. [PMID: 24859623 DOI: 10.1007/s00134-014-3344-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 05/14/2014] [Indexed: 12/13/2022]
Affiliation(s)
- Paul E Marik
- Division of Pulmonary and Critical Care Medicine, Eastern Virginia Medical School, 825 Fairfax Av, Suite 410, Norfolk, VA, 23507, USA,
| | | |
Collapse
|