Sepsis‐associated hypoglycemia on admission is associated with increased mortality in intensive care unit patients

Combined sepsis- and renal dysfunction-induced hypoglycaemia in an older patient taking cibenzoline

Key Clinical Message

An 86-year-old geriatric patient with sepsis presented cibenzoline-induced hypoglycaemia, although within the boundary range of cibenzoline blood concentration.

Abstract

An 86-year-old geriatric patient taking cibenzoline for ametropic hypertrophic cardiac tendinopathy was admitted to our hospital for the treatment of sepsis. Upon admission, blood cibenzoline levels of 400.1 ng/mL were observed. Antibiotic therapy was initiated and cibenzoline was discontinued. On Day 16, cibenzoline was administered orally at a reduced dose of 50 mg/day. Several days after restarting cibenzoline, the patient developed hypoglycaemia (64 mg/dL), prompting the administration of 20% glucose. The present case demonstrates a rational timeline for cibenzoline administration, considering the patient's renal dysfunction and sepsis. Clinicians should exercise caution when managing older patients with severe infections who are receiving cibenzoline, and should consider the possibility of blood glucose fluctuations regardless of cibenzoline blood levels. Further research is warranted to better understand and address the potential side effects of cibenzoline administration in geriatric populations.

Relative Adrenal Insufficiency Is a Risk Factor for Pediatric Sepsis: A Proof-of-Concept Study

Glucocorticoid (GC) therapy had been strongly recommended for pediatric sepsis (grade 1A). However, the recommendation was changed to grade 2C in 2020 due to weak evidence. About 32.8% of patients with pediatric septic develop relative adrenal insufficiency (RAI). But whether GC therapy should be determined by RAI status is controversial. This study utilized 21-day-old SF1CreSRBIfl/fl mice as the first pediatric RAI mouse model to assess the pathogenesis of RAI and evaluate GC therapy. RAI mice exhibited a substantially higher mortality rate in cecal ligation and puncture and cecal slurry-induced sepsis. These mice featured persistent inflammatory responses and were effectively rescued by GC therapy. RNA sequencing analysis revealed persistent inflammatory responses in RAI mice, caused by transcriptional dysregulation of AP-1 and NF-κB, and cytokine-induced secondary inflammatory response. Our findings support a precision medicine approach to guide GC therapy for pediatric patients based on the status of RAI.

Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit

Background

Sepsis is one of the major causes of admission to the pediatric intensive care unit (PICU), as well as a primary cause of poor outcomes. Glycemic variation may occur because of sepsis resulting in either hypoglycemia or hyperglycemia. Measuring the random blood glucose (RBG) level of patients presenting with sepsis in PICU is an easy way to assess their prognosis.

Objectives

A prospective study was done from February 2023 to June 2023 to evaluate the relation between the outcome of pediatric septic patients and blood glucose level upon PICU admission.

Patients and methods

One hundred three children diagnosed with sepsis underwent clinical assessment upon admission to the PICU and initial labs including blood glucose levels were done. Pediatric Sequential Organ Failure Assessment (pSOFA) was calculated for every patient. The outcome of sepsis including length of stay, review of body systems, and mortality was documented.

Results

Hypoglycemic patients had the highest percentage of non-survivors (20.4%). They had a higher pSOFA score with a median of 11 (interquartile range-IQR 7-15), shorter PICU stay with a median of 2 (IQR 1-6) days, lower RBG with a median of 95 (45-120), a higher percentage of ventilation (55.1%), and a higher percentage of inotropic support (87.8%) with statistical significance with p-value (< 0.001, < 0.001, 0.001, < 0.001, 0.002), respectively.

Conclusion

Critically ill patients with abnormal random blood sugar (RBS) had a higher possibility of non-survival particularly those with hypoglycemia. Accordingly, RBS measurement is a rapid and cheap method that could be used in any emergency and as an early indicator to detect outcome.

How to cite this article

Mohamed AO, Abd El-Megied MA, Hosni YA. Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(10):754-758.

J-shaped associations and joint effects of fasting glucose with inflammation and cytokines on COVID-19 mortality

OBJECTIVES

The aim of this study was to investigate the dose-response relationship of admission fasting glucose (FBG) with corona virus disease 2019 (COVID-19) mortality and to further evaluate potential interactions of hyperglycemia with inflammation and hypercoagulation on COVID-19 outcomes.

METHODS

This retrospective study included 2555 consecutively hospitalized patients with COVID-19, until death or discharge, in Wuhan Union hospital between January 1 and April 9, 2020. The poor early outcomes included admission to intensive care unit, intubation, and deaths occurring within 28 days. We used splines nested in Cox regression to visualize dose-response associations and generalized additive models to fit three-dimensional (3D) trend plots for joint effects of FBG with markers of inflammation and coagulation.

RESULTS

J-shaped associations existed between hospitalized mortality or poor early outcomes and FBG with a nadir at 5 mmol/L, which were more evident in women. 3D plots demonstrated significant joint effect trends, and patients with hyperglycemia and high neutrophil-lymphocyte ratio, C-reactive protein, lactate dehydrogenase, procalcitonin, d-dimer, and interleukin-6 had 7.4-25.3-fold risks; the proportions of joint associations attributed to additive interactions reached 30% to 54%.

CONCLUSIONS

FBG was associated with hospitalized mortality and poor early outcomes in a J-shaped manner, and a combination of hyperglycemia, inflammation, hypercoagulation, and cytokines conferred a dramatically higher risk.

Association between glucose-to-lymphocyte ratio and in-hospital mortality in intensive care patients with sepsis: A retrospective observational study based on Medical Information Mart for Intensive Care IV

Background

This study aimed to evaluate the association between the glucose-to-lymphocyte ratio (GLR) and in-hospital mortality in intensive care unit (ICUs) patients with sepsis.

Methods

This is a retrospective cohort study. Patients with sepsis from the Medical Information Mart for Intensive Care-IV (MIMIC-IV) database had their baseline data and in-hospital prognosis retrieved. Multivariable Cox regression analyses were applied to calculate adjusted hazard ratios (HR) with 95% confidence intervals (CI). Survival curves were plotted, and subgroup analyses were stratified by relevant covariates. To address the non-linearity relationship, curve fitting and a threshold effect analysis were performed.

Results

Of the 23,901 patients, 10,118 patients with sepsis were included. The overall in-hospital mortality rate was 17.1% (1,726/10,118). Adjusted for confounding factors in the multivariable Cox regression analysis models, when GLR was used as a categorical variable, patients in the highest GLR quartile had increased in-hospital mortality compared to patients in the lowest GLR quartile (HR = 1.26, 95% CI: 1.15–1.38). When GLR was used as a continuous variable, each unit increase in GLR was associated with a 2% increase in the prevalence of in-hospital mortality (adjusted HR = 1.02, 95% CI: 1.01–1.03, p = 0.001). Stratified analyses indicated that the correlation between the GLR and in-hospital mortality was stable. The non-linear relationship between GLR and in-hospital mortality was explored in a dose-dependent manner. In-hospital mortality increased by 67% (aHR = 1.67, 95% CI: 1.45–1.92) for every unit GLR increase. When GLR was beyond 1.68, in-hospital mortality did not significantly change (aHR: 1.04, 95% CI: 0.92–1.18).

Conclusion

There is a non-linear relationship between GLR and in-hospital mortality in intensive care patients with sepsis. A higher GLR in ICU patients is associated with in-hospital mortality in the United States. However, further research is needed to confirm the findings.