1
|
Hu J, Ouyang L, Li J, Li X, Zhong Y, Hou C. Mean Blood Glucose Level During ICU Hospitalization is a Strong Predictor of the Mortality of COVID-19. Diabetes Metab Syndr Obes 2024; 17:1903-1909. [PMID: 38706805 PMCID: PMC11070158 DOI: 10.2147/dmso.s450489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 04/16/2024] [Indexed: 05/07/2024] Open
Abstract
Objective To investigate the potential prognostic value of mean blood glucose (MBG) in hospital for prognosis of COVID-19 adult patients in the intensive unit care unit (ICU). Methods A single-site and retrospective study enrolled 107 patients diagnosed as COVID-19 from department of critical care medicine in the Second Xiangya Hospital between October 2022 and June 2023. Demographic information including glucose during ICU hospitalization, comorbidity, clinical data, types of medications and treatment, and clinical outcome were collected. The multivariate logistic and cox regression was used to explore the relationship between blood glucose changes and clinical outcomes of COVID-19 during ICU stay. Results In total, 107 adult patients confirmed with COVID-19 were included. Multivariate logistic regression results showed an increase in MBG was associated with ICU mortality rate. Compared with normal glucose group (MBG <= 7.8 mmol/L), the risk of ICU mortality, 7-day mortality and 28-day mortality from COVID-19 were significantly increased in high glucose group (MBG >7.8mmol/L). Conclusion MBG level during ICU hospitalization was strongly correlated to all-cause mortality and co-infection in COVID-19 patients. These findings further emphasize the importance of overall glucose management in severe cases of COVID-19.
Collapse
Affiliation(s)
- Jie Hu
- Critical Care Medicine Center, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, Key Laboratory Diseases Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| | - Lin Ouyang
- Department of Critical Care Medicine Center, Guilin Hospital of the Second Xiangya Hospital, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| | - Jinxiu Li
- Critical Care Medicine Center, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Xia Li
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, Key Laboratory Diseases Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| | - Yanjun Zhong
- Critical Care Medicine Center, The Second Xiangya Hospital, Central South University, Changsha, People’s Republic of China
| | - Can Hou
- National Clinical Research Center for Metabolic Diseases, Department of Metabolism and Endocrinology, Key Laboratory Diseases Immunology, Ministry of Education, The Second Xiangya Hospital of Central South University, Changsha, Hunan, People’s Republic of China
| |
Collapse
|
2
|
Liu X, Zhang G, Li D, Ruan Z, Wu B. Effect of 24 h glucose fluctuations on 30-day and 1-year mortality in patients with acute myocardial infarction: an analysis from the MIMIC-III database. Front Cardiovasc Med 2024; 11:1371606. [PMID: 38572310 PMCID: PMC10987860 DOI: 10.3389/fcvm.2024.1371606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 03/11/2024] [Indexed: 04/05/2024] Open
Abstract
Background It is recognized that patients' blood glucose fluctuates over time during acute disease episodes, especially during the outbreak of cardiovascular events, regardless of the presence of an abnormal blood glucose profile prior to admission to the hospital. Glucose fluctuations in patients with acute myocardial infarction (AMI) in the intensive care unit (ICU) are currently not adequately monitored and studied. We focused on blood glucose fluctuation values within 24 h of admission to assess their association with 30-day and 1-year mortality. Methods Data of patients with AMI aged 18 years or older from the Critical Care Medical Information Marketplace database III V1.4 were available for analysis in this research. Glucose data were obtained by measurement. A total of 390 of them were treated with PCI. The principal consequence was 30-day and 1-year mortality in patients with AMI. The effect of different glucose fluctuations within 24 h of admission on mortality was predicted by constructing a multivariate Cox regression model with four model adjustments and Kaplan-Meier survival curves. Additionally, we performed curve-fitting analyses to show the correlation between blood glucose fluctuations and risk of death. Results We selected 1,699 AMI patients into our study through screening. The included population was categorized into three groups based on the tertiles of blood glucose fluctuation values within 24 h of admission to the ICU. The three groups were <25 mg/dl, 25-88 mg/dl and >88 mg/dl. By cox regression analysis, the group with the highest blood glucose fluctuation values (>88 mg/dl) had the most significant increase in 30-day and 1-year mortality after excluding confounding factors (30-day mortality adjusted HR = 2.11; 95% CI = 1.49-2.98 p < 0.001; 1-year mortality adjusted HR = 1.83; 95% CI = 1.40-2.39 p < 0.001). As demonstrated by the Kaplan-Meier survival curves, the group with the greatest fluctuations in blood glucose has the worst 30-day and 1-year prognosis. Conclusions The extent of glucose fluctuations in patients with AMI in the first 24 h after ICU admission is an essential predictor as to 30-day as well as 1-year mortality. When blood glucose fluctuates more than 88 mg/dl within 24 h, mortality increases significantly with the range of blood glucose fluctuations.
Collapse
Affiliation(s)
- Xiaohe Liu
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Guihong Zhang
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Dan Li
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Zhishen Ruan
- The First Clinical Medical College, Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| | - Bo Wu
- Department of Cardiovascular Medicine, Affiliated Hospital of Shandong University of Traditional Chinese Medicine, Jinan, Shandong, China
| |
Collapse
|
3
|
Feng M, Zhou J. Relationship between time-weighted average glucose and mortality in critically ill patients: a retrospective analysis of the MIMIC-IV database. Sci Rep 2024; 14:4721. [PMID: 38413682 PMCID: PMC10899565 DOI: 10.1038/s41598-024-55504-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 02/24/2024] [Indexed: 02/29/2024] Open
Abstract
Blood glucose management in intensive care units (ICU) remains a controversial topic. We assessed the association between time-weighted average glucose (TWAG) levels and ICU mortality in critically ill patients in a real-world study. This retrospective study included critically ill patients from the Medical Information Mart for Intensive Care IV database. Glycemic distance is the difference between TWAG in the ICU and preadmission usual glycemia assessed with glycated hemoglobin at ICU admission. The TWAG and glycemic distance were divided into 4 groups and 3 groups, and their associations with ICU mortality risk were evaluated using multivariate logistic regression. Restricted cubic splines were used to explore the non-linear relationship. A total of 4737 adult patients were included. After adjusting for covariates, compared with TWAG ≤ 110 mg/dL, the odds ratios (ORs) of the TWAG > 110 mg/dL groups were 1.62 (95% CI 0.97-2.84, p = 0.075), 3.41 (95% CI 1.97-6.15, p < 0.05), and 6.62 (95% CI 3.6-12.6, p < 0.05). Compared with glycemic distance at - 15.1-20.1 mg/dL, the ORs of lower or higher groups were 0.78 (95% CI 0.50-1.21, p = 0.3) and 2.84 (95% CI 2.12-3.82, p < 0.05). The effect of hyperglycemia on ICU mortality was more pronounced in non-diabetic and non-septic patients. TWAG showed a U-shaped relationship with ICU mortality risk, and the mortality risk was minimal at 111 mg/dL. Maintaining glycemic distance ≤ 20.1 mg/dL may be beneficial. In different subgroups, the impact of hyperglycemia varied.
Collapse
Affiliation(s)
- Mengwen Feng
- Department of Critical Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China
| | - Jing Zhou
- Department of Geriatric Intensive Care Medicine, The First Affiliated Hospital of Nanjing Medical University, Nanjing, 210029, China.
| |
Collapse
|
4
|
Sun C, Zhou JH, Huang YL, Ning YL, Xu XH. The optimal blood glucose is significantly associated with lower mortality in critically ill patients with cardiogenic shock: an analysis revealed with time series blood glucose records. Eur J Med Res 2024; 29:129. [PMID: 38368401 PMCID: PMC10874009 DOI: 10.1186/s40001-024-01724-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 02/10/2024] [Indexed: 02/19/2024] Open
Abstract
BACKGROUND The optimal blood glucose (BG) level for patients with cardiogenic shock in the intensive care unit (ICU) remains unclear. Studies have found that both excessively high and low BG levels contribute to adverse cardiovascular events. Our study aims to investigate the optimal BG level for critically ill patients with cardiogenic shock and evaluate the effects of optimal BG on the prognosis of patients. METHODS A total of 2013 patients with cardiogenic shock obtained from the Medical Information Mart for Intensive Care (MIMIC) IV database were included in the final cohort for our retrospective observational study for data analysis. The exposure was time-weighted average BG (TWA-BG), which was calculated by the time-series BG records and corresponding time stamps of patients with cardiogenic shock during their stay in the ICU. The cut-off value of TWA-BG was identified by the restricted cubic spline curve and included patients were categorized into three groups: low TWA-BG group (TWA-BG ≤ 104 mg/dl), optimal TWA-BG group (104 < TWA-BG ≤ 138 mg/dl), and high TWA-BG group (TWA-BG > 138 mg/dl). The primary outcome was 28-day mortality, and the secondary outcomes were ICU and in-hospital mortality. We performed the log-rank test to detect whether there is a difference in mortality among different groups in the original cohort. Multiple distinct models were employed to validate the robustness of the results. RESULTS Our study revealed that the optimal BG level for critically ill patients with cardiogenic shock is 104-138 mg/dl. Compared to the optimal TWA-BG group, the low TWA-BG group (hazard ratio (HR): 1.67, 95% confidence interval (CI): 1.19-2.33, p = 0.002) and high TWA-BG group (HR: 1.72, 95% CI: 1.46-2.03, p < 0.001) exhibited higher 28-day mortality. Similarly, the low TWA-BG group and high TWA-BG group demonstrated higher risks in terms of ICU mortality (low TWA-BG group: HR: 2.30, 95% CI: 1.40-3.79, p < 0.001; high TWA-BG group: HR: 1.77, 95% CI: 1.45-2.17, p < 0.001) and in-hospital mortality (low TWA-BG group: HR: 1.73, 95% CI: 1.19-2.51, p = 0.001; high TWA-BG group: HR: 1.64, 95% CI: 1.38-1.95, p < 0.001). Sensitivity analysis conducted through propensity score matching and the subgroup analysis further substantiated the robustness of the results. CONCLUSION The optimal BG level for patients with cardiogenic shock is 104-138 mg/dl. BG levels below 104 mg/dl and above 138 mg/dl were associated with a less favorable prognosis.
Collapse
Affiliation(s)
- Ce Sun
- Department of Critical Care Medicine, Meizhou Hospital of Guangzhou University of Chinese Medicine, Meizhou, China
- Guangzhou University of Chinese Medicine, Guangzhou, China
| | - Ji-Hong Zhou
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Pulmonary and Critical Care Medicine (PCCM), Bao'an District Hospital of Chinese Medicine, Shenzhen, China
| | - Yan-Ling Huang
- Guangzhou University of Chinese Medicine, Guangzhou, China
- Department of Pulmonary and Critical Care Medicine (PCCM), Bao'an District Hospital of Chinese Medicine, Shenzhen, China
| | - Yi-Le Ning
- The First Clinical School, Guangzhou University of Chinese Medicine, Guangzhou, China.
| | - Xiang-Hui Xu
- Department of Critical Care Medicine, Bao'an District Hospital of Chinese Medicine, Shenzhen, China.
| |
Collapse
|
5
|
Cai W, Li Y, Guo K, Wu X, Chen C, Lin X. Association of glycemic variability with death and severe consciousness disturbance among critically ill patients with cerebrovascular disease: analysis of the MIMIC-IV database. Cardiovasc Diabetol 2023; 22:315. [PMID: 37974159 PMCID: PMC10652479 DOI: 10.1186/s12933-023-02048-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The association of glycemic variability with severe consciousness disturbance and in-hospital all-cause mortality in critically ill patients with cerebrovascular disease (CVD) remains unclear, This study aimed to investigate the association of glycemic variability with cognitive impairment and in-hospital death. METHOD We extracted all blood glucose measurements of patients diagnosed with CVD from the Medical Information Mart for Intensive Care IV (MIMIC-IV). Glycemic variability was defined as the coefficient of variation (CV), which was determined using the ratio of standard deviation and the mean blood glucose levels. Cox hazard regression models were applied to analyze the link between glycemic variability and outcomes. We also analyzed non-linear relationship between outcome indicators and glycemic variability using restricted cubic spline curves. RESULTS The present study included 2967 patients diagnosed with cerebral infarction and 1842 patients diagnosed with non-traumatic cerebral hemorrhage. Log-transformed CV was significantly related to cognitive impairment and in-hospital mortality, as determined by Cox regression. Increasing log-transformed CV was approximately linearly with the risk of cognitive impairment and in-hospital mortality. CONCLUSION High glycemic variability was found to be an independent risk factor for severe cognitive decline and in-hospital mortality in critically ill patients with CVD. Our study indicated that enhancing stability of glycemic variability may reduced adverse outcomes in patients with severe CVD.
Collapse
Affiliation(s)
- Weimin Cai
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Yaling Li
- Department Health Management Center, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 31000, China
| | - Kun Guo
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Xiao Wu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325000, China
| | - Chao Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, No. 2, Fuxue Lane, Wenzhou, 325000, China.
| | - Xinran Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, No. 2, Fuxue Lane, Wenzhou, 325000, China.
| |
Collapse
|
6
|
Su Y, Fan W, Liu Y, Hong K. Glycemic variability and in-hospital death of critically ill patients and the role of ventricular arrhythmias. Cardiovasc Diabetol 2023; 22:134. [PMID: 37308889 DOI: 10.1186/s12933-023-01861-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 05/20/2023] [Indexed: 06/14/2023] Open
Abstract
BACKGROUND Abnormal glycemic variability is common in the intensive care unit (ICU) and is associated with increased in-hospital mortality and major adverse cardiovascular events, but little is known about whether adverse outcomes are partly mediated by ventricular arrhythmias (VA). We aimed to explore the association between glycemic variability and VA in the ICU and whether VA related to glycemic variability mediate the increased risk of in-hospital death. METHODS We extracted all measurements of blood glucose during the ICU stay from The Medical Information Mart for Intensive Care IV (MIMIC-IV) database version 2.0. Glycemic variability was expressed by the coefficient of variation (CV), which was calculated by the ratio of standard deviation (SD) and average blood glucose values. The outcomes included the incidence of VA and in-hospital death. The KHB (Karlson, KB & Holm, A) is a method to analyze the mediation effect for nonlinear models, which was used to decompose the total effect of glycemic variability on in-hospital death into a direct and VA-mediated indirect effect. RESULTS Finally, 17,756 ICU patients with a median age of 64 years were enrolled; 47.2% of them were male, 64.0% were white, and 17.8% were admitted to the cardiac ICU. The total incidence of VA and in-hospital death were 10.6% and 12.8%, respectively. In the adjusted logistic model, each unit increase in log-transformed CV was associated with a 21% increased risk of VA (OR 1.21, 95% CI: 1.11-1.31) and a 30% increased risk (OR 1.30, 95% CI: 1.20-1.41) of in-hospital death. A total of 3.85% of the effect of glycemic variability on in-hospital death was related to the increased risk of VA. CONCLUSION High glycemic variability was an independent risk factor for in-hospital death in ICU patients, and the effect was caused in part by an increased risk of VA.
Collapse
Affiliation(s)
- Yuhao Su
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, No.1, Minde Road, 330006, Nanchang, Jiangxi, China
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China
| | - Weiguo Fan
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, No.1, Minde Road, 330006, Nanchang, Jiangxi, China
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China
| | - Yang Liu
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, No.1, Minde Road, 330006, Nanchang, Jiangxi, China
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China
| | - Kui Hong
- Department of Cardiovascular Medicine, The Second Affiliated Hospital of Nanchang University, No.1, Minde Road, 330006, Nanchang, Jiangxi, China.
- Jiangxi Key Laboratory of Molecular Medicine, Nanchang, Jiangxi, China.
- Department of Genetic Medicine, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China.
| |
Collapse
|
7
|
Krinsley JS, Rule P, Brownlee M, Roberts G, Preiser JC, Chaudry S, Dionne K, Heluey-Rodrigues C, Umpierrez GE, Hirsch IB. Acute and Chronic Glucose Control in Critically Ill Patients With Diabetes: The Impact of Prior Insulin Treatment. J Diabetes Sci Technol 2022; 16:1483-1495. [PMID: 34396800 PMCID: PMC9631540 DOI: 10.1177/19322968211032277] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Emerging data highlight the interactions of preadmission glycemia, reflected by admission HbA1c levels, glycemic control during critical illness, and mortality. The association of preadmission insulin treatment with outcomes is unknown. METHODS This observational cohort study includes 5245 patients admitted to the medical-surgical intensive care unit of a university-affiliated teaching hospital. Three groups were analyzed: patients with diabetes with prior insulin treatment (DM-INS, n = 538); patients with diabetes with no prior insulin treatment (DM-No-INS, n = 986); no history of diabetes (NO-DM, n = 3721). Groups were stratified by HbA1c level: <6.5%; 6.5%-7.9% and >8.0%. RESULTS Among the three strata of HbA1c, mean blood glucose (BG), coefficient of variation (CV), and hypoglycemia increased with increasing HbA1c, and were higher for DM-INS than for DM-No-INS. Among patients with HbA1c < 6.5%, mean BG ≥ 180 mg/dL and CV > 30% were associated with lower severity-adjusted mortality in DM-INS compared to patients with mean BG 80-140 mg/dL and CV < 15%, (P = .0058 and < .0001, respectively), but higher severity-adjusted mortality among DM-No-INS (P = .0001 and < .0001, respectively) and NON-DM (P < .0001 and < .0001, respectively). Among patients with HbA1c ≥ 8.0%, mean BG ≥ 180 mg/dL was associated with lower severity-adjusted mortality for both DM-INS and DM-No-INS than was mean BG 80-140 mg/dL (p < 0.0001 for both comparisons). CONCLUSIONS Significant differences in mortality were found among patients with diabetes based on insulin treatment and HbA1c at home and post-admission glycemic control. Prospective studies need to confirm an individualized approach to glycemic control in the critically ill.
Collapse
Affiliation(s)
- James S. Krinsley
- Division of Critical Care, Department
of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and
Surgeons, Stamford, CT, USA
- James S Krinsley MD, FCCM, FCCP, Division
of Critical Care, Department of Medicine, Stamford Hospital, and the Columbia
Vagelos College of Physicians and Surgeons, 1 Hospital Plaza, Stamford, CT
06902, USA. Emails: ;
| | | | - Michael Brownlee
- Einstein Diabetes Research Center,
Professor of Medicine and Pathology Emeritus, Albert Einstein College of Medicine,
Bronx, NY, USA
| | | | | | - Sherose Chaudry
- Division of Critical Care, Department
of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and
Surgeons, Stamford, CT, USA
| | - Krista Dionne
- Division of Critical Care, Department
of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and
Surgeons, Stamford, CT, USA
| | - Camilla Heluey-Rodrigues
- Division of Critical Care, Department
of Medicine, Stamford Hospital, and the Columbia Vagelos College of Physicians and
Surgeons, Stamford, CT, USA
| | | | - Irl B. Hirsch
- University of Washington Medicine
Diabetes Institute, Seattle, WA, USA
| |
Collapse
|
8
|
Glycemic control in critically ill patients with or without diabetes. BMC Anesthesiol 2022; 22:227. [PMID: 35842591 PMCID: PMC9288031 DOI: 10.1186/s12871-022-01769-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 07/08/2022] [Indexed: 11/22/2022] Open
Abstract
Background Early randomized controlled trials have demonstrated the benefits of tight glucose control. Subsequent NICE-SUGAR study found that tight glucose control increased mortality. The optimal glucose target in diabetic and nondiabetic patients remains unclear. This study aimed to evaluate the relationship between blood glucose levels and outcomes in critically ill patients with or without diabetes. Methods This was a retrospective analysis of the eICU database. Repeat ICU stays, ICU stays of less than 2 days, patients transferred from other ICUs, those with less than 2 blood glucose measurements, and those with missing data on hospital mortality were excluded. The primary outcome was hospital mortality. Generalised additive models were used to model relationship between glycemic control and mortality. Models were adjusted for age, APACHE IV scores, body mass index, admission diagnosis, mechanical ventilation, and use of vasopressor or inotropic agents. Results There were 52,107 patients in the analysis. Nondiabetes patients exhibited a J-shaped association between time-weighted average glucose and hospital mortality, while this association in diabetes patients was right-shifted and flattened. Using a TWA glucose of 100 mg/dL as the reference value, the adjusted odds ratio (OR) of TWA glucose of 140 mg/dL was 3.05 (95% confidence interval (CI) 3.03–3.08) in nondiabetes and 1.14 (95% CI 1.08–1.20) in diabetes patients. The adjusted OR of TWA glucose of 180 mg/dL were 4.20 (95% CI 4.07–4.33) and 1.49 (1.41–1.57) in patients with no diabetes and patients with diabetes, respectively. The adjusted ORs of TWA glucose of 80 mg/dL compared with 100 mg/dL were 1.74 (95% CI 1.57–1.92) in nondiabetes and 1.36 (95% CI 1.12–1.66) in patients with diabetes. The glucose ranges associated with a below-average risk of mortality were 80–120 mg/dL and 90–150 mg/dL for nondiabetes and diabetes patients, respectively. Hypoglycemia was associated with increased hospital mortality in both groups but to a lesser extent in diabetic patients. Glucose variability was positively associated with hospital mortality in nondiabetics. Conclusions Time-weighted average glucose, hypoglycemia, and glucose variability had different impacts on clinical outcomes in patients with and without diabetes. Compared with nondiabetic patients, diabetic patients showed a more blunted response to hypo- and hyperglycemia and glucose variability. Glycemic control strategies should be reconsidered to avoid both hypoglycemia and hyperglycemia. Supplementary Information The online version contains supplementary material available at 10.1186/s12871-022-01769-4.
Collapse
|
9
|
Henry H, Gilliot S, Genay S, Barthelemy C, Decaudin B, Odou P. Stability of 1-unit/mL insulin aspart solution in cyclic olefin copolymer vials and polypropylene syringes. Am J Health Syst Pharm 2021; 79:665-675. [PMID: 34971359 DOI: 10.1093/ajhp/zxab484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
DISCLAIMER In an effort to expedite the publication of articles, AJHP is posting manuscripts online as soon as possible after acceptance. Accepted manuscripts have been peer-reviewed and copyedited, but are posted online before technical formatting and author proofing. These manuscripts are not the final version of record and will be replaced with the final article (formatted per AJHP style and proofed by the authors) at a later time. PURPOSE This study evaluated the stability of diluted insulin aspart solutions (containing insulin aspart and preservatives) at their most commonly used concentration in intensive care units (1 unit/mL), in 2 container types: cyclic olefin copolymer (COC) vials and polypropylene (PP) syringes. METHODS Insulin aspart solution (1 unit/mL, diluted in 0.9% sodium chloride injection) was stored for 365 days in COC vials with gray stoppers and PP syringes at refrigerated (5±3°C) and ambient temperatures (25°C ± 2°C at 60% ± 5% relative humidity and protected from light). Chemical testing was conducted monthly using a validated high-performance liquid chromatography method (quantification of insulin aspart, phenol, and metacresol). Physical stability was evaluated monthly via pH measurements, visible and subvisible particle counts, and osmolality measurements. Sterility testing was also performed to validate the sterile preparation process and the maintenance of sterility throughout the study. RESULTS The limit of stability was set at 90% of the initial concentrations of insulin aspart, phenol, and metacresol. The physicochemical stability of 1-unit/mL insulin solutions stored refrigerated and protected from light, was unchanged in COC vials for the 365-day period and for 1 month in PP syringes. At ambient temperature, subvisible particulate contamination as well as the chemical stability of insulin and metacresol were acceptable for only 1 month's storage in PP syringes, while insulin chemical stability was maintained for only 3 months' storage in COC vials. CONCLUSION According to our results, it is not recommended to administer 1-unit/mL pharmacy-diluted insulin solutions after 3 months' storage in COC vials at ambient temperature or after 1 month in PP syringes at ambient temperature. The findings support storage of 1-unit/mL insulin aspart solution in COC vials at refrigerated temperature as the best option over the long term. Sterility was maintained in every condition. Both sterility and physicochemical stability are essential to authorize the administration of a parenteral insulin solution.
Collapse
Affiliation(s)
- Heloise Henry
- Groupe de Recherche sur les formes Injectables et les Technologies Associées (GRITA), Centre Hospitalier Universitaire de Lille, ULR 7365, Lille, France
| | - Sixtine Gilliot
- Groupe de Recherche sur les formes Injectables et les Technologies Associées (GRITA), Centre Hospitalier Universitaire de Lille, ULR 7365, Lille, France
| | - Stephanie Genay
- Groupe de Recherche sur les formes Injectables et les Technologies Associées (GRITA), Centre Hospitalier Universitaire de Lille, ULR 7365, Lille, France
| | - Christine Barthelemy
- Groupe de Recherche sur les formes Injectables et les Technologies Associées (GRITA), Centre Hospitalier Universitaire de Lille, ULR 7365, Lille, France
| | - Bertrand Decaudin
- Groupe de Recherche sur les formes Injectables et les Technologies Associées (GRITA), Centre Hospitalier Universitaire de Lille, ULR 7365, Lille, France
| | - Pascal Odou
- Groupe de Recherche sur les formes Injectables et les Technologies Associées (GRITA), Centre Hospitalier Universitaire de Lille, ULR 7365, Lille, France
| |
Collapse
|
10
|
Individualised versus conventional glucose control in critically-ill patients: the CONTROLING study-a randomized clinical trial. Intensive Care Med 2021; 47:1271-1283. [PMID: 34590159 PMCID: PMC8550173 DOI: 10.1007/s00134-021-06526-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 09/02/2021] [Indexed: 12/21/2022]
Abstract
Purpose Hyperglycaemia is an adaptive response to stress commonly observed in critical illness. Its management remains debated in the intensive care unit (ICU). Individualising hyperglycaemia management, by targeting the patient’s pre-admission usual glycaemia, could improve outcome. Methods In a multicentre, randomized, double-blind, parallel-group study, critically-ill adults were considered for inclusion. Patients underwent until ICU discharge either individualised glucose control by targeting the pre-admission usual glycaemia using the glycated haemoglobin A1c level at ICU admission (IC group), or conventional glucose control by maintaining glycaemia below 180 mg/dL (CC group). A non-commercial web application of a dynamic sliding-scale insulin protocol gave to nurses all instructions for glucose control in both groups. The primary outcome was death within 90 days. Results Owing to a low likelihood of benefit and evidence of the possibility of harm related to hypoglycaemia, the study was stopped early. 2075 patients were randomized; 1917 received the intervention, 942 in the IC group and 975 in the CC group. Although both groups showed significant differences in terms of glycaemic control, survival probability at 90-day was not significantly different (IC group: 67.2%, 95% CI [64.2%; 70.3%]; CC group: 69.6%, 95% CI [66.7%; 72.5%]). Severe hypoglycaemia (below 40 mg/dL) occurred in 3.9% of patients in the IC group and in 2.5% of patients in the CC group (p = 0.09). A post hoc analysis showed for non-diabetic patients a higher risk of 90-day mortality in the IC group compared to the CC group (HR 1.3, 95% CI [1.05; 1.59], p = 0.018). Conclusion Targeting an ICU patient’s pre-admission usual glycaemia using a dynamic sliding-scale insulin protocol did not demonstrate a survival benefit compared to maintaining glycaemia below 180 mg/dL. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06526-8.
Collapse
|
11
|
Stress Hyperglycemia and Osteocalcin in COVID-19 Critically Ill Patients on Artificial Nutrition. Nutrients 2021; 13:nu13093010. [PMID: 34578888 PMCID: PMC8470880 DOI: 10.3390/nu13093010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Revised: 08/25/2021] [Accepted: 08/25/2021] [Indexed: 12/16/2022] Open
Abstract
We aimed to study the possible association of stress hyperglycemia in COVID-19 critically ill patients with prognosis, artificial nutrition, circulating osteocalcin, and other serum markers of inflammation and compare them with non-COVID-19 patients. Fifty-two critical patients at the intensive care unit (ICU), 26 with COVID-19 and 26 non-COVID-19, were included. Glycemic control, delivery of artificial nutrition, serum osteocalcin, total and ICU stays, and mortality were recorded. Patients with COVID-19 had higher ICU stays, were on artificial nutrition for longer (p = 0.004), and needed more frequently insulin infusion therapy (p = 0.022) to control stress hyperglycemia. The need for insulin infusion therapy was associated with higher energy (p = 0.001) and glucose delivered through artificial nutrition (p = 0.040). Those patients with stress hyperglycemia showed higher ICU stays (23 ± 17 vs. 11 ± 13 days, p = 0.007). Serum osteocalcin was a good marker for hyperglycemia, as it inversely correlated with glycemia at admission in the ICU (r = -0.476, p = 0.001) and at days 2 (r = -0.409, p = 0.007) and 3 (r = -0.351, p = 0.049). In conclusion, hyperglycemia in critically ill COVID-19 patients was associated with longer ICU stays. Low circulating osteocalcin was a good marker for stress hyperglycemia.
Collapse
|
12
|
Wong D, Malik C, Dembek K, Estell K, Marchitello M, Wilson K. Evaluation of a continuous glucose monitoring system in neonatal foals. J Vet Intern Med 2021; 35:1995-2001. [PMID: 34096103 PMCID: PMC8295665 DOI: 10.1111/jvim.16186] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 05/06/2021] [Accepted: 05/18/2021] [Indexed: 02/06/2023] Open
Abstract
Background Monitoring blood glucose concentrations is common in critically ill neonatal foals, especially septic foals and those receiving naso‐esophageal feedings or IV parenteral nutrition. Glucose typically is measured using a point‐of‐care (POC) glucometer but requires repeated restraint and blood collections, which may cause irritation at venipuncture sites and increased demands on nursing staff. Continuous glucose monitoring systems (CGMS) may provide an accurate alternative for monitoring blood glucose concentration. Objectives To determine the correlation and accuracy of a CGMS to monitor neonatal foals' blood glucose concentrations as compared to a POC glucometer and laboratory chemistry analysis (CHEM). Animals Samples from 4 healthy and 4 ill neonatal foals. Methods A CGMS was placed on each foal, and glucose measurements acquired from this device were compared to simultaneous measurements of blood glucose concentration using a POC glucometer and CHEM. Results Two‐hundred matched glucose measurements were collected from 8 neonatal foals. The mean bias (95% limits of agreement) between CGMS and CHEM, CGMS and POC glucometer, and POC glucometer and CHEM was 3.97 mg/dL (−32.5 to 40.4), 18.2 mg/dL (−28.8 to 65.2), and 22.18 mg/dL (−9.3 to 53.67), respectively. The Pearson's correlation coefficient (r) was significantly correlated among all devices: GCMS and CHEM (r = 0.81), CGMS and POC glucometer (r = 0.77) and POC glucometer‐CHEM (r = 0.92). Conclusions and Clinical Importance Within the blood glucose concentration ranges in this study (78‐212 mg/dL), CGMS measurements were significantly correlated with CHEM, suggesting that it is an acceptable method to provide meaningful, immediate, and continuous glucose concentration measurements in neonatal foals while eliminating the need for repeated restraint and blood collection.
Collapse
Affiliation(s)
- David Wong
- Virginia Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| | - Caitlin Malik
- Virginia Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| | - Katarzyna Dembek
- College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Krista Estell
- Marion duPont Scott Equine Medical Center, Virginia Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| | - Megan Marchitello
- Marion duPont Scott Equine Medical Center, Virginia Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| | - Katie Wilson
- Virginia Maryland College of Veterinary Medicine, Virginia Tech, Blacksburg, Virginia, USA
| |
Collapse
|
13
|
Al-Yousif N, Rawal S, Jurczak M, Mahmud H, Shah FA. Endogenous Glucose Production in Critical Illness. Nutr Clin Pract 2021; 36:344-359. [PMID: 33682953 DOI: 10.1002/ncp.10646] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Regulation of endogenous glucose production (EGP) by hormonal, neuronal, and metabolic signaling pathways contributes to the maintenance of euglycemia under normal physiologic conditions. EGP is defined by the generation of glucose from substrates through glycogenolysis and gluconeogenesis, usually in fasted states, for local and systemic use. Abnormal increases in EGP are noted in patients with diabetes mellitus type 2, and elevated EGP may also impact the pathogenesis of nonalcoholic fatty liver disease and congestive heart failure. In this narrative review, we performed a literature search in PubMed to identify recently published English language articles characterizing EGP in critical illness. Evidence from preclinical and clinical studies demonstrates that critical illness can disrupt EGP through multiple mechanisms including increased systemic inflammation, counterregulatory hormone and catecholamine release, alterations in the hypothalamic-pituitary axis, insulin resistance, lactic acidosis, and iatrogenic insults such as vasopressors and glucocorticoids administered as part of clinical care. EGP contributes to hyperglycemia in critical illness when abnormally elevated and to hypoglycemia when abnormally depressed, each of which has been independently associated with increased mortality. Increased EGP may also promote protein catabolism that could worsen critical illness myopathy and impede recovery. Better understanding of the mechanisms and factors contributing to dysregulated EGP in critical illness may help in the development of therapeutic strategies that promote euglycemia, reduce intensive care unit-associated catabolism, and improve patient outcomes.
Collapse
Affiliation(s)
- Nameer Al-Yousif
- Department of Internal Medicine, UPMC Mercy Hospital, Pittsburgh, Pennsylvania, USA
| | - Sagar Rawal
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael Jurczak
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Hussain Mahmud
- Division of Endocrinology and Metabolism, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Faraaz Ali Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
- VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Acute Lung Injury Center of Excellence, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| |
Collapse
|
14
|
Abstract
PURPOSE OF REVIEW To summarize the advances in literature that support the best current practices regarding glucose control in the critically ill. RECENT FINDINGS There are differences between patients with and without diabetes regarding the relationship of glucose metrics during acute illness to mortality. Among patients with diabetes, an assessment of preadmission glycemia, using measurement of Hemoglobin A1c (HgbA1c) informs the choice of glucose targets. For patients without diabetes and for patients with low HgbA1c levels, increasing mean glycemia during critical illness is independently associated with increasing risk of mortality. For patients with poor preadmission glucose control the appropriate blood glucose target has not yet been established. New metrics, including stress hyperglycemia ratio and glycemic gap, have been developed to describe the relationship between acute and chronic glycemia. SUMMARY A 'personalized' approach to glycemic control in the critically ill, with recognition of preadmission glycemia, is supported by an emerging literature and is suitable for testing in future interventional trials.
Collapse
|
15
|
Srinath R, Mechanick JI. Dietary management of blood glucose in medical critically ill patients with overweight/obesity. Curr Opin Clin Nutr Metab Care 2020; 23:116-120. [PMID: 32004236 DOI: 10.1097/mco.0000000000000636] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE OF REVIEW As the obesity epidemic continues, there is a greater proportion of patients with overweight, obesity, and other forms of adiposity-based chronic disease that require intensive care. Nutrition therapy in the ICU is a vital part of critical care but can be challenging in this setting because of the increased risk of stress hyperglycemia and adverse impact of obesity- and diabetes-related complications. RECENT FINDINGS Current guidelines favor early nutritional therapy with a hypocaloric, high-protein diet in patients with overweight/obesity. More aggressive protein intake may be useful in those with greater severity of overweight/obesity with an upper limit of 3 g/kg ideal body weight per day. Although there is no specific recommendation, choosing enteral formulas with higher fat content and slower digesting carbohydrates may assist with glucose control. Supplementation with immunonutrients is recommended, given their known benefits in obesity and in reducing inflammation, but must be done in an individualized manner. SUMMARY Aggressive nutritional therapy is crucial in patients with overweight/obesity to support ongoing metabolic demands. Although a hypocaloric high-protein feeding strategy is a starting point, nutritional therapy should be approached in an individualized manner taking into account age, weight and BMI, basal metabolism, nutrition status, complications, and comorbidities.
Collapse
Affiliation(s)
| | - Jeffrey I Mechanick
- Divisions of Cardiology and Endocrinology, Diabetes and Bone Disease, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|
16
|
Abstract
PURPOSE OF REVIEW To provide an update of glycemic management during metabolic stress related to surgery or critical illness. RECENT FINDINGS There is a clear association between severe hyperglycemia, hypoglycemia, and high glycemic variability and poor outcomes of postoperative or critically ill patients. However, the impressive beneficial effects of tight glycemic management (TGM) by intensive insulin therapy reported in one study were never reproduced. Hence, the recommendation of TGM is now replaced by more liberal blood glucose (BG) targets (< 180 mg/dL or 10 mM). Recent data support the concept of targeting individualized blood glucose (BG) values according to the presence of diabetes mellitus/chronic hyperglycemia, the presence of brain injury, and the time from injury. A more liberal glycemic management goal is currently advised during metabolic stress and could be switched to individualized glycemic management once validated by prospective trials.
Collapse
Affiliation(s)
- Wasineenart Mongkolpun
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bruna Provenzano
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| |
Collapse
|