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Adigbli D, Li Y, Hammond N, Chatoor R, Devaux AG, Li Q, Billot L, Annane D, Arabi Y, Bilotta F, Bohé J, Brunkhorst FM, Cavalcanti AB, Cook D, Engel C, Green-LaRoche D, He W, Henderson W, Hoedemaekers C, Iapichino G, Kalfon P, de La Rosa G, Lahooti A, Mackenzie I, Mahendran S, Mélot C, Mitchell I, Oksanen T, Polli F, Preiser JC, Garcia Soriano F, Vlok R, Wang L, Xu Y, Delaney AP, Di Tanna GL, Finfer S. A Patient-Level Meta-Analysis of Intensive Glucose Control in Critically Ill Adults. NEJM EVIDENCE 2024; 3:EVIDoa2400082. [PMID: 38864749 DOI: 10.1056/evidoa2400082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2024]
Abstract
BACKGROUND Whether intensive glucose control reduces mortality in critically ill patients remains uncertain. Patient-level meta-analyses can provide more precise estimates of treatment effects than are currently available. METHODS We pooled individual patient data from randomized trials investigating intensive glucose control in critically ill adults. The primary outcome was in-hospital mortality. Secondary outcomes included survival to 90 days and time to live cessation of treatment with vasopressors or inotropes, mechanical ventilation, and newly commenced renal replacement. Severe hypoglycemia was a safety outcome. RESULTS Of 38 eligible trials (n=29,537 participants), 20 (n=14,171 participants) provided individual patient data including in-hospital mortality status for 7059 and 7049 participants allocated to intensive and conventional glucose control, respectively. Of these 1930 (27.3%) and 1891 (26.8%) individuals assigned to intensive and conventional control, respectively, died (risk ratio, 1.02; 95% confidence interval [CI], 0.96 to 1.07; P=0.52; moderate certainty). There was no apparent heterogeneity of treatment effect on in-hospital mortality in any examined subgroups. Intensive glucose control increased the risk of severe hypoglycemia (risk ratio, 3.38; 95% CI, 2.99 to 3.83; P<0.0001). CONCLUSIONS Intensive glucose control was not associated with reduced mortality risk but increased the risk of severe hypoglycemia. We did not identify a subgroup of patients in whom intensive glucose control was beneficial. (Funded by the Australian National Health and Medical Research Council and others; PROSPERO number CRD42021278869.).
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Affiliation(s)
- Derick Adigbli
- Critical Care Division, The George Institute for Global Health, Sydney
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
- Medical School, Faculty of Medical Sciences, University College London, London
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Yang Li
- Critical Care Division, The George Institute for Global Health, Sydney
| | - Naomi Hammond
- Critical Care Division, The George Institute for Global Health, Sydney
- Royal North Shore Hospital, Malcolm Fisher Department of Intensive Care, St Leonards, NSW, Australia
| | - Richard Chatoor
- Royal North Shore Hospital, Malcolm Fisher Department of Intensive Care, St Leonards, NSW, Australia
| | - Anthony G Devaux
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
| | - Qiang Li
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
| | - Laurent Billot
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
| | - Djillali Annane
- Department of Intensive Care, Hôpital Raymond-Poincare, Garches, France
- PROMETHEUS IHU, Université Paris-Saclay, Garches, France
- Laboratory of Infection & Inflammation, School of Medicine Simone Veil Santé, Université Paris-Saclay, Montigny Le Bretonneux, France
- FHU SEPSIS (Saclay and Paris Seine Nord Endeavour to PerSonalize Interventions for Sepsis), Garches, France
| | - Yaseen Arabi
- Intensive Care Medicine, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
| | - Federico Bilotta
- Department of Anesthesiology and Intensive Care Medicine, University of Rome La Sapienza, Rome
| | - Julien Bohé
- Service d'Anesthésie-Réanimation-Médecine Intensive, Hospices Civils de Lyon, Groupement Hospitalier Sud, Lyon, France
| | - Frank Martin Brunkhorst
- Department of Anaesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | | | - Deborah Cook
- Departments of Medicine, Clinical Epidemiology & Biostatistics (Division of Critical Care), McMaster University, Hamilton, ON, Canada
| | - Christoph Engel
- Institute for Medical Informatics, Statistics and Epidemiology, Leipzig University, Leipzig, Germany
| | | | - Wei He
- Department of Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, Beijing
| | - William Henderson
- Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Cornelia Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Gaetano Iapichino
- Anestesiologia e Rianimazione, Università degli Studi di Milano, Milan
| | | | | | - Afsaneh Lahooti
- Critical Care Division, The George Institute for Global Health, Sydney
- School of Science, Western Sydney University, Campbelltown, NSW, Australia
| | | | - Sajeev Mahendran
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, St Leonards, NSW, Australia
| | - Christian Mélot
- Faculté de Médecine, Université Libre de Bruxelles, Brussels
| | - Imogen Mitchell
- Office of Research and Education, Canberra Health Services Library, Canberra, ACT, Australia
- School of Medicine and Psychology, Australian National University, Canberra, ACT, Australia
| | - Tuomas Oksanen
- Division of Intensive Care Medicine, Department of Anesthesiology and Intensive Care, HUS Helsinki University Hospital, Helsinki
| | - Federico Polli
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan
| | | | - Francisco Garcia Soriano
- Departamento de Clínica Médica-Emergências Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo
| | - Ruan Vlok
- Critical Care Division, The George Institute for Global Health, Sydney
- CareFlight Australia, Wentworthville, NSW, Australia
| | - Lingcong Wang
- Department ICU, The First Affiliated Hospital, Zhejiang Chinese Medical University, Hangzhou, China
| | - Yuan Xu
- Department of Critical Care Medicine, School of Clinical Medicine, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing
| | - Anthony P Delaney
- Critical Care Division, The George Institute for Global Health, Sydney
- The George Institute for Global Health, Biostatistics and Data Science Division, Barangaroo, NSW, Australia
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, St Leonards, NSW, Australia
| | - Gian Luca Di Tanna
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
- Department of Clinical Care, University of Bern, Bern, Switzerland
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, Sydney
- Faculty of Medicine and Health, University of New South Wales, Randwick, NSW, Australia
- School of Public Health, Imperial College London, London
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van Veggel KM, Kruithof MK, Roelandse-Koop E, Eekhoff EMW, Nanayakkara PWB. Follow-up of patients with hyperglycemia in the emergency department without a history of diabetes mellitus. Eur J Intern Med 2014; 25:909-13. [PMID: 25468253 DOI: 10.1016/j.ejim.2014.11.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2014] [Revised: 10/30/2014] [Accepted: 11/05/2014] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The aim of this study is to determine the prevalence of hyperglycemia in emergency department patients without a history of diabetes mellitus, and to investigate whether these patients were referred to a general practitioner or to the outpatient clinic for follow-up with further diagnostic testing and treatment. METHODS We conducted a retrospective cohort pilot study of adult patients who were seen at the emergency department of an urban academic hospital in the Netherlands between the 1st of January and the 29th of February 2008, who had an initial (unknown fasting or non-fasting) plasma glucose level ≥ 7.8 mmol/L (140 mg/dL). The medical records of these patients were retrieved to evaluate whether these patients were referred for follow-up. RESULTS During the data collecting period 5317 patients presented at the ED, 343 of these patients were identified with a plasma glucose ≥ 7.8 mmol/L. Using exclusion criteria, eventually 154 patients were included in this study. The prevalence of incidentally found hyperglycemia in emergency department patients without a history of diabetes mellitus in this period was 2.9%. For 98.7% of the hyperglycemic patients no follow-up was arranged by the treating physician. None of the patients was treated with a hypoglycemic agent in the emergency department. CONCLUSION A substantial percentage (2.9%) of our study population had hyperglycemia and thus was at risk for undiagnosed diabetes mellitus and prediabetes. To date, recognition and follow-up of hyperglycemia in emergency department patients is poor. We presume that major health benefits may be achieved when the follow-up of hyperglycemia is performed more frequently.
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Affiliation(s)
- Kristin M van Veggel
- Acute Medicine Section, Department of Internal Medicine, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Maartje K Kruithof
- Department of Emergency Medicine, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Elianne Roelandse-Koop
- Department of Clinical Chemistry, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Elisabeth M W Eekhoff
- Acute Medicine Section, Department of Internal Medicine, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
| | - Prabath W B Nanayakkara
- Acute Medicine Section, Department of Internal Medicine, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands; Department of Emergency Medicine, VU University Medical Centre, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands.
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Zanoni FL, Benabou S, Greco KV, Moreno ACR, Cruz JWMC, Filgueira FP, Martinez MB, Figueiredo LFPD, Silva MRE, Sannomiya P. Mesenteric microcirculatory dysfunctions and translocation of indigenous bacteria in a rat model of strangulated small bowel obstruction. Clinics (Sao Paulo) 2009; 64:911-9. [PMID: 19759886 PMCID: PMC2745135 DOI: 10.1590/s1807-59322009000900013] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2009] [Accepted: 06/11/2009] [Indexed: 01/04/2023] Open
Abstract
PURPOSE Bacterial translocation has been shown to occur in critically ill patients after extensive trauma, shock, sepsis, or thermal injury. The present study investigates mesenteric microcirculatory dysfunctions, the bacterial translocation phenomenon, and hemodynamic/metabolic disturbances in a rat model of intestinal obstruction and ischemia. METHODS Anesthetized (pentobarbital 50 mg/kg, i.p.) male Wistar rats (250-350 g) were submitted to intestinal obstruction or laparotomy without intestinal obstruction (Sham) and were evaluated 24 hours later. Bacterial translocation was assessed by bacterial culture of the mesenteric lymph nodes (MLN), liver, spleen, and blood. Leukocyte-endothelial interactions in the mesenteric microcirculation were assessed by intravital microscopy, and P-selectin and intercellular adhesion molecule (ICAM)-1 expressions were quantified by immunohistochemistry. Hematocrit, blood gases, lactate, glucose, white blood cells, serum urea, creatinine, bilirubin, and hepatic enzymes were measured. RESULTS About 86% of intestinal obstruction rats presented positive cultures for E. coli in samples of the mesenteric lymph nodes, liver, and spleen, and 57% had positive hemocultures. In comparison to the Sham rats, intestinal obstruction induced neutrophilia and increased the number of rolling (approximately 2-fold), adherent (approximately 5-fold), and migrated leukocytes (approximately 11-fold); this increase was accompanied by an increased expression of P-selectin (approximately 2-fold) and intercellular adhesion molecule-1 (approximately 2-fold) in the mesenteric microcirculation. Intestinal obstruction rats exhibited decreased PaCO2, alkalosis, hyperlactatemia, and hyperglycemia, and increased blood potassium, hepatic enzyme activity, serum urea, creatinine, and bilirubin. A high mortality rate was observed after intestinal obstruction (83% at 72 h vs. 0% in Sham rats). CONCLUSION Intestinal obstruction and ischemia in rats is a relevant model for the in vivo study of mesenteric microcirculatory dysfunction and the occurrence of bacterial translocation. This model parallels the events implicated in multiple organ dysfunction (MOD) and death.
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Affiliation(s)
- Fernando Luiz Zanoni
- Heart Institute (InCor), LIM 11, University of São Paulo Medical School, São Paulo/SP, Brazil.
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