The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: a randomized prospective pilot trial

A systematic review and meta-analysis on glycemic control in traumatic brain injury

BACKGROUND

Hyperglycemia is associated with adverse outcomes in patent with traumatic brain injury. There is convincing evidence of the deleterious effects of early systemic hyperglycemia on neurological outcomes and guides management toward intensive glycemic control. The purpose of this systematic review and meta analysis is to evaluate and summarize the level of evidence on the role of glycemic control in traumatic brain injury.

METHODS

A systematic review and meta-analysis were performed following PRISMA guidelines. This review involved studies conducted in humans covering glycemic control in traumatic brain injury. A systematic literature search was performed in PubMed, Embase, EBSCO Host, Scopus, ScienceDirect, Medline, and LILACS from database inception to October 2020. The risk of bias was evaluated with the GRADE quality Scale.

RESULTS

The results of this meta-analysis that involved 1236 patients included in 10 studies suggest that intensive glycemic control did not show significant differences in mortality compared with conservative management (RR 0.99 [95 % CI 0.81-1.21] p = 0.92). Intensive glycemic control reduced the risk of unfavorable clinical outcomes compared to standard management (RR 0.87 [95 % CI 0.78-0.96] p = 0.007) and increased favorable clinical outcomes compared to standard neurocritical care (RR 1.19 [95 % CI 1.02-138] p = 0.003).

CONCLUSIONS

The possible effect of glycemic control could be associated with silent hypoglycemic episodes during intensive care. Further studies evaluating the impact of glycemic control in traumatic brain injury are necessary.

Relationship between stress hyperglycemia ratio and prognosis in patients with aneurysmal subarachnoid hemorrhage: a two-center retrospective study

Previous research have demonstrated that the stress hyperglycemia ratio (SHR) accurately reflects acute hyperglycemic states and correlates with adverse outcomes. This study aims to explore the relationship between SHR and the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH). Patients with aSAH were categorized into four groups based on SHR tertiles. Functional outcomes were evaluated at 12 months using the modified Rankin Scale (mRS), with scores ranging from 0 to 2 indicating a good outcome and 3-6 indicating a poor outcome. The associations between SHR and functional outcomes were analyzed using logistic regression models and restricted cubic spline analysis. A total of 127 patients exhibited poor functional outcomes. Following comprehensive adjustments, those in the highest SHR tertile had a significantly increased risk of poor prognosis compared to those in the lowest tertile (odds ratio [OR], 4.12; 95% confidence interval [CI]: 1.87-9.06). Moreover, each unit increase in SHR was associated with a 7.51-fold increase in the risk of poor prognosis (OR, 7.51; 95% CI: 3.19-17.70). Further analysis using restricted cubic spline confirmed a linear correlation between SHR and poor prognosis (P for nonlinearity = 0.609). Similar patterns were observed across all studied subgroups. Elevated SHR significantly correlates with poor functional prognosis at one year in patients with aSAH, independent of their diabetes status.

The Hawkins Sign of the Talus: The Impact of Patient Factors on Prediction Accuracy

BACKGROUND

Osteonecrosis is a complication of talar neck fractures associated with chronic pain and poor functional outcomes. The Hawkins sign, the radiographic presence of subchondral lucency seen in the talar dome 6 to 8 weeks after trauma, is a strong predictor of preserved talar vascularity. This study sought to assess the accuracy of the Hawkins sign in a contemporary cohort and assess factors associated with inaccuracy.

METHODS

A retrospective review of talar neck fractures at a level-I trauma center from 2008 to 2016 was conducted. Both the Hawkins sign and osteonecrosis were evaluated on radiographs. The Hawkins sign was determined on the basis of radiographs taken approximately 6 to 8 weeks after injury, whereas osteonecrosis was determined based on radiographs taken throughout follow-up. The Hawkins sign accuracy was assessed using proportions with 95% confidence intervals (CIs), and associations were examined with Fisher exact testing.

RESULTS

In total, 105 talar neck fractures were identified. The Hawkins sign was observed in 21 tali, 3 (14% [95% CI, 3% to 36%]) of which later developed osteonecrosis. In the remaining 84 tali without a Hawkins sign, 32 (38% [95% CI, 28% to 49%]) developed osteonecrosis. Of the 3 tali that developed osteonecrosis following observation of the Hawkins sign, all were in patients who smoked.

CONCLUSIONS

A positive Hawkins sign may not be a reliable predictor of preserved talar vascularity in all patients. We identified 3 patients with a positive Hawkins sign who developed osteonecrosis, all of whom were smokers. Factors impairing the restoration of microvascular blood supply to the talus may lead to osteonecrosis despite the presence of preserved macrovascular blood flow and an observed Hawkins sign. Further research is needed to understand the factors limiting Hawkins sign accuracy.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Contemporary management of aneurysmal subarachnoid haemorrhage. An update for the intensivist

Aneurysmal subarachnoid haemorrhage (aSAH) is a rare yet profoundly debilitating condition associated with high global case fatality and morbidity rates. The key determinants of functional outcome include early brain injury, rebleeding of the ruptured aneurysm and delayed cerebral ischaemia. The only effective way to reduce the risk of rebleeding is to secure the ruptured aneurysm quickly. Prompt diagnosis, transfer to specialized centers, and meticulous management in the intensive care unit (ICU) significantly improved the prognosis of aSAH. Recently, multimodality monitoring with specific interventions to correct pathophysiological imbalances has been proposed. Vigilance extends beyond intracranial concerns to encompass systemic respiratory and haemodynamic monitoring, as derangements in these systems can precipitate secondary brain damage. Challenges persist in treating aSAH patients, exacerbated by a paucity of robust clinical evidence, with many interventions showing no benefit when tested in rigorous clinical trials. Given the growing body of literature in this field and the issuance of contemporary guidelines, our objective is to furnish an updated review of essential principles of ICU management for this patient population. Our review will discuss the epidemiology, initial stabilization, treatment strategies, long-term prognostic factors, the identification and management of post-aSAH complications. We aim to offer practical clinical guidance to intensivists, grounded in current evidence and expert clinical experience, while adhering to a concise format.

Our Scientific Journey through the Ups and Downs of Blood Glucose Control in the ICU

This article tells the story of our long search for the answer to one question: Is stress hyperglycemia in critically ill patients adaptive or maladaptive? Our earlier work had suggested the lack of hepatic insulin effect and hyperglycemia as jointly predicting poor outcome. Therefore, we hypothesized that insulin infusion to reach normoglycemia, tight glucose control, improves outcome. In three randomized controlled trials (RCTs), we found morbidity and mortality benefit with tight glucose control. Moving from the bed to the bench, we attributed benefits to the prevention of glucose toxicity in cells taking up glucose in an insulin-independent, glucose concentration gradient-dependent manner, counteracted rather than synergized by insulin. Several subsequent RCTs did not confirm benefit, and the large Normoglycemia in Intensive Care Evaluation-Survival Using Glucose Algorithm Regulation, or "NICE-SUGAR," trial found increased mortality with tight glucose control associated with severe hypoglycemia. Our subsequent clinical and mechanistic research revealed that early use of parenteral nutrition, the context of our initial RCTs, had been a confounder. Early parenteral nutrition (early-PN) aggravated hyperglycemia, suppressed vital cell damage removal, and hampered recovery. Therefore, in our next and largest "TGC-fast" RCT, we retested our hypothesis, without the use of early-PN and with a computer algorithm for tight glucose control that avoided severe hypoglycemia. In this trial, tight glucose control prevented kidney and liver damage, though with much smaller effect sizes than in our initial RCTs without affecting mortality. Our quest ends with the strong recommendation to omit early-PN for patients in the ICU, as this reduces need of blood glucose control and allows cellular housekeeping systems to play evolutionary selected roles in the recovery process. Once again, less is more in critical care.

Factors associated with the time required for CRP normalization in pyogenic spondylitis: A retrospective observational study

Background

Treatment for pyogenic spondylitis tends to be prolonged; however, few studies have examined the factors associated with the time required for infection control. Therefore, we analyzed a consecutive cohort of patients to identify factors associated with the time required to control infection in pyogenic spondylitis. This study aimed to clarify the factors linked to the duration necessary for achieving infection control in cases of pyogenic spondylitis, using C-reactive protein (CRP) normalization as an indicator.

Methods

In this retrospective observational study, we investigated 108 patients diagnosed with pyogenic spondylitis. We evaluated the number of days from the first visit to CRP normalization; for cases wherein CRP did not normalize, the number of days to the date of final blood sampling was evaluated. In the present study, infection control in pyogenic spondylitis was defined as a CRP falling within the normal range (≤0.14 mg/dL). We performed univariate and multivariate Cox regression analyses to identify various factors associated with the time required for CRP normalization in pyogenic spondylitis.

Results

The mean time required for CRP normalization was 148 days. Univariate Cox regression analysis showed that the serum creatinine level, estimated glomerular filtration rate (eGFR), lymphocyte percentage, neutrophil percentage, CRP level, CRP-albumin ratio, and neutrophil-to-lymphocyte ratio were significantly associated with the time required to control infection. Multivariate Cox regression analysis showed that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were the independent factors associated with a longer infection control time.

Conclusions

We found that a higher neutrophil percentage, diabetes mellitus, and a lower eGFR were significantly associated with a longer time for CRP normalization in pyogenic spondylitis. These findings may help identify patients with pyogenic spondylitis who are at a high risk for an extended infection control period.

2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage: A Guideline From the American Heart Association/American Stroke Association

AIM

The "2023 Guideline for the Management of Patients With Aneurysmal Subarachnoid Hemorrhage" replaces the 2012 "Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage." The 2023 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with aneurysmal subarachnoid hemorrhage.

METHODS

A comprehensive search for literature published since the 2012 guideline, derived from research principally involving human subjects, published in English, and indexed in MEDLINE, PubMed, Cochrane Library, and other selected databases relevant to this guideline, was conducted between March 2022 and June 2022. In addition, the guideline writing group reviewed documents on related subject matter previously published by the American Heart Association. Newer studies published between July 2022 and November 2022 that affected recommendation content, Class of Recommendation, or Level of Evidence were included if appropriate. Structure: Aneurysmal subarachnoid hemorrhage is a significant global public health threat and a severely morbid and often deadly condition. The 2023 aneurysmal subarachnoid hemorrhage guideline provides recommendations based on current evidence for the treatment of these patients. The recommendations present an evidence-based approach to preventing, diagnosing, and managing patients with aneurysmal subarachnoid hemorrhage, with the intent to improve quality of care and align with patients' and their families' and caregivers' interests. Many recommendations from the previous aneurysmal subarachnoid hemorrhage guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Clinical relevance of glucose metrics during the early brain injury period after aneurysmal subarachnoid hemorrhage: An opportunity for continuous glucose monitoring

Hyperglycaemia, hypoglycaemia and higher glucose variability during the Early Brain Injury (EBI) period of aneurysmal subarachnoid hemorrhage (aSAH) have been associated with poor clinical outcome. However, it is unclear whether these associations are due to direct glucose-driven injury or if hyperglycaemia simply acts as a marker of initial severity. Actually, strict glucose control with intensive insulin therapy has not been demonstrated as an effective strategy for improving clinical outcomes after aSAH. Currently published studies describing an association between hyperglycaemia and prognosis in aSAH patients have been based on isolated glucose measurements and did not incorporate comprehensive dynamic evaluations, such as those derived from subcutaneous continuous glucose monitoring devices (CMG). Arguably, a more accurate knowledge on glycaemic patterns during the acute phase of aSAH could increase our understanding of the relevance of glycaemia as a prognostic factor in this disease as well as to underpin its contribution to secondary focal and diffuse brain injury. Herein, we have summarized the available evidence on the diagnostic and prognostic relevance of glucose metrics during the acute phase of cerebrovascular diseases, focusing in the EBI period after aSAH. Overall, obtaining a more precise scope of acute longitudinal glucose profiles could eventually be useful for improving glucose management protocols in the setting of acute aSAH and to advance toward a more personalized management of aSAH patients during the EBI phase.

Association between hyperglycemia at admission and mortality in aneurysmal subarachnoid hemorrhage

BACKGROUND

Elevated blood glucose is frequently detected early after aneurysmal subarachnoid hemorrhage (aSAH). We aimed to investigate whether hyperglycemia at admission is associated with mortality in patients with aSAH.

METHODS

In a multicenter observational study of patients with aSAH, we defined normal glycemia, mild hyperglycemia, moderate hyperglycemia, and severe hyperglycemia as blood glucose of 4.00-6.09 mmol/L, 6.10-7.80 mmol/L, 7.81-10.00 mmol/L, and > 10.00 mmol/L, respectively. We performed propensity score matching to obtain the adjusted odds ratios (OR) with 95 % confidence intervals (CI).

RESULTS

Of 6771 patients with aSAH, 511(7.5 %) had died in hospital, and hyperglycemia at admission was observed in 4804 (70.9 %). Propensity scores matching analyses indicated that compared with normal glycemia, the odds of in-hospital mortality were slightly lower in patients with mild hyperglycemia (OR 0.89, 95 % CI 0.56-1.40), significantly higher in patients with moderate hyperglycemia (OR 1.90, 95 % CI 1.20-3.01), and in patients with severe hyperglycemia (OR 3.45, 95 % CI 2.15-5.53; P trend < 0.001). Long-term survival was worse among patients with hyperglycemia and was proportional to its severity. Similar dose-response associations were evident for poor functional outcomes and major disability. Hyperglycemia was associated with an increased risk of hospital-acquired infections (OR 1.46, 95 % CI 1.29-1.66) and rebleeding (OR 1.58, 95 % CI 1.06-2.35).

CONCLUSIONS

Among aSAH patients, hyperglycemia at admission was independently associated with increased mortality. Both moderate hyperglycemia and severe hyperglycemia were associated with an increased risk of mortality, but these associations were not seen in mild hyperglycemia (blood glucose 6.10-7.80 mmol/L).

Glycemic Control Regimens in the Prevention of Surgical Site Infections: A Meta-Analysis of Randomized Clinical Trials

Background

Increased risk of surgical site infections (SSIs) caused by hyperglycemia makes it necessary to follow perioperative glucose lowering strategies to reduce postoperative complications. A meta-analysis was conducted to understand the efficacy of intensive vs. conventional blood glucose lowering regimens on the incidence of SSIs and hypoglycemia from various randomized controlled studies (RCTs).

Materials and Methods

A systematic literature review was conducted using MEDLINE and Central databases for RCTs that involved intensive (lower blood glucose target levels) vs. conventional (higher blood glucose target levels) strategies in patients undergoing various types of surgeries. The primary outcomes were SSIs or postoperative wound infections. Hypoglycemia and mortality outcomes were also studied. A random-effects model was used to calculate the pooled risk ratio (RR), and subgroup analyses were performed.

Results

A total of 29 RCTs were included in the meta-analysis with the information from 14,126 patients. A reduction in overall incidence of SSIs was found (RR 0.63, 0.50-0.80, p = 0.0002, I 2= 56%). Subgroup analyses showed that intensive insulin regimens decreased the risk of SSIs in patients with diabetes, in cardiac and abdominal surgical procedures, and during the intraoperative and postoperative phases of surgery. However, the risk of hypoglycemia and mortality was increased in the intensive group compared to the conventional group.

Conclusion

The results of the meta-analysis provide support for the use of intensive insulin regimens during the perioperative phase for decreasing the incidence of SSIs in certain patient populations and surgical categories.

Optimal Glucose Target After Aneurysmal Subarachnoid Hemorrhage: A Matched Cohort Study

BACKGROUND

Hyperglycemia has been associated with poor outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). However, there remains debate as to what optimal glucose targets should be in this patient population.

OBJECTIVE

To assess whether we could identify an optimal glucose target for patients with aSAH.

METHODS

We performed a post hoc analysis of the "clazosentan to overcome neurological ischemia and infarction occurring after subarachnoid hemorrhage" trial data set. Patients had laboratory results drawn daily for the entirety of their intensive care unit stay. Maximum blood glucose levels were assessed for a relationship with unfavorable outcomes using multiple logistic regression analysis. Maximum blood glucose levels were dichotomized based on the Youden index, which identified a maximum level of <9.2 mmol/L as the optimal cut point for prediction of unfavorable outcomes. Nearest neighbor matching was used to assess the relationship between maintaining glucose levels below the cut point and unfavorable functional outcomes (defined as a modified Rankin score of >2 at 3 mo post-aSAH). The matching was performed after calculation of a propensity score based on identified predictors of outcome and glucose levels.

RESULTS

Three hundred eighty-nine patients were included in the matched analysis. Propensity scores were balanced on both the covariates and outcomes of interest. There was a significant average treatment effect (-0.143: 95% confidence interval -0.267 to -0.019) for patients who maintained glucose levels <9.2 mmol/L.

CONCLUSION

Maintaining glucose levels below the identified cut point was associated with a decreased risk for unfavorable outcomes in this retrospective matched study.

Establishment and validation of prognosis model for patients with cerebral contusion

Background And Objective

Cerebral Contusion (CC) is one of the most serious injury types in patients with traumatic brain injury (TBI). In this study, the baseline data, imaging features and laboratory examinations of patients with CC were summarized and analyzed to develop and validate a prediction model of nomogram to evaluate the clinical outcomes of patients.

Methods

A total of 426 patients with cerebral contusion (CC) admitted to the People’s Hospital of Qinghai Province and Affiliated Hospital of Qingdao University from January 2018 to January 2021 were included in this study, We randomly divided the cohort into a training cohort (n = 284) and a validation cohort (n = 142) with a ratio of 2:1.At Least absolute shrinkage and selection operator (Lasso) regression were used for screening high-risk factors affecting patient prognosis and development of the predictive model. The identification ability and clinical application value of the prediction model were analyzed through the analysis of receiver operating characteristic curve (ROC), calibration curve, and decision curve analysis (DCA).

Results

Twelve independent prognostic factors, including age, Glasgow Coma Score (GCS), Basal cistern status, Midline shift (MLS), Third ventricle status, intracranial pressure (ICP) and CT grade of cerebral edema,etc., were selected by Lasso regression analysis and included in the nomogram. The model showed good predictive performance, with a C index of (0.87, 95% CI, 0.026–0.952) in the training cohort and (0.93, 95% CI, 0.032–0.965) in the validation cohort. Clinical decision curve analysis (DCA) also showed that the model brought high clinical benefits to patients.

Conclusion

This study established a high accuracy of nomogram model to predict the prognosis of patients with CC, its low cost, easy to promote, is especially applicable in the acute environment, at the same time, CSF-glucose/lactate ratio(C-G/L), volume of contusion, and mean CT values of edema zone, which were included for the first time in this study, were independent predictors of poor prognosis in patients with CC. However, this model still has some limitations and deficiencies, which require large sample and multi-center prospective studies to verify and improve our results.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12883-021-02482-4.

Admission Hyperglycemia Predicts Long-Term Mortality in Critically Ill Patients With Subarachnoid Hemorrhage: A Retrospective Analysis of the MIMIC-III Database

Subarachnoid hemorrhage (SAH) is a severe subtype of stroke with high mortality. Hyperglycemia is a common phenomenon in critically ill patients and associated with poor clinical outcome. However, the predictive value of admission hyperglycemia for 30 and 90-day all-cause mortality in critically ill patients with SAH remains controversial. All SAH patients between 2001 and 2012 were included based on the MIMIC-III database and were further classified according to the tertiles of blood glucose (BG) measured on intensive care unit (ICU) admission. Clinical information including demographic data, comorbidities, and laboratory indicators were exacted and analyzed. The primary outcomes were 30- and 90-day all-cause mortality. A total of 1,298 SAH patients were included. The 30 and 90-day mortality rates were 19.80% and 22.73%, respectively. Subjects in the high glucose tertile were older, were overweight, had higher sequential organ failure assessment (SOFA) and Simplified Acute Physiology Score II (SAPS II) scores, and presented higher mortality rate. Generalized additive model revealed a U-shaped relationship between BG and 30 and 90-day all-cause mortality. Furthermore, Kaplan-Meier (K-M) survival curve also illustrated that subjects with admission hyperglycemia presented lower survival rate and shorter survival time. In Cox analysis, after adjustment for potential confounders, admission hyperglycemia was related to an increase in 30- and 90-day all-cause mortality in SAH patients. In subgroup analysis, the association between admission hyperglycemia and all-cause mortality was consistent. In conclusion, admission hyperglycemia is associated with significantly increased 30- and 90-day all-cause mortality in critically ill patients with SAH.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members.As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Association of Plasma Glucose to Potassium Ratio and Mortality After Aneurysmal Subarachnoid Hemorrhage

Objectives: Hyperglycemia and hypokalemia are common problems in patients with aneurysmal subarachnoid hemorrhage (aSAH). The aim of this study was to determine whether the plasma glucose to potassium ratio (GPR) predicts mortality due to aSAH. Methods: We prospectively recruited aSAH patients and healthy controls between March 2007 and May 2017. Clinical outcomes included mortality and poor outcome (modified Rankin scale score of 3-6) after 3 months. Multivariable analysis was used to determine the association between plasma GPR and 3-month mortality in aSAH patients. Results: A total of 553 patients were recruited, and the mortality rate was 11%. The GPR was significantly elevated in aSAH patients compared with controls, in patients with a poor outcome than with a good outcome and in non-survivals than in survivals. Multivariable analysis showed that the plasma GPR was an independent factor associated with 3-month mortality. The area under the curve of the GPR was 0.747 in predicting 3-month mortality. Conclusion: The plasma GPR on admission has potential as a predictor of 3-month mortality in patients with aSAH.

Relationship Between Glycosylated Hemoglobin and Short-Term Mortality of Spontaneous Intracerebral Hemorrhage

Background: The relationship between glycosylated hemoglobin (HbA1c) and prognosis of spontaneous intracerebral hemorrhage (SICH) patients has not been fully elucidated. This study aimed to reveal the relationship between HbA1c levels and short-term mortality after patient admission with SICH. Methods: It was a large-scale, multicenter, cross-sectional study. From August 1, 2015, to July 31, 2019, a total of 41910 SICH patients were included in the study from the Chinese Stroke Center Alliance (CSCA) program. Finally, we comprehensively analyzed the data from 21,116 patients with SICH. HbA1c was categorized into four groups by quartile. Univariate and multivariate logistic regression analyses were used to assess the association between HbA1c levels and short-term mortality in SICH patients. Results: The average age of the 21,116 patients was 62.8 ± 13.2 years; 13,052 (61.8%) of them were male, and 507 (2.4%) of them died. Compared to the higher three quartiles of HbA1c, the lowest quartile (≤5.10%) had higher short-term mortality. In subgroup analysis with or without diabetes mellitus (DM) patients, the mortality of the Q3 group at 5.60-6.10% was significantly lower than that of the Q1 group at ≤5.10%. After adjustment for potential influencing factors, the ROC curve of HbA1c can better predict the short-term mortality of patients with SICH (AUC = 0.6286 P < 0.001). Conclusions: Therefore, we concluded that low or extremely low HbA1c levels (≤5.10%) after stroke were associated with higher short-term mortality in SICH patients, with or without DM.

Glycemic Gap Predicts in-Hospital Mortality in Diabetic Patients with Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

The relationship between admission hyperglycemia and intracerebral hemorrhage (ICH) outcome remains controversial. Glycemic gap (GG) is a superior indicator of glucose homeostatic response to physical stress compared to admission glucose levels. We aimed to evaluate the association between GG and in-hospital mortality in ICH.

METHODS

We retrospectively identified consecutive patients hospitalized for spontaneous ICH at the 2 healthcare systems in the Twin Cities area, MN, between January 2008 and December 2017. Patients without glycosylated hemoglobin (HbA1c) test or those admitted beyond 24 hours post-ICH were excluded. Demographics, medical history, admission tests, and computed tomography data were recorded. GG was computed using admission glucose level minus HbA1c-derived average glucose. The association between GG and time to in-hospital mortality was evaluated by Cox regression analysis. Receiver operating characteristic (ROC) analysis with the DeLong test was used to evaluate the ability of GG to predict in-hospital death.

RESULTS

Among 345 included subjects, 63 (25.7%) died during the hospital stay. Compared with survivors, non-survivors presented with a lower Glasgow coma scale score, larger hematoma volume, and higher white blood cells count, glucose, and GG levels at admission (p<0.001). GG remained an independent predictor of in-hospital mortality after adjusting for known ICH outcome predictors and potential confounders [adjusted hazard ratio: 1.09, 95% confidence interval (CI): 1.02-1.18, p = 0.018]. GG showed a good discriminative power (area under the ROC curve: 0.75, 95% CI: 0.68-0.82) in predicting in-hospital death and performed better than admission glucose levels in diabetic patients (p = 0.030 for DeLong test).

CONCLUSIONS

Admission GG is associated with the risk of in-hospital mortality and can potentially represent a useful prognostic biomarker for ICH patients with diabetes.

Glycemic indices predict outcomes after aneurysmal subarachnoid hemorrhage: a retrospective single center comparative analysis

Although hyperglycemia is associated with worse outcomes after aneurysmal subarachnoid hemorrhage (aSAH), there is no consensus on the optimal glucose control metric, acceptable in-hospital glucose ranges, or suitable insulin regimens in this population. In this single-center retrospective cohort study of aSAH patients, admission glucose, and hospital glucose mean (MHG), minimum (MinG), maximum (MaxG), and variability were compared. Primary endpoints (mortality, complications, and vasospasm) were assessed using multivariate logistic regressions. Of the 217 patients included, complications occurred in 83 (38.2%), 124 (57.1%) had vasospasm, and 41 (18.9%) died. MHG was independently associated with (p < 0.001) mortality, MaxG (p = 0.017) with complications, and lower MinG (p = 0.015) with vasospasm. Patients with MHG ≥ 140 mg/dL had 10 × increased odds of death [odds ratio (OR) = 10.3; 95% CI 4.6–21.5; p < 0.0001] while those with MinG ≤ 90 mg/dL had nearly 2× increased odds of vasospasm (OR = 1.8; 95% CI 1.01–3.21; p = 0.0422). While inpatient insulin was associated with increased complications and provided no mortality benefit, among those with MHG ≥ 140 mg/dL insulin therapy resulted in lower mortality (OR = 0.3; 95% CI 0.1–0.9; p = 0.0358), but no increased complication risk. While elevated MHG and MaxG are highly associated with poorer outcomes after aSAH, lower MinG is associated with increased vasospasm risk. Future trials should consider initiating insulin therapy based on MHG rather than other hyperglycemia measures.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020)

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2020 (J-SSCG 2020), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created as revised from J-SSCG 2016 jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in September 2020 and published in February 2021. An English-language version of these guidelines was created based on the contents of the original Japanese-language version. The purpose of this guideline is to assist medical staff in making appropriate decisions to improve the prognosis of patients undergoing treatment for sepsis and septic shock. We aimed to provide high-quality guidelines that are easy to use and understand for specialists, general clinicians, and multidisciplinary medical professionals. J-SSCG 2016 took up new subjects that were not present in SSCG 2016 (e.g., ICU-acquired weakness [ICU-AW], post-intensive care syndrome [PICS], and body temperature management). The J-SSCG 2020 covered a total of 22 areas with four additional new areas (patient- and family-centered care, sepsis treatment system, neuro-intensive treatment, and stress ulcers). A total of 118 important clinical issues (clinical questions, CQs) were extracted regardless of the presence or absence of evidence. These CQs also include those that have been given particular focus within Japan. This is a large-scale guideline covering multiple fields; thus, in addition to the 25 committee members, we had the participation and support of a total of 226 members who are professionals (physicians, nurses, physiotherapists, clinical engineers, and pharmacists) and medical workers with a history of sepsis or critical illness. The GRADE method was adopted for making recommendations, and the modified Delphi method was used to determine recommendations by voting from all committee members. As a result, 79 GRADE-based recommendations, 5 Good Practice Statements (GPS), 18 expert consensuses, 27 answers to background questions (BQs), and summaries of definitions and diagnosis of sepsis were created as responses to 118 CQs. We also incorporated visual information for each CQ according to the time course of treatment, and we will also distribute this as an app. The J-SSCG 2020 is expected to be widely used as a useful bedside guideline in the field of sepsis treatment both in Japan and overseas involving multiple disciplines.

Aneurysmal Subarachnoid Hemorrhage: the Last Decade

Aneurysmal subarachnoid hemorrhage (SAH) affects six to nine people per 100,000 per year, has a 35% mortality, and leaves many with lasting disabilities, often related to cognitive dysfunction. Clinical decision rules and more sensitive computed tomography (CT) have made the diagnosis of SAH easier, but physicians must maintain a high index of suspicion. The management of these patients is based on a limited number of randomized clinical trials (RCTs). Early repair of the ruptured aneurysm by endovascular coiling or neurosurgical clipping is essential, and coiling is superior to clipping in cases amenable to both treatments. Aneurysm repair prevents rebleeding, leaving the most important prognostic factors for outcome early brain injury from the hemorrhage, which is reflected in the neurologic condition of the patient, and delayed cerebral ischemia (DCI). Observational studies suggest outcomes are better when patients are managed in specialized neurologic intensive care units with inter- or multidisciplinary clinical groups. Medical management aims to minimize early brain injury, cerebral edema, hydrocephalus, increased intracranial pressure (ICP), and medical complications. Management then focuses on preventing, detecting, and treating DCI. Nimodipine is the only pharmacologic treatment that is approved for SAH in most countries, as no other intervention has demonstrated efficacy. In fact, much of SAH management is derived from studies in other patient populations. Therefore, further study of complications, including DCI and other medical complications, is needed to optimize outcomes for this fragile patient population.

Perioperative Management of Aneurysmal Subarachnoid Hemorrhage

Aneurysmal subarachnoid hemorrhage is an acute neurologic emergency. Prompt definitive treatment of the aneurysm by craniotomy and clipping or endovascular intervention with coils and/or stents is needed to prevent rebleeding. Extracranial manifestations of aneurysmal subarachnoid hemorrhage include cardiac dysfunction, neurogenic pulmonary edema, fluid and electrolyte imbalances, and hyperglycemia. Data on the impact of anesthesia on long-term neurologic outcomes of aneurysmal subarachnoid hemorrhage do not exist. Perioperative management should therefore focus on optimizing systemic physiology, facilitating timely definitive treatment, and selecting an anesthetic technique based on patient characteristics, severity of aneurysmal subarachnoid hemorrhage, and the planned intervention and monitoring. Anesthesiologists should be familiar with evoked potential monitoring, electroencephalographic burst suppression, temporary clipping, management of external ventricular drains, adenosine-induced cardiac standstill, and rapid ventricular pacing to effectively care for these patients.

Bibliometric Analysis of the Top 100 Most Cited Articles on Cerebral Vasospasm

OBJECTIVE

Bibliometric analysis reflects the scientific recognition and influential performance of a published article within its field. Our aim is to identify and analyze the top 100 most-cited articles on cerebral vasospasm.

METHODS

A title-specific search was carried out using the Scopus database. The top 100 cited articles including the keywords "Cerebral Vasospasm" AND "Vasospasm" were retrieved and stratified in a descending order: title, authors, institution, publishing journal, country of origin, year of publication, and topic of each article were studied.

RESULTS

The top 100 articles have an accumulative citation count of 20,972, with 209 average citations per article. Publication dates ranged from 1968 to 2012, with the most productive years between 1998 and 2005. Clinical studies are the most frequent category, followed by pathophysiology. The list includes 7 clinical trials, which received accumulative citations of 1525. The top cited article had received 2109 citations, with 52.7 citations per year. The top 100 articles were published across 14 countries, with most originating from the United States. The lead research institution was the University of Alberta. The most used journal was Journal of Neurosurgery.

CONCLUSIONS

Bibliometric analysis has garnered major interest in recent years. It shows the publication trends, knowledge evolution, and evidence-based practice throughout the years. The collection of highly cited articles may assist physicians in gaining a better understanding of the nature of cerebral vasospasm and optimize their clinical practice.

Association of systemic secondary brain insults and outcome in patients with convulsive status epilepticus: A post hoc study of a randomized controlled trial

OBJECTIVE

To evaluate the association between systemic factors (mean arterial blood pressure, arterial partial pressures of carbon dioxide and oxygen, body temperature, natremia, and glycemia) on day 1 and neurologic outcomes 90 days after convulsive status epilepticus.

METHODS

This was a post hoc analysis of the Evaluation of Therapeutic Hypothermia in Convulsive Status Epilepticus in Adults in Intensive Care (HYBERNATUS) multicenter open-label controlled trial, which randomized 270 critically ill patients with convulsive status epilepticus requiring mechanical ventilation to therapeutic hypothermia (32°C-34°C for 24 hours) plus standard care or standard care alone between March 2011 and January 2015. The primary endpoint was a Glasgow Outcome Scale score of 5, defining a favorable outcome, 90 days after convulsive status epilepticus.

RESULTS

The 172 men and 93 women had a median age of 57 years (45-68 years). Among them, 130 (49%) had a history of epilepsy, and 59 (29%) had a primary brain insult. Convulsive status epilepticus was refractory in 86 (32%) patients, and total seizure duration was 67 minutes (35-120 minutes). The 90-day outcome was unfavorable in 126 (48%) patients. In multivariate analysis, none of the systemic secondary brain insults were associated with outcome; achieving an unfavorable outcome was associated with age >65 years (odds ratio [OR] 2.17, 95% confidence interval [CI] 1.20-3.85; p = 0.01), refractory convulsive status epilepticus (OR 2.00, 95% CI 1.04-3.85; p = 0.04), primary brain insult (OR 2.00, 95% CI 1.02-4.00; p = 0.047), and no bystander-witnessed seizure onset (OR 2.49, 95% CI 1.05-5.59; p = 0.04).

CONCLUSIONS

In our population, systemic secondary brain insults were not associated with outcome in critically ill patients with convulsive status epilepticus.

CLINICALTRIALSGOV IDENTIFIER

NCT01359332.

Impact of hyperglycemia on neuronal apoptosis after subarachnoid hemorrhage in rodent brain: An experimental research

BACKGROUND

Hyperglycemia, a derangement after subarachnoid hemorrhage (SAH), is known to be associated with unfavorable outcomes. Whether the connection between hyperglycemia and poor prognosis results from severe neuronal apoptosis is unknown, and we aim at investigating their relationship.

MATERIAL AND METHODS

Streptozotocin (STZ) was administrated to trigger hyperglycemia before SAH induction in Sprague-Dawley rats that were assigned to one of four groups: control, SAH only, hyperglycemia only, and SAH with hyperglycemia. The severity of neuronal apoptosis was analyzed by terminal deoxynucleotidyl transferase-mediated dUTP nickend labelling (TUNEL) staining of cerebral cortex.

RESULTS

When subjected to SAH, hyperglycemic animals had worse neurobehavioral functions than normoglycemic ones. Hyperglycemia-exacerbated apoptosis was evident by greater increases in cleaved caspase-3 expression and TUNEL-positive cell density in the SAH with hyperglycemia group than those in the SAH only group, whereas there was no significant difference in cleaved caspase-9 expression and Bax/Bcl-2 ratio between the two groups. Furthermore, there was a remarkable decrease in the ratio of phosphorylated extracellular regulated kinase (ERK)/total ERK in the hyperglycemic rats after SAH.

CONCLUSION

Hyperglycemia aggravated neuronal apoptosis after SAH and was associated with impaired neurological outcomes. Activation of the extrinsic caspase cascade through the ERK signal pathway may contribute to hyperglycemia-mediated apoptosis.

Characterization of tracheotomized patients after spontaneous subarachnoid hemorrhage

Spontaneous subarachnoid hemorrhage (SAH) is a catastrophic event with high disability and fatality rates. Post-SAH survivors may require prolonged intubation with the assistance of mechanical ventilators, and some patients will undergo tracheostomy to facilitate their pulmonary hygiene and airway protection. The aim of this study is to identify the incidence and risk factors of the need for tracheostomy after spontaneous SAH. We used a retrospective approach and enrolled 838 adult patients with a primary diagnosis of spontaneous SAH who survived >7 days after hospitalization. Medical information was retrieved from the administrative database utilizing diagnostic and procedure codes by the International Classification of Diseases, Ninth Revision, Clinical Modification. Patients with first-ever SAH included 329 men and 509 women, and their average age was 56.9 ± 14.4 years, ranging between 18 and 91 years. Fifty-eight of these 838 patients underwent tracheostomy procedures, and the overall incidence was 6.9%. In a multivariate logistic regression model, the independent risk factors of the need for tracheostomy were underlying diabetes mellitus (P = .02), hydrocephalus (P < .01), and pneumonia (P < .01). The mean duration of hospital stay was 26.0 ± 15.3 and 16.8 ± 12.2 days for patients with and without a tracheostomy, respectively (P < .01). In conclusion, a significant percentage of post-SAH survivors underwent tracheostomy during acute hospitalization. Attention to independent risk factors, including preexisting diabetes mellitus, concomitant hydrocephalus, and nosocomial pneumonia, is essential for timely patient selection for tracheostomy.

Is intensive glucose control bad for critically ill patients? A systematic review and meta-analysis

Background: The monitoring and management of blood glucose concentration are standard practices in critical settings as hyperglycaemia has been shown close association with poorer outcomes. Several meta-analyses have revealed that intensive glucose control has no benefit in decreasing short-term mortality among critically ill patients, while the studies these meta-analyses have incorporated have been largely divergent. We aim to perform a more comprehensive meta-analysis addressing this problem to provide stronger evidence. Methods: We conducted comprehensive searches for relevant randomized controlled studies in online databases, including the Cochrane Library, EMBASE, and PubMed databases, up to September 1, 2018. The clinical data, which included all-cause mortality, severe hypoglycemia, need for RRT, infection resulting in sepsis, ICU mortality, 90-day mortality, 180-day mortality, and hospital and ICU lengths of stay, were screened and analyzed after data extraction. We applied odds ratios (ORs) to analyze dichotomous outcomes and mean differences for continuous outcomes with a random effects model. Results: A total of 57 RCTs involving a total of 21840 patients were finally included. Patients admitted to the ICU who underwent intensive glucose control showed significantly reduced all-cause mortality (OR: 0.89; 95% CI: 0.80-1.00; P=0.04; I2=32%), reduced infection rate (OR: 0.65, 95% CI: 0.51-0.82, P=0.0002; I2=47%), a lower occurrence of acquired sepsis (OR: 0.80, 95% CI: 0.65-0.99, P=0.04; I2=0%) and shortened length of ICU stay (MD: -0.70, 95% CI: -1.21--0.19, P=0.007, I2=70%) when compared to the same parameters as those treated with the usual care strategy. However, patients in the intensive glucose control group presented with a significantly higher risk of severe hypoglycemia (OR: 5.63, 95% CI: 4.02-7.87, P<0.00001; I2=67%). Conclusions: Critically ill patients undergoing intensive glucose control showed significantly reduced all-cause mortality, length of ICU stay and incidence of acquired infection and sepsis compared to the same parameters in patients treated with the usual care strategy, while the intensive glucose control strategy was associated with higher occurrence of severe hypoglycemic events.

Updates in Glycemic Management in the Hospital

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.

The use of GLP-1 receptor agonists in hospitalised patients: An untapped potential

In the outpatient setting, glucagon-like peptide-1 (GLP-1) receptor agonists have proved to be highly efficacious drugs that provide glycaemic control with a low risk of hypoglycaemia. These characteristics make GLP-1 receptor agonists attractive agents to treat dysglycaemia in perioperative or high-dependency hospital settings, where glycaemic variability and hyperglycaemia are associated with poor prognosis. GLP-1 also has a direct action on the myocardium and vasculature-which may be advantageous in the immediate aftermath of a vascular insult. This is a narrative review of the work in this area. The aim was to determine the populations of hospitalised patients being evaluated and the clinical and mechanistic end-points tested, with the institution of GLP-1 therapy in hospital. We searched the PubMed, Embase, and Google scholar databases, combining the term "glucagon-like peptide 1" OR "GLP-1" OR "incretin" OR "liraglutide" OR "exenatide" OR "lixisenatide" OR "dulaglutide" OR "albiglutide" AND "inpatient" OR "hospital" OR "perioperative" OR "postoperative" OR "surgery" OR "myocardial infarction" OR "stroke" OR "cerebrovascular disease" OR "transient ischaemic attack" OR "ICU" OR "critical care" OR "critical illness" OR "CCU" OR "coronary care unit." Pilot studies were reported in the fields of acute stroke, cardiac resuscitation, coronary care, and perioperative care that showed advantages for GLP-1 therapy, with normalisation of glucose, lower glucose variability, and lower risk of hypoglycaemia. Animal and human studies have reported improvements in myocardial performance when given acutely after vascular insult or surgery, but these have yet to be translated into randomised clinical trials.

Diabetes, dysglycemia, and vascular surgery

BACKGROUND

Abnormalities in glucose metabolism are common in patients with arterial disease. Chronic hyperglycemia and insulin resistance contribute to the complexity of vascular disorders. They also overlap with the effects of perioperative hyperglycemia on adverse perioperative outcomes. We provide an overview of the pathophysiologic consequences of dysglycemia and the evidence behind glycemic control in patients undergoing vascular surgery.

METHODS

We searched the literature for major studies evaluating the pathophysiology of hyperglycemia in microvascular and macrovascular beds, randomized trials in perioperative populations, and meta-analyses. The literature was summarized to guide therapy in the population of vascular patients and for the perioperative period.

RESULTS

National standards for glycemic control after vascular interventions were not identified. Mounting evidence exists for the long-term consequences of poor glycemic control on the progression of vascular disease. Similarly, there is a large body of evidence supporting tight control of hyperglycemia after general and cardiac surgery during the critical perioperative period. The absolute glucose target remains controversial. Randomized controlled studies are lacking in vascular surgery patients, but the current evidence can be extrapolated to guide management after vascular interventions. Glycated hemoglobin is a biomarker for increased mortality and vascular morbidity after vascular surgery.

CONCLUSIONS

Hyperglycemia contributes to poor outcome in the vascular patient. Further vascular focused studies are required to determine the proper perioperative serum glucose target and the long-term glycated hemoglobin range.

Glucose control in the ICU

PURPOSE OF REVIEW

Critically ill patients usually develop hyperglycemia, which is associated with adverse outcome. Controversy exists whether the relationship is causal or not. This review summarizes recent evidence regarding glucose control in the ICU.

RECENT FINDINGS

Despite promising effects of tight glucose control in pioneer randomized controlled trials, the benefit has not been confirmed in subsequent multicenter studies and one trial found potential harm. This discrepancy could be explained by methodological differences between the trials rather than by a different case mix. Strategies to improve the efficacy and safety of tight glucose control have been developed, including the use of computerized treatment algorithms.

SUMMARY

The ideal blood glucose target remains unclear and may depend on the context. As compared with tolerating severe hyperglycemia, tight glucose control is well tolerated and effective in patients receiving early parenteral nutrition when provided with a protocol that includes frequent, accurate glucose measurements and avoids large glucose fluctuations. All patient subgroups potentially benefit, with the possible exception of patients with poorly controlled diabetes, who may need less aggressive glucose control. It remains unclear whether tight glucose control is beneficial or not in the absence of early parenteral nutrition.

Association of Admission Serum Glucose-Phosphate Ratio with Severity and Prognosis of Aneurysmal Subarachnoid Hemorrhage

BACKGROUND AND PURPOSE

Serum hyperglycemia and hypophosphatemia have been reported to be common in patients with aneurysmal subarachnoid hemorrhage (aSAH). This study aimed to explore whether admission serum glucose-phosphate ratio was associated with the severity and prognosis of aSAH.

METHODS

We retrospectively analyzed 198 patients with aSAH who were admitted within 24 hours of hemorrhage to a single academic hospital from June 2016 to September 2017. The following determinations were recorded: aSAH severity on admission, assessment by the World Federation of Neurosurgical Societies grading scale (WFNS), Fisher score defined according to the computed tomography results, and 3-month outcome assessed by the Glasgow Outcome Scale. A statistical analysis of the clinical and laboratory risk factors of poor outcome was conducted.

RESULTS

Admission serum glucose-phosphate ratio was increased in a WFNS grade-dependent manner and was higher in patients who had a poor outcome than in those who had a good outcome 3 months after aSAH. Multiple binomial logistic regression analysis showed that serum glucose-phosphate ratio, along with age, WFNS grade, and intraventricular hemorrhage, was associated with 3-month poor outcome after aSAH when we controlled for Fisher score, acute hydrocephalus, delayed cerebral ischemia, symptomatic cerebral vasospasm, serum glucose and phosphate levels, and glucose-potassium ratio. Receiver operating characteristic analysis showed that the area under the curve for glucose-phosphate ratio was significantly higher than age and intraventricular hemorrhage.

CONCLUSIONS

The study shows that the glucose-phosphate ratio is a potential biomarker that can reflect disease severity and prognosis in aSAH patients.

Influence of Admission Blood Glucose in Predicting Outcome in Patients With Spontaneous Intracerebral Hematoma

Background and Aims: Hyperglycemia or elevated blood glucose levels have been associated with poor outcomes in patients with ischemic stroke yet control of hyperglycemia has not resulted in good outcomes. High admission blood glucose (ABG) values have been mitigated by other poor prognosticators like large hematoma volume, intraventricular extension (IVE) of hematoma and poor GCS. The aim of this study was to evaluate the effects of blood glucose levels at admission, on mortality and functional outcomes at discharge and 3 months follow up. Methods: This was a retrospective observational study conducted at a tertiary care. Patients with spontaneous SICH were enrolled from a prospective SICH register maintained at our hospital. Blood glucose values were recorded on admission. Patients with traumatic hematomas, vascular malformations, aneurysms, and coagulation abnormalities were excluded from our study. Results: A total of 510 patients were included in the study. We dichotomised our cohort into two groups, group A with ABG>160 mg/dl and group B with ABG<160 mg/dl. Mean blood glucose levels in these two groups were 220.73 mg/dl and 124.37 mg/dl respectively, with group A having twice the mortality. mRS at discharge and 3 months was better in Group B (p ≤ 0.001) as compared to Group A. Age, GCS, volume of hematoma, ABG, IVE and Hydrocephalus were significant predictors of mortality and poor outcome on univariate analysis with a p < 0.05. The relationship between ABG and mortality (P = 0.249, 95% CI 0.948-1.006) and outcome (P = 0.538, 95% CI 0.997-1.005) failed to reach statistical significance on multivariate logistic regression. Age, Volume of hematoma and GCS were stronger predictors of mortality and morbidity. Conclusion: Admission blood glucose levels was not an independent predictor of mortality in our study when adjusted with age, GCS, and hematoma volume. The effect of high ABG on SICH outcome is probably multifactorial and warrants further research.

Therapeutic effect of intensive glycemic control therapy in patients with traumatic brain injury: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Hyperglycemia is associated with dismal outcomes in patients with traumatic brain injury (TBI), which is frequently treated with insulin therapy. In this study, a systematic review and meta-analysis of the published randomized controlled trials (RCTs) was performed to assess the safety and efficacy of intensive glycemic control (IGC) versus conventional glycemic control (CGC) for patients following TBI.

METHODS

Databases, including PubMed, Embase, and the Cochran database, were retrieved up to January 2018. The outcomes evaluated in this study included mortality, neurological outcome, infection rate, hypoglycemia episode, and length of stay (LOS) in intensive care unit (ICU). The enrolled trials were analyzed using the Review Manager 5.3 software.

RESULTS

A total of 7 randomized controlled trials (RCTs) involving 1013 cases were enrolled in this study, and the results indicated no significant difference in 6-month mortality (risk ratio [RR], 0.92; 95% confidence interval [CI] 0.76-1.10; P = .34). Subsequently, IGC was associated with a better neurological outcome (RR, 1.22; 95% CI 1.05-1.43; P = .01), lower infection rate (RR, 0.65; 95% CI 0.51-0.82; P = .0003) and shorter LOS in ICU (mean difference [MD] = -1.37; 95%CI = -2.11, -0.63; P = .0003). In addition, IGC would also increase the risk of hypoglycemia episode (RR, 4.53; 95% CI 2.18-9.42; P < .001).

CONCLUSIONS

IGC plays a protective role in improving neurological outcome, decreasing infection rate and reducing the LOS in ICU. However, IGC therapy can also remarkably increase the risk of hypoglycemia, but it will not affect the mortality in TBI patients.

Postoperative tight glycemic control significantly reduces postoperative infection rates in patients undergoing surgery: a meta-analysis

BACKGROUND

The benefit results of postoperative tight glycemic control (TGC) were controversial and there was a lack of well-powered studies that support current guideline recommendations.

METHODS

The EMBASE, MEDLINE, and the Cochrane Library databases were searched utilizing the key words "Blood Glucose", "insulin" and "Postoperative Period" to retrieve all randomized controlled trials evaluating the benefits of postoperative TGC as compared to conventional glycemic control (CGC) in patients undergoing surgery.

RESULTS

Fifteen studies involving 5053 patients were identified. As compared to CGC group, there were lower risks of total postoperative infection (9.4% vs. 15.8%; RR 0.586, 95% CI 0.504 to 0.680, p <  0.001) and wound infection (4.6% vs. 7.2%; RR 0.620, 95% CI 0.422 to 0.910, p = 0.015) in TGC group. TGC also showed a lower risk of postoperative short-term mortality (3.8% vs. 5.4%; RR 0.692, 95% CI 0.527 to 0.909, p = 0.008), but sensitivity analyses showed that the result was mainly influenced by one study. The patients in the TGC group experienced a significant higher rate of postoperative hypoglycemia (22.3% vs. 11.0%; RR 3.145, 95% CI 1.928 to 5.131, p <  0.001) and severe hypoglycemia (2.8% vs. 0.7%; RR 3.821, 95% CI 1.796 to 8.127, p <  0.001) as compared to CGC group. TGC showed less length of ICU stay (SMD, - 0.428 days; 95% CI, - 0.833 to - 0.022 days; p = 0.039). However, TGC showed a neutral effect on neurological dysfunction (1.1% vs. 2.4%; RR 0.499, 95% CI 0.219 to 1.137, p = 0.098), acute renal failure (3.3% vs. 5.4%, RR 0.610, 95% CI 0.359 to 1.038, p = 0.068), duration of mechanical ventilation (p = 0.201) and length of hospitalization (p = 0.082).

CONCLUSIONS

TGC immediately after surgery significantly reduces total postoperative infection rates and short-term mortality. However, it might limit conclusion regarding the efficacy of TGC for short-term mortality in sensitivity analyses. The patients in the TGC group experienced a significant higher rate of postoperative hypoglycemia. This study may suggest that TGC should be administrated under close glucose monitoring in patients undergoing surgery, especially in those with high postoperative infection risk.

Aneurysmal subarachnoid hemorrhage: intensive care for improving neurological outcome

Background

Aneurysmal subarachnoid hemorrhage is a life-threatening disease requiring neurocritical care. Delayed cerebral ischemia is a well-known complication that contributes to unfavorable neurological outcomes. Cerebral vasospasm has been thought to be the main cause of delayed cerebral ischemia, and although several studies were able to decrease cerebral vasospasm, none showed improved neurological outcomes. Our target is not cerebral vasospasm but improving neurological outcomes. The purpose of this review is to discuss what intensivists should know and can do to improve clinical outcomes in subarachnoid hemorrhage patients.

Main body of the abstract

Delayed cerebral ischemia is thought to be due to not only vasospasm but also multifactorial mechanisms. Additionally, the concept of early brain injury, which occurs within the first 72 h after the hemorrhage, has become an important concern. Increasing sympathetic activity after the hemorrhage is associated with cardiopulmonary complications and poor outcomes. Serum lactate measurement may be a valuable marker reflecting the severity of sympathetic activity. The transpulmonary thermodilution method will bring about an advanced understanding of hemodynamic management. Fever is a well-recognized symptom and targeted temperature management is an anticipated intervention. To avoid hyperglycemia and hypoglycemia, performing moderate glucose control and minimizing glucose variability are important concepts in glycemic management, but the optimal target range remains unknown. Dysnatremia seems to be associated with negative outcomes. It is not clear yet that maintaining normonatremia actively improves neurological outcomes. Optimal duration of intensive care management has not been determined.

Short conclusion

Although we have an advanced understanding of the pathophysiology and clinical characteristics of subarachnoid hemorrhage, there are many controversies in the intensive care unit management of subarachnoid hemorrhage. With an awareness of not only delayed cerebral ischemia but also early brain injury, more attention should be given to various aspects to improve neurological outcomes.

Comparison of intensive versus conventional insulin therapy in traumatic brain injury: a meta-analysis of randomized controlled trials

OBJECTIVE

To compare intensive insulin therapy (IIT) and conventional insulin therapy (CIT) on clinical outcomes of patients with traumatic brain injury (TBI).

METHODS

MEDLINE, EMBASE, Google Scholar, ISI Web of Science, and Cochrane Library were systematically searched for randomized controlled trials (RCTs) comparing IIT to CIT in patients with TBI. Study-level characteristics, intensive care unit (ICU) events, and long-term functional outcomes were extracted from the articles. Meta-analysis was performed with random-effect models.

RESULTS

Seven RCTs comprising 1070 patients were included. Although IIT was associated with better neurologic outcome (GOS > 3) (RR=0.87, 95% CI=0.78-0.97; P=0.01; I²=0%), sensitivity analysis revealed that one study influenced this overall estimate (RR=0.90, 95% CI=0.80-1.01, P=0.07; I²=0%). IIT was strongly associated with higher risk of hypoglycaemia (RR=5.79, 95% CI=3.27-10.26, P<0.01; I²=38%). IIT and CIT did not differ in terms of early or late mortality (RR=0.96, 95% CI=0.79-1.17, P=0.7; I²=0%), infection rate (RR=0.82, 95% CI=0.59-1.14, P=0.23; I²=68%), or ICU length of stay (SMD= -0.14, 95% CI=-0.35 to 0.07, P=0.18; I²=45%0.) Conclusions: IIT did not improve long-term neurologic outcome, mortality, or infection rate and was associated with increased risk of hypoglycaemia. Additional well-designed RCTs with defined TBI subgroups should be performed to generate more powerful conclusions.

Korean Clinical Practice Guidelines for Aneurysmal Subarachnoid Hemorrhage

Despite advancements in treating ruptured cerebral aneurysms, an aneurysmal subarachnoid hemorrhage (aSAH) is still a grave cerebrovascular disease associated with a high rate of morbidity and mortality. Based on the literature published to date, worldwide academic and governmental committees have developed clinical practice guidelines (CPGs) to propose standards for disease management in order to achieve the best treatment outcomes for aSAHs. In 2013, the Korean Society of Cerebrovascular Surgeons issued a Korean version of the CPGs for aSAHs. The group researched all articles and major foreign CPGs published in English until December 2015 using several search engines. Based on these articles, levels of evidence and grades of recommendations were determined by our society as well as by other related Quality Control Committees from neurointervention, neurology and rehabilitation medicine. The Korean version of the CPGs for aSAHs includes risk factors, diagnosis, initial management, medical and surgical management to prevent rebleeding, management of delayed cerebral ischemia and vasospasm, treatment of hydrocephalus, treatment of medical complications and early rehabilitation. The CPGs are not the absolute standard but are the present reference as the evidence is still incomplete, each environment of clinical practice is different, and there is a high probability of variation in the current recommendations. The CPGs will be useful in the fields of clinical practice and research.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

BACKGROUND AND PURPOSE

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 and published in the Journal of JSICM, [2017; Volume 24 (supplement 2)] 10.3918/jsicm.24S0001 and Journal of Japanese Association for Acute Medicine [2017; Volume 28, (supplement 1)] http://onlinelibrary.wiley.com/doi/10.1002/jja2.2017.28.issue-S1/issuetoc.This abridged English edition of the J-SSCG 2016 was produced with permission from the Japanese Association of Acute Medicine and the Japanese Society for Intensive Care Medicine.

METHODS

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ) and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (> 66.6%) majority vote of each of the 19 committee members.

RESULTS

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation, and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty-seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for five CQs.

CONCLUSIONS

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016)

Background and Purpose

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J-SSCG 2016), a Japanese-specific set of clinical practice guidelines for sepsis and septic shock created jointly by the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine, was first released in February 2017 in Japanese. An English-language version of these guidelines was created based on the contents of the original Japanese-language version.

Methods

Members of the Japanese Society of Intensive Care Medicine and the Japanese Association for Acute Medicine were selected and organized into 19 committee members and 52 working group members. The guidelines were prepared in accordance with the Medical Information Network Distribution Service (Minds) creation procedures. The Academic Guidelines Promotion Team was organized to oversee and provide academic support to the respective activities allocated to each Guideline Creation Team. To improve quality assurance and workflow transparency, a mutual peer review system was established, and discussions within each team were open to the public. Public comments were collected once after the initial formulation of a clinical question (CQ), and twice during the review of the final draft. Recommendations were determined to have been adopted after obtaining support from a two-thirds (>66.6%) majority vote of each of the 19 committee members.

Results

A total of 87 CQs were selected among 19 clinical areas, including pediatric topics and several other important areas not covered in the first edition of the Japanese guidelines (J-SSCG 2012). The approval rate obtained through committee voting, in addition to ratings of the strengths of the recommendation and its supporting evidence were also added to each recommendation statement. We conducted meta-analyses for 29 CQs. Thirty seven CQs contained recommendations in the form of an expert consensus due to insufficient evidence. No recommendations were provided for 5 CQs.

Conclusions

Based on the evidence gathered, we were able to formulate Japanese-specific clinical practice guidelines that are tailored to the Japanese context in a highly transparent manner. These guidelines can easily be used not only by specialists, but also by non-specialists, general clinicians, nurses, pharmacists, clinical engineers, and other healthcare professionals.

European Stroke Organisation (ESO) guidelines on glycaemia management in acute stroke

Background

Hyperglycaemia is a frequent complication in acute stroke that has been shown to be independently associated with larger infarct size, haematoma growth, poor clinical outcome and mortality. This Guideline Document presents the European Stroke Organisation (ESO) Guidelines for the management of blood glucose levels in patients with acute ischemic or haemorrhagic stroke.

Methods

The working group identified related questions and developed its recommendations based on evidence from randomised controlled trials following the standard operating procedure of the ESO. This Guideline Document was reviewed and approved by the European Stroke Organisation Guidelines Committee and the European Stroke Organisation Executive Committee.

Results

We found low-quality evidence from clinical trials in ischemic or haemorrhagic stroke exploring the use of intravenous insulin aimed to achieve a tight glycaemic control with different glucose level targets and several other sources of heterogeneity. None of these trials neither the meta-analysis of them have demonstrated any significant benefit of tight glycaemic control with intravenous insulin in acute ischemic or haemorrhagic stroke patients on functional outcome or in survival and they have shown an increased risk for hypoglycaemia.

Conclusions

We suggest against the routine use of tight glycaemic control with intravenous insulin as a means to improve outcomes. The currently available data about the management of glycaemia in patients with acute stroke are limited and the strengths of the recommendations are therefore weak. Nevertheless, this does not prevent that hyperglycaemia in acute stroke patients could be treated as any other hospitalised patient.

Endocrine and Metabolic Alterations in Sepsis and Implications for Treatment

Sepsis induces profound neuroendocrine and metabolic alterations. During the acute phase, the neuroendocrine changes are directed toward restoration of homeostasis, and also limit unnecessary energy consumption in the setting of restricted nutrient availability. Such changes are probably adaptive. In patients not recovering quickly, a prolonged critically ill phase may ensue, with different neuroendocrine changes, which may represent a maladaptive response. Whether stress hyperglycemia should be aggressively treated or tolerated remains a matter of debate. Until new evidence from randomized controlled trials becomes available, preventing severe hyperglycemia is recommended. Evidence supports withholding parenteral nutrition in the acute phase of sepsis.

Continuous glucose monitoring in the ICU: clinical considerations and consensus

Glucose management in intensive care unit (ICU) patients has been a matter of debate for almost two decades. Compared to intermittent monitoring systems, continuous glucose monitoring (CGM) can offer benefit in the prevention of severe hyperglycemia and hypoglycemia by enabling insulin infusions to be adjusted more rapidly and potentially more accurately because trends in glucose concentrations can be more readily identified. Increasingly, it is apparent that a single glucose target/range may not be optimal for all patients at all times and, as with many other aspects of critical care patient management, a personalized approach to glucose control may be more appropriate. Here we consider some of the evidence supporting different glucose targets in various groups of patients, focusing on those with and without diabetes and neurological ICU patients. We also discuss some of the reasons why, despite evidence of benefit, CGM devices are still not widely employed in the ICU and propose areas of research needed to help move CGM from the research arena to routine clinical use.