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Khan SA, Demidowich AP, Tschudy MM, Wedler J, Lamy W, Akpandak I, Alexander LA, Misra I, Sidhaye A, Rotello L, Zilbermint M. Increasing Frequency of Hemoglobin A1c Measurements in Hospitalized Patients With Diabetes: A Quality Improvement Project Using Lean Six Sigma. J Diabetes Sci Technol 2024; 18:866-873. [PMID: 36788726 PMCID: PMC11307218 DOI: 10.1177/19322968231153883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
BACKGROUND The American Diabetes Association (ADA) recommends measuring A1c in all inpatients with diabetes if not performed in the prior three months. Our objective was to determine the impact of utilizing Lean Six Sigma to increase the frequency of A1c measurements in hospitalized patients. METHODS We evaluated inpatients with diabetes mellitus consecutively admitted in a community hospital between January 2016 and June 2021, excluding those who had an A1c in the electronic health record (EHR) in the previous three months. Lean Six Sigma was utilized to define the extent of the problem and devise solutions. The intervention bundle delivered between November 2017 and February 2018 included (1) provider education on the utility of A1c, (2) more rapid turnaround of A1c results, and (3) an EHR glucose-management tab and insulin order set that included A1c. Hospital encounter and patient-level data were extracted from the EHR via bulk query. Frequency of A1c measurement was compared before (January 2016-November 2017) and after the intervention (March 2018-June 2021) using χ2 analysis. RESULTS Demographics did not differ preintervention versus postintervention (mean age [range]: 70.9 [18-104] years, sex: 52.2% male, race: 57.0% white). A1c measurements significantly increased following implementation of the intervention bundle (61.2% vs 74.5%, P < .001). This level was sustained for more than two years following the initial intervention. Patients seen by the diabetes consult service (40.4% vs 51.7%, P < 0.001) and length of stay (mean: 135 hours vs 149 hours, P < 0.001) both increased postintervention. CONCLUSIONS We demonstrate a novel approach in improving A1c in hospitalized patients. Lean Six Sigma may represent a valuable methodology for community hospitals to improve inpatient diabetes care.
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Affiliation(s)
- Sara Atiq Khan
- Division of Endocrinology, Diabetes and Nutrition, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Andrew P. Demidowich
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Howard County General Hospital, Columbia, MD, USA
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Megan M. Tschudy
- Division of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Joyce Wedler
- Department of Information Systems, Suburban Hospital, Bethesda, MD, USA
| | - Wilson Lamy
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Iniuboho Akpandak
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Lee Ann Alexander
- Department of Pharmacy, Suburban Hospital, Johns Hopkins Medicine, Bethesda, MD, USA
| | - Isha Misra
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Aniket Sidhaye
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leo Rotello
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
| | - Mihail Zilbermint
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Hospital Medicine, Johns Hopkins Community Physicians at Suburban Hospital, Bethesda, MD, USA
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Mattina A, Raffa GM, Giusti MA, Conoscenti E, Morsolini M, Mularoni A, Fazzina ML, Di Carlo D, Cipriani M, Musumeci F, Arcadipane A, Pilato M, Conaldi PG, Bellavia D. Impact of systematic diabetes screening on peri-operative infections in patients undergoing cardiac surgery. Sci Rep 2024; 14:14182. [PMID: 38898227 PMCID: PMC11187113 DOI: 10.1038/s41598-024-65064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 06/17/2024] [Indexed: 06/21/2024] Open
Abstract
Detection of high glycated hemoglobin (A1c) is associated with worse postoperative outcomes, including predisposition to develop systemic and local infectious events. Diabetes and infectious Outcomes in Cardiac Surgery (DOCS) study is a retrospective case-control study aimed to assess in DM and non-DM cardiac surgery patients if a new screening and management model, consisting of systematic A1c evaluation followed by a specialized DM consult, could reduce perioperative infections and 30-days mortality. Effective July 2021, all patients admitted to the cardiac surgery of IRCCS ISMETT were tested for A1c. According to the new protocol, glucose values of patients with A1c ≥ 6% or with known diabetes were monitored. The diabetes team was activated to manage therapy daily until discharge or provide indications for the diagnostic-therapeutic process. Propensity score was used to match 573 patients managed according to the new protocol (the Screen+ Group) to 573 patients admitted before July 2021 and subjected to the traditional management (Screen-). Perioperative prevalence of infections from any cause, including surgical wound infections (SWI), was significantly lower in the Screen+ as compared with the Screen- matched patients (66 [11%] vs. 103 [18%] p = 0.003). No significant difference was observed in 30-day mortality. A1c analysis identified undiagnosed DM in 12% of patients without known metabolic conditions. In a population of patients undergoing cardiac surgery, systematic A1c evaluation at admission followed by specialist DM management reduces perioperative infectious complications, including SWI. Furthermore, A1c screening for patients undergoing cardiac surgery unmasks unknown DM and enhances risk stratification.
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Affiliation(s)
- Alessandro Mattina
- Diabetes Service, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy.
| | - Giuseppe Maria Raffa
- Heart Center, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Maria Ausilia Giusti
- Diabetes Service, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Elena Conoscenti
- Directorate of Health Professions, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Marco Morsolini
- Heart Center, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Alessandra Mularoni
- Unit of Infectious Diseases and Infection Control, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Maria Luisa Fazzina
- Quality and Accreditation Department, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Daniele Di Carlo
- Laboratory of Clinical Pathology, Microbiology and Virology, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Manlio Cipriani
- Heart Center, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Francesco Musumeci
- Heart Center, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Michele Pilato
- Heart Center, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Pier Giulio Conaldi
- Department of Research, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
| | - Diego Bellavia
- Department of Research, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione), UPMC (University of Pittsburgh Medical Center), 90127, Palermo, Italy
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See KC. Metformin-associated lactic acidosis: A mini review of pathophysiology, diagnosis and management in critically ill patients. World J Diabetes 2024; 15:1178-1186. [PMID: 38983827 PMCID: PMC11229964 DOI: 10.4239/wjd.v15.i6.1178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Revised: 04/04/2024] [Accepted: 04/23/2024] [Indexed: 06/11/2024] Open
Abstract
Metformin is a common diabetes drug that may reduce lactate clearance by inhibiting mitochondrial oxidative phosphorylation, leading to metformin-associated lactic acidosis (MALA). As diabetes mellitus is a common chronic metabolic condition found in critically ill patients, pre-existing metformin use can often be found in critically ill patients admitted to the intensive care unit or the high dependency unit. The aim of this narrative mini review is therefore to update clinicians about MALA, and to provide a practical approach to its diagnosis and treatment. MALA in critically ill patients may be suspected in a patient who has received metformin and who has a high anion gap metabolic acidosis, and confirmed when lactate exceeds 5 mmol/L. Risk factors include those that reduce renal elimination of metformin (renal impairment from any cause, histamine-2 receptor antagonists, ribociclib) and excessive alcohol consumption (as ethanol oxidation consumes nicotinamide adenine dinucleotides that are also required for lactate metabolism). Treatment of MALA involves immediate cessation of metformin, supportive management, treating other concurrent causes of lactic acidosis like sepsis, and treating any coexisting diabetic ketoacidosis. Severe MALA requires extracorporeal removal of metformin with either intermittent hemodialysis or continuous kidney replacement therapy. The optimal time to restart metformin has not been well-studied. It is nonetheless reasonable to first ensure that lactic acidosis has resolved, and then recheck the kidney function post-recovery from critical illness, ensuring that the estimated glomerular filtration rate is 30 mL/min/1.73 m2 or better before restarting metformin.
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Affiliation(s)
- Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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4
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Mishra K, Mishra S, Katial T. Accuracy of point-of-care capillary blood sugar measurements in critically ill patients: An observational study. Int J Crit Illn Inj Sci 2024; 14:74-78. [PMID: 39005980 PMCID: PMC11245140 DOI: 10.4103/ijciis.ijciis_76_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/22/2024] [Accepted: 02/09/2024] [Indexed: 07/16/2024] Open
Abstract
Background Accurately monitoring blood glucose levels is vital for critically ill individuals. Point-of-care (POC) glucose meters are commonly used in local intensive care units (ICUs). This study aimed to assess the precision of POC glucose meter readings in critically ill individuals with specific evaluation in patients with and without shock against the reference standard of venous blood glucose measurements. Methods An observational study was done on adult patients admitted in the ICU at a teaching institution. Capillary blood samples were collected from the patient's fingertip using lancet device with aseptic measures. The sample was analyzed using the GlucoCare Sense Glucometer (RMD Mediaids Limited, Taiwan). At the same time, 2 ml of blood was drawn from the patient's peripheral veins and analyzed by glucose oxidase-peroxidase method as reference. Results POC glucose measurements averaged 140 ± 20.23 mg/dl, while laboratory values were recorded as 116.10 ± 17.13 mg/dl. The difference between the two methods was 24.34 ± 12.01 mg/dl. A strong correlation (r = 0.805) was found between capillary and laboratory blood glucose levels, indicating a significant association (P < 0.0001). Twenty-two (44%) patients were in shock during the study. The mean difference between laboratory and POC blood glucose levels was higher in patients with circulatory shock (36.82 ± 4.84 mg/dl) than those without shock (14.61 ± 4.49 mg/dl), P < 0.05. Conclusion POC glucose meters may lead to underdetection of hypoglycemia in critically ill patients, as their values are higher than laboratory values. Moreover, the results showed that POC glucometers are inaccurate for monitoring glucose in hypotensive patients in shock. Standard venous glucose monitoring methods may be more appropriate for these patients.
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Affiliation(s)
- Keshabanand Mishra
- Department of Anaesthesiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Shivanand Mishra
- Department of Anaesthesiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - Tanmay Katial
- Department of Anaesthesiology, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
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van Wilpe R, van Zuylen ML, Hermanides J, DeVries JH, Preckel B, Hulst AH. Preoperative Glycosylated Haemoglobin Screening to Identify Older Adult Patients with Undiagnosed Diabetes Mellitus-A Retrospective Cohort Study. J Pers Med 2024; 14:219. [PMID: 38392652 PMCID: PMC10890067 DOI: 10.3390/jpm14020219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 02/13/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024] Open
Abstract
More than 25% of older adults in Europe have diabetes mellitus. It is estimated that 45% of patients with diabetes are currently undiagnosed, which is a known risk factor for perioperative morbidity. We investigated whether routine HbA1c screening in older adult patients undergoing surgery would identify patients with undiagnosed diabetes. We included patients aged ≥65 years without a diagnosis of diabetes who visited the preoperative assessment clinic at the Amsterdam University Medical Center and underwent HbA1c screening within three months before surgery. Patients undergoing cardiac surgery were excluded. We assessed the prevalence of undiagnosed diabetes (defined as HbA1c ≥ 48 mmol·mol-1) and prediabetes (HbA1c 39-47 mmol·mol-1). Using a multivariate regression model, we analysed the ability of HbA1c to predict days alive and at home within 30 days after surgery. From January to December 2019, we screened 2015 patients ≥65 years at our clinic. Of these, 697 patients without a diagnosis of diabetes underwent HbA1c screening. The prevalence of undiagnosed diabetes and prediabetes was 3.7% (95%CI 2.5-5.4%) and 42.9% (95%CI 39.2-46.7%), respectively. Preoperative HbA1c was not associated with days alive and at home within 30 days after surgery. In conclusion, we identified a small number of patients with undiagnosed diabetes and a high prevalence of prediabetes based on preoperative HbA1c screening in a cohort of older adults undergoing non-cardiac surgery. The relevance of prediabetes in the perioperative setting is unclear. Screening for HbA1c in older adult patients undergoing non-cardiac surgery does not appear to help predict postoperative outcome.
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Affiliation(s)
- Robert van Wilpe
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Mark L van Zuylen
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
- Department of Paediatric Intensive Care, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Jeroen Hermanides
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - J Hans DeVries
- Department of Endocrinology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Benedikt Preckel
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
| | - Abraham H Hulst
- Department of Anaesthesiology, Amsterdam University Medical Center, University of Amsterdam, Meibergdreef 9, Postbus 22660, 1105 AZ Amsterdam, The Netherlands
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Galindo RJ, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S295-S306. [PMID: 38078585 PMCID: PMC10725815 DOI: 10.2337/dc24-s016] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Arunachala Murthy T, Chapman M, Jones KL, Horowitz M, Marathe CS. Inter-relationships between gastric emptying and glycaemia: Implications for clinical practice. World J Diabetes 2023; 14:447-459. [PMID: 37273253 PMCID: PMC10236995 DOI: 10.4239/wjd.v14.i5.447] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/09/2022] [Accepted: 04/07/2023] [Indexed: 05/15/2023] Open
Abstract
Gastric emptying (GE) exhibits a wide inter-individual variation and is a major determinant of postprandial glycaemia in health and diabetes; the rise in blood glucose following oral carbohydrate is greater when GE is relatively more rapid and more sustained when glucose tolerance is impaired. Conversely, GE is influenced by the acute glycaemic environment acute hyperglycaemia slows, while acute hypoglycaemia accelerates it. Delayed GE (gastroparesis) occurs frequently in diabetes and critical illness. In diabetes, this poses challenges for management, particularly in hospitalised individuals and/or those using insulin. In critical illness it compromises the delivery of nutrition and increases the risk of regurgitation and aspiration with consequent lung dysfunction and ventilator dependence. Substantial advances in knowledge relating to GE, which is now recognised as a major determinant of the magnitude of the rise in blood glucose after a meal in both health and diabetes and, the impact of acute glycaemic environment on the rate of GE have been made and the use of gut-based therapies such as glucagon-like peptide-1 receptor agonists, which may profoundly impact GE, in the management of type 2 diabetes, has become commonplace. This necessitates an increased understanding of the complex inter-relationships of GE with glycaemia, its implications in hospitalised patients and the relevance of dysglycaemia and its management, particularly in critical illness. Current approaches to management of gastroparesis to achieve more personalised diabetes care, relevant to clinical practice, is detailed. Further studies focusing on the interactions of medications affecting GE and the glycaemic environment in hospitalised patients, are required.
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Affiliation(s)
- Tejaswini Arunachala Murthy
- Adelaide Medical School, University of Adelaide, Adelaide 5000, SA, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Marianne Chapman
- Adelaide Medical School, University of Adelaide, Adelaide 5000, SA, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide 5000, SA, Australia
| | - Karen L Jones
- Adelaide Medical School, University of Adelaide, Adelaide 5000, SA, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide 5000, SA, Australia
| | - Michael Horowitz
- Adelaide Medical School, University of Adelaide, Adelaide 5000, SA, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide 5000, SA, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
| | - Chinmay S Marathe
- Adelaide Medical School, University of Adelaide, Adelaide 5000, SA, Australia
- NHMRC Centre of Clinical Research Excellence in Nutritional Physiology, Interventions and Outcomes, University of Adelaide, Adelaide 5000, SA, Australia
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide 5000, SA, Australia
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8
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Tran NK, LaValley C, Bagley B, Rodrigo J. Point of care blood glucose devices in the hospital setting. Crit Rev Clin Lab Sci 2023; 60:290-299. [PMID: 36734399 DOI: 10.1080/10408363.2023.2170316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Dysglycemia is common among hospitalized patients. Accurate point-of-care (POC) glucose monitoring is necessary for the safe administration of insulin. Unfortunately, POC glucose meters are not all created equal. Interfering factors such as abnormal hematocrit, abnormal oxygen tension, and oxidizing/reducing substances can lead to inaccurate glucose measurements and result in inappropriate insulin dosing. The introduction of autocorrecting glucose meters has changed the POC testing landscape. Autocorrecting glucose meters provide more accurate measurements and have been associated with improved glycemic control in hospitalized patients. Continuous glucose monitoring has also created interest in using these platforms in at-risk inpatient populations. Future glucose monitoring technologies such as artificial intelligence/machine learning, wearable smart devices, and closed-loop insulin management systems are poised to transform glycemic management. The goal of this review is to provide an overview of glucose monitoring technology, summarize the clinical impact of glucose monitoring accuracy, and highlight emerging and future POC glucose monitoring technologies.
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Affiliation(s)
- Nam K Tran
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, USA
| | - Clayton LaValley
- Patient Care Services, University of California Davis, Sacramento, CA, USA
| | - Berit Bagley
- Patient Care Services, University of California Davis, Sacramento, CA, USA
| | - John Rodrigo
- Department of Pathology and Laboratory Medicine, University of California Davis, Sacramento, CA, USA
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Pharaboz A, Kimmoun A, Gunst J, Duarte K, Merkling T, Gayat E, Mebazaa A, Glenn-Chousterman B. Association between type II diabetes mellitus and 90-day mortality in a large multicenter prospectively collected cohort. A FROG ICU post-hoc study. J Crit Care 2023; 73:154195. [PMID: 36368176 DOI: 10.1016/j.jcrc.2022.154195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 09/01/2022] [Accepted: 10/17/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Factors associated with adverse outcomes in ICU patients with type II (T2DM) are poorly defined. The main goal of this study is to determine the impact of pre-existing T2DM on 90-day mortality post ICU admission. MATERIAL Post-hoc analysis from the FROG-ICU cohort. All patients admitted to ICU who were ventilated and/or treated by a vasoactive agent for >24 h were included. Association between T2DM and 90-day mortality was analyzed in unmatched, and populations matched by propensity score (PS) method to balance confounders recorded before ICU admission. Analysis was performed in non-imputed and imputed datasets. RESULTS 2002 patients were included, and 16% had a history of T2DM. The latter were at inclusion more severely ill (SAPSII score 51(39-67) vs 48(35-61), p < 0.0001; Charlson score 2(1-3) vs 0(0-2), p < 0.0001). In the unmatched cohort, T2DM patients had a higher 90-day risk of death compared to no-DM patients (HR 1.35(1.1-1.65)). The 90-day risk of death was not significantly different T2DM and no T2DM patients after PS matching (HR: 0.81 (0.56-1.18). Results were similar with the analysis performed on imputed datasets (pooled HR: 0.95 (0.69-1.30)). CONCLUSIONS In the present study, T2DM was not associated with 90-day mortality post ICU admission.
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Affiliation(s)
- Alexandre Pharaboz
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, CHRU de Nancy, Médecine Intensive et Réanimation Brabois, INSERM INSERM U942 and U1116, F-CRIN-INIC RCT, Vandœuvre-lès-Nancy, France
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven Herestraat 49, B-3000 Leuven, Belgium
| | - Kevin Duarte
- Université de Lorraine, CHRU de Nancy, INSERM CIC-P 1433, INSERM, F-CRIN-INI CRCT, Vandœuvre-lès-Nancy, France
| | - Thomas Merkling
- Université de Lorraine, CHRU de Nancy, INSERM CIC-P 1433, INSERM, F-CRIN-INI CRCT, Vandœuvre-lès-Nancy, France
| | - Etienne Gayat
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France
| | - Alexandre Mebazaa
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France
| | - Benjamin Glenn-Chousterman
- Université de Paris, AP-HP, CHU Lariboisière, Department of Anesthesiology and Critical Care, FHU PROMICE, INSERM U942, F-CRIN-INI CRCT, Paris, France.
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Liu C, Pang K, Tong J, Ouyang W, Li L, Tang Y. The association between hemoglobin A1c and all-cause mortality in the ICU: A cross-section study based on MIMIC-IV 2.0. Front Endocrinol (Lausanne) 2023; 14:1124342. [PMID: 36875458 PMCID: PMC9975393 DOI: 10.3389/fendo.2023.1124342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 01/31/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND Hyperglycemia has been reported to be associated with the outcomes of patients in the intensive care unit (ICU). However, the relationship between hemoglobin A1c (HbA1c) and long-term or short-term mortality in the ICU is still unknown. This study used the Medical Information Mart for Intensive Care (MIMIC)-IV database to investigate the relationship between HbA1c and long-term or short-term mortality among ICU patients without a diabetes diagnosis. METHODS A total of 3,154 critically ill patients without a diabetes diagnosis who had HbA1c measurements were extracted and analyzed from the MIMIC-IV. The primary outcome was 1-year mortality, while the secondary outcomes were 30-day mortality and 90-day mortality after ICU discharge. HbA1c levels were classified into four levels according to three HbA1c values (5.0%, 5.7%, and 6.5%). The Cox regression model was used to investigate the relationship between the highest HbA1c measurement and mortality. Finally, this correlation was validated using the XGBoost machine learning model and Cox regression after propensity score matching (PSM). RESULTS The study eventually included 3,154 critically ill patients without diabetes who had HbA1c measurements in the database. HbA1c levels of below 5.0% or above 6.5% were significantly associated with 1-year mortality after adjusting for covariates in Cox regression (HR: 1.37; 95% CI: 1.02-1.84 or HR: 1.62; 95% CI: 1.20-2.18). In addition, HbA1c 6.5% was linked to 30-day mortality (HR: 1.81; 95% CI: 1.21-2.71) and 90-day mortality (HR: 1.62; 95% CI: 1.14-2.29). The restricted cubic spline demonstrated a U-shaped relationship between HbA1c levels and 1-year mortality. The AUCs of the training and testing datasets in the XGBoost model were 0.928 and 0.826, respectively, while the SHAP plot revealed that HbA1c was somewhat important for the 1-year mortality. Higher HbA1c levels in Cox regression were still significantly associated with 1-year mortality after PSM for other factors. CONCLUSIONS The 1-year mortality, 30-day mortality, and 90-day mortality rates for critically ill patients after discharge from ICU are significantly associated with HbA1c. HbA1c < 5.0% and ≥6.5% would increase 30-day, 90-day, and 1-year mortality, while levels between 5.0% and 6.5% of HbA1c did not significantly affect these outcomes.
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Affiliation(s)
- Chunxia Liu
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Ke Pang
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Jianbin Tong
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Wen Ouyang
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
| | - Liang Li
- Department of Gastrointestinal Surgery, Third Xiangya Hospital, Central South University, Changsha, China
| | - Yongzhong Tang
- Department of Anesthesiology, Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Yongzhong Tang,
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11
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Mader JK, Brix JM, Aberer F, Vonbank A, Resl M, Hochfellner DA, Ress C, Pieber TR, Stechemesser L, Sourij H. [Hospital diabetes management (Update 2023)]. Wien Klin Wochenschr 2023; 135:242-255. [PMID: 37101046 PMCID: PMC10133359 DOI: 10.1007/s00508-023-02177-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/28/2023]
Abstract
This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral/injectable antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.
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Affiliation(s)
- Julia K Mader
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
| | - Johanna M Brix
- Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Klinik Landstraße, Wien, Österreich
| | - Felix Aberer
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Alexander Vonbank
- Innere Medizin I mit Kardiologie, Angiologie, Endokrinologie, Diabetologie und Intensivmedizin, Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Michael Resl
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Daniel A Hochfellner
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Claudia Ress
- Innere Medizin, Department I, Medizinische Universität Innsbruck, Innsbruck, Österreich
| | - Thomas R Pieber
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I, Paracelsus Medizinische Privatuniversität - Landeskrankenhaus, Salzburg, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
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12
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ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, Collins BS, Hilliard ME, Isaacs D, Johnson EL, Kahan S, Khunti K, Leon J, Lyons SK, Perry ML, Prahalad P, Pratley RE, Seley JJ, Stanton RC, Gabbay RA, on behalf of the American Diabetes Association. 16. Diabetes Care in the Hospital: Standards of Care in Diabetes-2023. Diabetes Care 2023; 46:S267-S278. [PMID: 36507644 PMCID: PMC9810470 DOI: 10.2337/dc23-s016] [Citation(s) in RCA: 68] [Impact Index Per Article: 68.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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13
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Krinsley JS, Roberts G, Brownlee M, Schwartz M, Preiser JC, Rule P, Wang Y, Bahgat J, Umpierrez GE, Hirsch IB. Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill. J Endocr Soc 2022; 7:bvac180. [PMID: 36532359 PMCID: PMC9753064 DOI: 10.1210/jendso/bvac180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Indexed: 11/27/2022] Open
Abstract
Context The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM). Methods This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c] - 46.7 mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality). Results Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P < .0001) and coefficient of variation (P < .0001) but similar rates of hypoglycemia (P = .08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P = .0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P < .0001]) were higher in undiagDM than in DM. Conclusion These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.
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Affiliation(s)
- James S Krinsley
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | - Gregory Roberts
- Department of Pharmacology, Flinders Medical Centre, Bedford Park, SA 5042, Australia
| | - Michael Brownlee
- Department of Medicine, Albert Einstein College of Medicine, Bronx, NY 10461, USA
| | - Michael Schwartz
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme University Hospital, Brussels 1070, Belgium
| | - Peter Rule
- PRI Consultants, Los Altos Hills, CA 94024, USA
| | - Yu Wang
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | - Joseph Bahgat
- Department of Medicine, Stamford Hospital and Columbia Vagelos Columbia College of Physicians and Surgeons, Stamford, CT 06902, USA
| | | | - Irl B Hirsch
- Department of Medicine, University of Washington School of Medicine, Seattle, WA 98195, USA
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14
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Halvorsen S, Mehilli J, Cassese S, Hall TS, Abdelhamid M, Barbato E, De Hert S, de Laval I, Geisler T, Hinterbuchner L, Ibanez B, Lenarczyk R, Mansmann UR, McGreavy P, Mueller C, Muneretto C, Niessner A, Potpara TS, Ristić A, Sade LE, Schirmer H, Schüpke S, Sillesen H, Skulstad H, Torracca L, Tutarel O, Van Der Meer P, Wojakowski W, Zacharowski K. 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery. Eur Heart J 2022; 43:3826-3924. [PMID: 36017553 DOI: 10.1093/eurheartj/ehac270] [Citation(s) in RCA: 247] [Impact Index Per Article: 123.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
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15
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Ye J, Li Q, Nie J. Prevalence, Characteristics, and Associated Risk Factors of Wrist Fractures in Americans Above 50: The Cross-Sectional NHANES Study. Front Endocrinol (Lausanne) 2022; 13:800129. [PMID: 35547001 PMCID: PMC9082306 DOI: 10.3389/fendo.2022.800129] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 03/11/2022] [Indexed: 11/13/2022] Open
Abstract
SUMMARY By analyzing data from NHANES, we aimed to evaluate the prevalence, characteristics, and associated factors of wrist fractures in Americans aged 50 and above. INTRODUCTION Wrist fractures, whose prevalence increases with age, are one of the most common fractures in the United States. However, epidemiological studies on the prevalence of wrist fractures of certain ages were limited. METHODS The data of Americans aged 50 or above from 2013-2014 and 2017-2018 in NHANES were extracted and analyzed. RESULTS The prevalence of wrist fractures among Americans whose age was 50 or above was 12%, which was similar between men and women (men 12.8% vs. women 11.4%, p = 0.267). Among those who had experienced their first wrist fracture, 17.8% of the population experienced a second wrist fracture. The top two causes of the first wrist fracture were a fall from a standing height (56%) or a hard fall (34.8%). The prevalence of wrist fractures was higher in men than in women (13.7% versus 8.7%, p = 0.023) aged < 60, but higher in women than in men aged ≥ 60 (11.8% versus 14.3%, p = 0.007). Multivariate analysis showed that obesity, frequent drinking, current smoking, high serum phosphate level, non-Hispanic white women, and osteoporosis were independently associated with wrist fractures. Stratified by race, osteoporosis, frequent drinking, and high serum phosphate level were risk factors for wrist fractures in all races. As for Mexican Americans, non-Hispanic whites, and other races including multi-racial, current smoking was a risk factor of wrist factures. Furthermore, obesity was positively associated with wrist fractures in Mexican Americans, other Hispanics, and non-Hispanic whites. CONCLUSION The prevalence of wrist fractures in Americans aged 50 and above was 12%. Falling from a standing height was the main cause of the first wrist fracture. Frequent drinking, current smoker, high serum phosphate level, osteoporosis, obesity, and non-Hispanic women were more likely to experience wrist fractures.
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Affiliation(s)
- Juncai Ye
- Department of Orthopedics, Zhejiang Hospital, Hangzhou, China
- *Correspondence: Juncai Ye, ; Jing Nie,
| | - Qiao Li
- Department of Orthopedics, The Second Clinical Medical College of Zhejiang Chinese Medical University, Hangzhou, China
| | - Jing Nie
- Department of Orthopedics, Traumatology and Orthopedics Hospital of Traditional Chinese Medicine of Xiaoshan District, Hangzhou, China
- *Correspondence: Juncai Ye, ; Jing Nie,
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16
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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17
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The implications of hyperoxia, type 1 diabetes and sex on cardiovascular physiology in mice. Sci Rep 2021; 11:23086. [PMID: 34845324 PMCID: PMC8630164 DOI: 10.1038/s41598-021-02550-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 11/10/2021] [Indexed: 01/09/2023] Open
Abstract
Oxygen supplementation, although a cornerstone of emergency and cardiovascular medicine, often results in hyperoxia, a condition characterized by excessive tissue oxygen which results in adverse cardiac remodeling and subsequent injurious effects to physiological function. Cardiac remodeling is further influenced by various risk factors, including pre-existing conditions and sex. Thus, the purpose of this experiment was to investigate cardiac remodeling in Type I Diabetic (Akita) mice subjected to hyperoxic treatment. Overall, we demonstrated that Akita mice experience distinct challenges from wild type (WT) mice. Specifically, Akita males at both normoxia and hyperoxia showed significant decreases in body and heart weights, prolonged PR, QRS, and QTc intervals, and reduced %EF and %FS at normoxia compared to WT controls. Moreover, Akita males largely resemble female mice (both WT and Akita) with regards to the parameters studied. Finally, statistical analysis revealed hyperoxia to have the greatest influence on cardiac pathophysiology, followed by sex, and finally genotype. Taken together, our data suggest that Type I diabetic patients may have distinct cardiac pathophysiology under hyperoxia compared to uncomplicated patients, with males being at high risk. These findings can be used to enhance provision of care in ICU patients with Type I diabetes as a comorbid condition.
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18
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Chen L, Sun W, Liu Y, Zhang L, Lv Y, Wang Q, Long D, Wang Y, Zhao S, Rong S, Yu L, Liu L. Association of Early-Phase In-Hospital Glycemic Fluctuation With Mortality in Adult Patients With Coronavirus Disease 2019. Diabetes Care 2021; 44:865-873. [PMID: 33479161 DOI: 10.2337/dc20-0780] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 12/21/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To investigate the association of in-hospital early-phase glycemic control with adverse outcomes among inpatients with coronavirus disease 2019 (COVID-19) in Wuhan, China. RESEARCH DESIGN AND METHODS The study is a large case series, and data were obtained regarding consecutive patients hospitalized with COVID-19 in the Central Hospital of Wuhan between 2 January and 15 February 2020. All patients with definite outcomes (death or discharge) were included. Demographic, clinical, treatment, and laboratory information were extracted from electronic medical records. We collected daily fasting glucose data from standard morning fasting blood biochemistry to determine glycemic status and fluctuation (calculated as the square root of the variance of daily fasting glucose levels) during the 1st week of hospitalization. RESULTS A total of 548 patients were included in the study (median age 57 years; 298 [54%] were women, and n = 99 had diabetes [18%]), 215 suffered acute respiratory distress syndrome (ARDS), 489 survived, and 59 died. Patients who had higher mean levels of glucose during their 1st week of hospitalization were older and more likely to have a comorbidity and abnormal laboratory markers, prolonged hospital stays, increased expenses, and greater risks of severe pneumonia, ARDS, and death. Compared with patients with the lowest quartile of glycemic fluctuation, those who had the highest quartile of fluctuation magnitude had an increased risk of ARDS (risk ratio 1.97 [95% CI 1.01, 4.04]) and mortality (hazard ratio 2.73 [95% CI 1.06, 7.73]). CONCLUSIONS These results may have implications for optimizing glycemic control strategies in COVID-19 patients during the early phase of hospitalization.
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Affiliation(s)
- Liangkai Chen
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenwu Sun
- Intensive Care Unit, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanli Liu
- Intensive Care Unit, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Lijuan Zhang
- Intensive Care Unit, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanling Lv
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qiang Wang
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ding Long
- Intensive Care Unit, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yujun Wang
- Intensive Care Unit, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Su Zhao
- Department of Pulmonary and Critical Care Medicine, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuang Rong
- Department of Nutrition and Food Hygiene, School of Public Health, Medical College, Wuhan University of Science and Technology, Wuhan, China
| | - Li Yu
- Intensive Care Unit, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Liegang Liu
- Department of Nutrition and Food Hygiene, Hubei Key Laboratory of Food Nutrition and Safety, and Ministry of Education Key Laboratory of Environment and Health, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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19
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Yeh T, Yeung M, Mendelsohn Curanaj FA. Managing Patients with Insulin Pumps and Continuous Glucose Monitors in the Hospital: to Wear or Not to Wear. Curr Diab Rep 2021; 21:7. [PMID: 33449214 PMCID: PMC7810103 DOI: 10.1007/s11892-021-01375-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW As the prevalence of diabetes mellitus in the USA continues to rise, so does the popularity of diabetes management devices such as continuous glucose monitors (CGMs) and insulin pumps. The use of this technology has been shown to improve outpatient glycemic outcomes and quality of life and oftentimes may be continued in the hospital setting. Our aim is to review the current guidelines and available evidence on the continuation of insulin pumps and CGMs in the inpatient setting. RECENT FINDINGS Patients with diabetes are at higher risk for hospitalizations and complications due to hyper- or hypoglycemia, metabolic co-morbidities, or as seen recently, more severe illness from infections such as SARS-CoV-2. The maintenance of euglycemia is important to decrease both morbidity and mortality in the hospital setting. There is consensus among experts and medical societies that inpatient use of diabetes technology in carefully selected patients with proper institutional protocols is safe and can improve inpatient glycemic outcomes and reduce hypoglycemia. During the COVID-19 pandemic, CGMs played a vital role in managing hyperglycemia in some hospitalized patients. Insulin pumps and CGMs have the potential to transform glycemic management in hospitalized patients. In order for institutions to safely and effectively incorporate these technologies on their inpatient units, hospital-based providers will need to be able to understand how to manage and utilize these devices in their practice in conjunction with diabetes experts.
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Affiliation(s)
- Tiffany Yeh
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA.
| | - Michele Yeung
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
| | - Felicia A Mendelsohn Curanaj
- Department of Medicine, Division of Endocrinology, Diabetes, and Metabolism, Weill Cornell Medicine / New York Presbyterian Hospital, 1305 York Avenue, 4th Floor, New York, NY, 10021, USA
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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21
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Balintescu A, Palmgren I, Lipcsey M, Oldner A, Larsson A, Cronhjort M, Lind M, Wernerman J, Mårtensson J. Prevalence and impact of chronic dysglycemia in intensive care unit patients-A retrospective cohort study. Acta Anaesthesiol Scand 2021; 65:82-91. [PMID: 32888188 DOI: 10.1111/aas.13695] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The prevalence of chronic dysglycemia (diabetes and prediabetes) in patients admitted to Swedish intensive care units (ICUs) is unknown. We aimed to determine the prevalence of such chronic dysglycemia and asses its impact on blood glucose control and patient-centered outcomes in critically ill patients. METHODS In this retrospective observational cohort study, we obtained glycated hemoglobin A1c (HbA1c) in patients admitted to four tertiary ICUs in Sweden between March and August 2016. Based on previous diabetes history and HbA1c we determined the prevalence of chronic dysglycemia. We used multivariable regression analyses to study the association of chronic dysglycemia with the time-weighted average blood glucose concentration, glycemic lability index (GLI), and development of hypoglycemia (co-primary outcomes), and with ICU length of stay, mechanical ventilation duration, renal replacement therapy (RRT) use, vasopressor use, ICU-acquired infections, and mortality (exploratory clinical outcomes). RESULTS Of 943 patients, 312 (33%) had chronic dysglycemia. Of these 312 patients, 84 (27%) had prediabetes, 43 (14%) had undiagnosed diabetes and 185 (59%) had known diabetes. Chronic dysglycemia was independently associated with higher time-weighted average blood glucose concentration (P < .001), higher GLI (P < .001), and hypoglycemia (P < .001). Chronic dysglycemia was independently associated with RRT use (adjusted odds ratio 1.97, 95% CI 1.24-3.13, P = .004) but not with other exploratory clinical outcomes. CONCLUSIONS In four tertiary Swedish ICUs, measurement of HbA1c showed that one-third of patients had chronic dysglycemia. Chronic dysglycemia was associated with marked derangements in glycemic control, and a greater need for renal replacement therapy.
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Affiliation(s)
- Anca Balintescu
- Section of Anaesthesia and Intensive Care Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden
| | - Ida Palmgren
- Section of Anaesthesia and Intensive Care Hudiksvall Hospital Hudiksvall Sweden
| | - Miklós Lipcsey
- Hedenstierna Laboratory Section of Anaesthesiology and Intensive Care Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Anders Oldner
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Section of Anaesthesia and Intensive Care Department of Physiology and Pharmacology Karolinska Institute Stockholm Sweden
| | - Anders Larsson
- Department of Medical Sciences Clinical Chemistry Uppsala University Uppsala Sweden
| | - Maria Cronhjort
- Section of Anaesthesia and Intensive Care Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden
| | - Marcus Lind
- Department of Medicine NU Hospital Group Uddevalla Sweden
- Department of Molecular and Clinical Medicine University of Gothenburg Gothenburg Sweden
| | - Jan Wernerman
- Division of Anaesthesia and Intensive Care Department of Clinical Science Intervention and Technology (CLINTEC) Karolinska Institute Stockholm Sweden
| | - Johan Mårtensson
- Department of Perioperative Medicine and Intensive Care Karolinska University Hospital Stockholm Sweden
- Section of Anaesthesia and Intensive Care Department of Physiology and Pharmacology Karolinska Institute Stockholm Sweden
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22
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Lin S, He W, Zeng M. Association of Diabetes and Admission Blood Glucose Levels with Short-Term Outcomes in Patients with Critical Illnesses. J Inflamm Res 2020; 13:1151-1166. [PMID: 33376380 PMCID: PMC7764887 DOI: 10.2147/jir.s287510] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 12/04/2020] [Indexed: 12/16/2022] Open
Abstract
Background Association of diabetes and admission glucose on the short-term prognosis in patients with critical illnesses are currently ambiguous. We aimed to determine whether diabetes and admission glucose affects short-term prognosis of critically ill patients. Methods We performed a retrospective analysis of data on 46,476 critically ill patients from the critical care database. Association of diabetes with 28-day mortality was assessed by inverse probability weighting based on the propensity score. Smoothing splines and threshold effect analysis were applied to explore the relationship between admission glucose and clinical outcomes. Results Of the 33,680 patients enrolled in the study, 8,701 (25.83%) had diabetes. In the main analysis, the 28-day mortality was reduced by 29% (hazard ratio (HR)=0.71, 95% confidence interval (CI) 0.67–0.76) in patients with diabetes compared to those without diabetes. The E-value of 2.17 indicated robustness to unmeasured confounders. Significant interactions were observed for glucose at ICU admission, admission type, and insulin use (Interaction P <0.05). A V-shaped relationship was observed between admission glucose and 28-day mortality in non-diabetic patients, with the lowest 28-day mortality corresponding to a glucose level of 101.75 mg/dl (95% CI 94.64–105.80 mg/dl), and admission hypoglycemia or hyperglycemia should be avoided, especially in patients admitted to the surgical intensive care unit (SICU), cardiac surgery recovery unit (CSRU), and coronary care unit (CCU); for diabetic patients, elevated admission glucose does not appear to be associated with a poor prognosis and perhaps may be beneficial except for CCU and CSRU. Conclusion The non-detrimental effect of diabetes on the short-term prognosis of critically ill patients was further confirmed, which would reduce 28-day mortality by approximately 29%. For non-diabetic patients, the admission glucose level corresponding to the lowest 28-day mortality was 101.75 mg/dl (95% CI 94.64–105.80 mg/dl); however, for diabetics, the appropriate admission glucose threshold remains unresolved.
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Affiliation(s)
- Shan Lin
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Wanmei He
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
| | - Mian Zeng
- Department of Medical Intensive Care Unit, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong, People's Republic of China
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Gosmanov AR, Mendez CE, Umpierrez GE. Challenges and Strategies for Inpatient Diabetes Management in Older Adults. Diabetes Spectr 2020; 33:227-235. [PMID: 32848344 PMCID: PMC7428658 DOI: 10.2337/ds20-0008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Adults older than 65 years of age are the fastest growing segment of the U.S. population. Aging is also one of the most important risk factors for diabetes, and about one-third of all individuals with diabetes are in this age-group. Older people with diabetes are more likely to have comorbidities such as hypertension, ischemic heart disease, chronic kidney disease, and cognitive impairment, which lead to higher rates of hospital admissions compared with individuals without diabetes. Professional organizations have recommended patient-centric individualized glycemic reduction approaches, with an emphasis on potential harms of intensive glycemic control and overtreatment in older adults. Insulin therapy remains a mainstay of diabetes management in the inpatient setting regardless of patients' age; however, there is uncertainty about optimal glycemic targets during the hospital stay. Increasing evidence supports selective use of dipeptidyl peptidase-4 inhibitors, alone or in combination with low-dose basal insulin, in older noncritically ill patients with mild to moderate hyperglycemia. This article reviews the prevalence, diagnosis, and monitoring of, and the available treatment strategies for, diabetes among elderly patients in the inpatient setting.
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Affiliation(s)
- Aidar R. Gosmanov
- Department of Medicine, Division of Endocrinology, Albany Medical College, Albany, NY
- Section of Endocrinology, Stratton VA Medical Center, Albany, NY
| | - Carlos E. Mendez
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI
- Division of Diabetes and Endocrinology, Milwaukee VA Medical Center, Milwaukee, WI
| | - Guillermo E. Umpierrez
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
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Abstract
BACKGROUND To summarize new evidence regarding the methodological aspects of blood glucose control in the intensive care unit (ICU). METHODS We reviewed the literature on blood glucose control in the ICU up to August 2019 through Ovid Medline and Pubmed. RESULTS Since the publication of the Leuven studies, the benefits of glycemic control have been recognized. However, the methodology of blood glucose control, notably the blood glucose measurement accuracy and the insulin titration protocol, plays an important but underestimated role. This may partially explain the negative results of the large, pragmatic multicenter trials and made everyone realize that tight glycemic control with less-frequent glucose measurements on less accurate blood glucose meters is neither feasible nor advisable in daily practice. Blood gas analyzers remain the gold standard. New generation point-of-care blood glucose meters may be an alternative when using whole blood of critically ill patients in combination with a clinically validated insulin dosing algorithm. CONCLUSION When implementing blood glucose management in an ICU one needs to take into account the interaction between aimed glycemic target and blood glucose measurement methodology.
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Affiliation(s)
- Gert-Jan Eerdekens
- Department of Anesthesiology, University Hospitals Leuven, Belgium
- Department of Anesthesia and Intensive Care Medicine, ZOL-Genk, Belgium
- Gert-Jan Eerdekens, MD, Department of Anesthesia UZ Leuven, Herestraat 49, Leuven 3000, Belgium.
| | - Steffen Rex
- Department of Anesthesiology, University Hospitals Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, Belgium
| | - Dieter Mesotten
- Department of Anesthesia and Intensive Care Medicine, ZOL-Genk, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Belgium
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc20-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc20-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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26
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Deng Y, Wang L, Hou Y, Ma J, Chi R, Ye H, Zhai Y, Zhang D, Gao L, Hu L, Hou T, Li J, Tan N, Chen C. The influence of glycemic status on the performance of cystatin C for acute kidney injury detection in the critically ill. Ren Fail 2019; 41:139-149. [PMID: 30942122 PMCID: PMC6450510 DOI: 10.1080/0886022x.2019.1586722] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Serum cystatin C (sCysC) used clinically for detecting early acute kidney injury (AKI) was reported to be independently associated with hemoglobin (HbA1c) levels, diabetes, and prediabetes. We aimed to assess the influence of HbA1c levels, diabetes, or prediabetes on the performance of sCysC for AKI detection in critically ill adults. METHODS A prospective observational study was conducted in a mixed medical-surgical intensive care unit (ICU). Patients were divided into four quartiles based on levels of HbA1c or serum glucose at ICU admission, respectively. Additionally, patients were stratified into four subgroups according to HbA1c levels and history of diabetes, namely recognized diabetes (previous diagnosis of diabetes), unrecognized diabetes, prediabetes, and normal glycemic status. Comparisons were made using the area under the receiver operator characteristic curve (AUC) for AKI detection, and reassessed after patient stratification by above-mentioned glycemic status. RESULTS Multivariable linear regression revealed that HbA1c levels and history of diabetes were positively related with sCysC (all p < .05). Although stratification for above-mentioned glycemic status displayed no significant difference between AUC of sCysC (all p > .05), sCysC yielded the highest AUCs for detecting AKI in diabetic patients. Moreover, higher optimal cutoff values of sCysC to detect AKI were observed in patients with versus without diabetes. CONCLUSION Glycemic status has no significant impact on the accuracy of sCysC for AKI detection in critically ill adults and a higher optimal cutoff value of sCysC for AKI detection should be considered in diabetic patients.
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Affiliation(s)
- Yujun Deng
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, People's Republic of China
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Lin Wang
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
- Shantou University Medical College, Shantou, People's Republic of China
| | - Yating Hou
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Jianchao Ma
- Department of Nephrology, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Ruibin Chi
- Department of Critical Care Medicine, Xiaolan Hospital of Southern Medical University, Zhongshan, People’s Republic of China
| | - Heng Ye
- Department of Critical Care Medicine, Guangzhou Nansha Central Hospital, Nansha, People’s Republic of China
| | - Yiling Zhai
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Danqing Zhang
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Lu Gao
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Linhui Hu
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Tieying Hou
- Department of Clinical Laboratory, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Jinghua Li
- Department of Clinical Laboratory, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
| | - Ning Tan
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, People's Republic of China
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Key Laboratory of Coronary Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People's Republic of China
- Ning Tan The Second School of Clinical Medicine, Southern Medical University, Guangzhou510280, Guangdong, People's Republic of China; Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Key Laboratory of Coronary Disease, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou510100, Guangdong, People's Republic of China
| | - Chunbo Chen
- The Second School of Clinical Medicine, Southern Medical University, Guangzhou, People's Republic of China
- Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, People’s Republic of China
- National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, P.R. China
- CONTACT Chunbo Chen The Second School of Clinical Medicine, Southern Medical University, Guangzhou510280, Guangdong, People's Republic of China; Department of Critical Care Medicine, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, 106 Zhongshan Er Road, Guangzhou510080, Guangdong Province, People’s Republic of China; National Clinical Research Center for Kidney Disease, State Key Laboratory of Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou510515, Guangdong Province, P.R. China
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27
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Abstract
Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.
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Affiliation(s)
- Pedro D. Salinas
- Aurora Critical Care Services,
University of Wisconsin School of Medicine and Public Health, Milwaukee, WI,
USA
| | - Carlos E. Mendez
- Froedtert and Medical College of
Wisconsin, Division of Diabetes and Endocrinology, Zablocki Veteran Affairs Medical
Center, Milwaukee, WI, USA
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28
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Mader JK, Brix J, Aberer F, Vonbank A, Resl M, Pieber TR, Stechemesser L, Sourij H. [Hospital diabetes management (Update 2019)]. Wien Klin Wochenschr 2019; 131:200-211. [PMID: 30980162 DOI: 10.1007/s00508-019-1447-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This position statement presents the recommendations of the Austrian Diabetes Association for diabetes management of adult patients during inpatient stay. It is based on the current evidence with respect to blood glucose targets, insulin therapy and treatment with oral antidiabetic drugs during inpatient hospitalization. Additionally, special circumstances such as intravenous insulin therapy, concomitant therapy with glucocorticoids and use of diabetes technology during hospitalization are discussed.
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Affiliation(s)
- Julia K Mader
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich.
| | - Johanna Brix
- 1. Medizinische Abteilung mit Diabetologie, Endokrinologie und Nephrologie, Krankenanstalt Rudolfstiftung, Wien, Österreich
| | - Felix Aberer
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Alexander Vonbank
- Innere Medizin I mit Kardiologie, Angiologie, Endokrinologie, Diabetologie und Intensivmedizin, Akademisches Lehrkrankenhaus Feldkirch, Feldkirch, Österreich
| | - Michael Resl
- Abteilung für Innere Medizin, Konventhospital der Barmherzigen Brüder Linz, Linz, Österreich
| | - Thomas R Pieber
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
| | - Lars Stechemesser
- Universitätsklinik für Innere Medizin I, Paracelsus Medizinische Privatuniversität - Landeskrankenhaus, Salzburg, Österreich
| | - Harald Sourij
- Klinische Abteilung für Endokrinologie und Diabetologie, Universitätsklinik für Innere Medizin, Medizinische Universität Graz, Auenbruggerplatz 15, 8036, Graz, Österreich
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29
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Hemoglobin A1c and Permissive Hyperglycemia in Patients in the Intensive Care Unit with Diabetes. Crit Care Clin 2019; 35:289-300. [DOI: 10.1016/j.ccc.2018.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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30
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Dutt T, Kashyap R, Surani S. Do we need to screen every patient in intensive care unit for diabetes in community with high prevalence of diabetes? World J Diabetes 2019; 10:137-139. [PMID: 30891149 PMCID: PMC6422860 DOI: 10.4239/wjd.v10.i3.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 02/27/2019] [Accepted: 03/08/2019] [Indexed: 02/05/2023] Open
Abstract
Diabetes mellitus (DM) is marked as global health care challenge with almost 10% of the United States population being diagnosed with DM. A sizeable percentage of patients are oblivious of their disease, in spite of easily accessibility knowledge about its early signs and symptoms and rapid diagnostic modalities. Critically ill patients with undiagnosed DM are likely to have an increased mortality as compared to intensive care unit (ICU) patients with diagnosed DM. DM may have adverse effect on ICU patients causing organ failure and complications. Early Screening of patients at the risk of developing disease may prevent long term complications. Early screening and management may be beneficial as controlled DM patients have similar morbidity as non DM patients in ICU. An intense glycaemic and blood pressure control improves retinopathy and albuminuria, but may not affect the macrovascular outcomes.
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Affiliation(s)
- Taru Dutt
- Department of Neurology Research, Mayo Clinic, Rochester, MN 55902, United States
| | - Rahul Kashyap
- Department of Anesthesiology and Peri-operative Medicine, Critical Care IMP, Mayo Clinic, Rochester, MN 55902, United States
| | - Salim Surani
- Health Science Center, Texas A and M University, Corpus Christi, TX 78404, United States
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31
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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33
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Aramendi I, Burghi G, Manzanares W. Dysglycemia in the critically ill patient: current evidence and future perspectives. Rev Bras Ter Intensiva 2018; 29:364-372. [PMID: 29044305 PMCID: PMC5632980 DOI: 10.5935/0103-507x.20170054] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/16/2017] [Indexed: 12/11/2022] Open
Abstract
Dysglycemia in critically ill patients (hyperglycemia, hypoglycemia, glycemic
variability and time in range) is a biomarker of disease severity and is
associated with higher mortality. However, this impact appears to be weakened in
patients with previous diabetes mellitus, particularly in those with poor
premorbid glycemic control; this phenomenon has been called "diabetes paradox".
This phenomenon determines that glycated hemoglobin (HbA1c) values should be
considered in choosing glycemic control protocols on admission to an intensive
care unit and that patients' target blood glucose ranges should be adjusted
according to their HbA1c values. Therefore, HbA1c emerges as a simple tool that
allows information that has therapeutic utility and prognostic value to be
obtained in the intensive care unit.
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Affiliation(s)
- Ignacio Aramendi
- Centro Nacional de Quemados, Hospital de Clínicas Dr. Manuel Quintela, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - Gastón Burghi
- Centro Nacional de Quemados, Hospital de Clínicas Dr. Manuel Quintela, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
| | - William Manzanares
- Cátedra de Medicina Intensiva, Hospital de Clínicas Dr. Manuel Quintela, Facultad de Medicina, Universidad de la República - Montevideo, Uruguay
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34
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Abstract
The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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35
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Du YT, Kar P, Abdelhamid YA, Horowitz M, Deane AM. Glycated haemoglobin is increased in critically ill patients with stress hyperglycaemia: Implications for risk of diabetes in survivors of critical illness. Diabetes Res Clin Pract 2018; 135:73-75. [PMID: 29133202 DOI: 10.1016/j.diabres.2017.10.029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/02/2017] [Accepted: 10/26/2017] [Indexed: 02/07/2023]
Abstract
It remains uncertain if stress hyperglycaemia (SH) indicates a long-term predisposition to the development of type 2 diabetes. We conducted a retrospective observational study in critically ill patients and found SH to be associated with an increased HbA1c, which may indicate an increased risk of type 2 diabetes.
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Affiliation(s)
- Yang T Du
- Discipline of Medicine, The University of Adelaide, Adelaide, SA 5000, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia.
| | - Palash Kar
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5000, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, SA 5000, Australia; Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Michael Horowitz
- Discipline of Medicine, The University of Adelaide, Adelaide, SA 5000, Australia; Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA 5000, Australia
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC 3050, Australia
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36
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Diabetes Is Not Associated With Increased 90-Day Mortality Risk in Critically Ill Patients With Sepsis. Crit Care Med 2017; 45:e1026-e1035. [PMID: 28737575 DOI: 10.1097/ccm.0000000000002590] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To determine the association of pre-existing diabetes, hyperglycemia, and hypoglycemia during the first 24 hours of ICU admissions with 90-day mortality in patients with sepsis admitted to the ICU. DESIGN We used mixed effects logistic regression to analyze the association of diabetes, hyperglycemia, and hypoglycemia with 90-day mortality (n = 128,222). SETTING All ICUs in the Netherlands between January 2009 and 2014 that participated in the Dutch National Intensive Care Evaluation registry. PATIENTS All unplanned ICU admissions in patients with sepsis. INTERVENTIONS The association between 90-day mortality and pre-existing diabetes, hyperglycemia, and hypoglycemia, corrected for other factors, was analyzed using a generalized linear mixed effect model. MEASUREMENTS AND MAIN RESULTS In a multivariable analysis, diabetes was not associated with increased 90-day mortality. In diabetes patients, only severe hypoglycemia in the absence of hyperglycemia was associated with increased 90-day mortality (odds ratio, 2.95; 95% CI, 1.19-7.32), whereas in patients without pre-existing diabetes, several combinations of abnormal glucose levels were associated with increased 90-day mortality. CONCLUSIONS In the current retrospective large database review, diabetes was not associated with adjusted 90-day mortality risk in critically ill patients admitted with sepsis.
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39
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Affiliation(s)
- Mala Dharmalingam
- Department of Endocrinology, M.S. Ramaiah Medical College, Bengaluru, Karnataka, India
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40
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Affiliation(s)
- S K Todi
- Department of Critical Care Medicine, AMRI Hospitals, Kolkata, West Bengal, India
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41
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Plummer MP, Finnis ME, Phillips LK, Kar P, Bihari S, Biradar V, Moodie S, Horowitz M, Shaw JE, Deane AM. Stress Induced Hyperglycemia and the Subsequent Risk of Type 2 Diabetes in Survivors of Critical Illness. PLoS One 2016; 11:e0165923. [PMID: 27824898 PMCID: PMC5100960 DOI: 10.1371/journal.pone.0165923] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/19/2016] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Stress induced hyperglycemia occurs in critically ill patients who have normal glucose tolerance following resolution of their acute illness. The objective was to evaluate the association between stress induced hyperglycemia and incident diabetes in survivors of critical illness. DESIGN Retrospective cohort study. SETTING All adult patients surviving admission to a public hospital intensive care unit (ICU) in South Australia between 2004 and 2011. PATIENTS Stress induced hyperglycemia was defined as a blood glucose ≥ 11.1 mmol/L (200 mg/dL) within 24 hours of ICU admission. Prevalent diabetes was identified through ICD-10 coding or prior registration with the Australian National Diabetes Service Scheme (NDSS). Incident diabetes was identified as NDSS registration beyond 30 days after hospital discharge until July 2015. The predicted risk of developing diabetes was described as sub-hazard ratios using competing risk regression. Survival was assessed using Cox proportional hazards regression. MAIN RESULTS Stress induced hyperglycemia was identified in 2,883 (17%) of 17,074 patients without diabetes. The incidence of type 2 diabetes following critical illness was 4.8% (821 of 17,074). The risk of diabetes in patients with stress induced hyperglycemia was approximately double that of those without (HR 1.91 (95% CI 1.62, 2.26), p<0.001) and was sustained regardless of age or severity of illness. CONCLUSIONS Stress induced hyperglycemia identifies patients at subsequent risk of incident diabetes.
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Affiliation(s)
- Mark P. Plummer
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
- * E-mail:
| | - Mark E. Finnis
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
| | - Liza K. Phillips
- Discipline of Medicine, University of Adelaide, Level 6 Eleanor Harrald Building, Adelaide, South Australia, Australia
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Palash Kar
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
| | - Shailesh Bihari
- Department of Critical Care Medicine, Flinders University, Bedford Park, South Australia, Australia
- Department of Intensive Care Medicine, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Vishwanath Biradar
- Department of Intensive Care Medicine, Lyell McEwin Hospital, Elizabeth Vale, South Australia, Australia
| | - Stewart Moodie
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Discipline of Medicine, University of Adelaide, Level 6 Eleanor Harrald Building, Adelaide, South Australia, Australia
- Department of Endocrinology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Jonathan E. Shaw
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Adam M. Deane
- Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Level 5 Eleanor Harrald Building, Adelaide, South Australia, Australia
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42
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Haldar R, Khandelwal A, Gupta D, Srivastava S, Singh PK. Acute post-operative diabetic ketoacidosis: Atypical harbinger unmasking latent diabetes mellitus. Indian J Anaesth 2016; 60:763-765. [PMID: 27761041 PMCID: PMC5064702 DOI: 10.4103/0019-5049.191697] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Hyperglycaemia following surgical and anaesthetic stress is a well-established entity which might have undesirable clinical consequences in known diabetics. We encountered a rare event where an undiagnosed diabetic patient developed ketoacidosis in the immediate post-operative period which was her initial presenting symptom of deranged glucoregulation. Presumably, the stress induced by surgery and anaesthesia lead to the genesis of this event. We discuss the management of this case. In addition, we highlight the importance of glycosylated haemoglobin as a subject of future research in identifying such “at risk” patients and for stratifying the risk of hyperglycaemic complications in perioperative settings.
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Affiliation(s)
- Rudrashish Haldar
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ankur Khandelwal
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Devendra Gupta
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shashi Srivastava
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Prabhat K Singh
- Department of Anaesthesiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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