Diabetes Is Not Associated With Increased 90-Day Mortality Risk in Critically Ill Patients With Sepsis

Prevalence and outcomes of chronic comorbid conditions in patients with sepsis in Korea: a nationwide cohort study from 2011 to 2016

BACKGROUND

Chronic comorbid conditions are common in patients with sepsis and may affect the outcomes. This study aimed to evaluate the prevalence and outcomes of common comorbidities in patients with sepsis.

METHODS

We conducted a nationwide retrospective cohort study. Using data from the National Health Insurance Service of Korea. Adult patients (age ≥ 18 years) who were hospitalized in tertiary or general hospitals with a diagnosis of sepsis between 2011 and 2016 were analyzed. After screening of all International Classification of Diseases 10th revision codes for comorbidities, we identified hypertension, diabetes mellitus (DM), liver cirrhosis (LC), chronic kidney disease (CKD), and malignancy as prevalent comorbidities.

RESULTS

Overall, 373,539 patients diagnosed with sepsis were hospitalized in Korea between 2011 and 2016. Among them, 46.7% had hypertension, 23.6% had DM, 7.4% had LC, 13.7% had CKD, and 30.7% had malignancy. In-hospital mortality rates for patients with hypertension, DM, LC, CKD, and malignancy were 25.5%, 25.2%, 34.5%, 28.0%, and 33.3%, respectively, showing a decreasing trend over time (P < 0.001). After adjusting for baseline characteristics, male sex, older age, use of mechanical ventilation, and continuous renal replacement therapy, LC, CKD, and malignancy were significantly associated with in-hospital mortality.

CONCLUSIONS

Hypertension is the most prevalent comorbidity in patients with sepsis, and it is associated with an increased survival rate. Additionally, liver cirrhosis, chronic kidney disease, and malignancy result in higher mortality rates than hypertension and DM, and are significant risk factors for in-hospital mortality in patients with sepsis.

National ICU Registries as Enablers of Clinical Research and Quality Improvement

OBJECTIVES

Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement.

DATA SOURCES

English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix.

STUDY SELECTION

Original research, review articles, letters, and commentaries, were considered.

DATA EXTRACTION

Data from relevant literature were identified, reviewed, and integrated into a concise narrative review.

DATA SYNTHESIS

CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs.

CONCLUSIONS

ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.

The relationship between hyperglycaemia on admission and patient outcome is modified by hyperlactatemia and diabetic status: a retrospective analysis of the eICU collaborative research database

Both blood glucose and lactate are well-known predictors of organ dysfunction and mortality in critically ill patients. Previous research has shown that concurrent adjustment for glucose and lactate modifies the relationship between these variables and patient outcomes, including blunting of the association between blood glucose and patient outcome. We aim to investigate the relationship between ICU admission blood glucose and hospital mortality while accounting for lactate and diabetic status. Across 43,250 ICU admissions, weighted to account for missing data, we assessed the predictive ability of several logistic regression and generalised additive models that included blood glucose, blood lactate and diabetic status. We found that inclusion of blood glucose marginally improved predictive performance in all patients: AUC-ROC 0.665 versus 0.659 (p = 0.005), with a greater degree of improvement seen in non-diabetics: AUC-ROC 0.675 versus 0.663 (p < 0.001). Inspection of the estimated risk profiles revealed the standard U-shaped risk profile for blood glucose was only present in non-diabetic patients after controlling for blood lactate levels. Future research should aim to utilise observational data to estimate whether interventions such as insulin further modify this effect, with the goal of informing future RCTs of interventions targeting glycaemic control in the ICU.

Use of Peak Glucose Level and Peak Glycemic Gap in Mortality Risk Stratification in Critically Ill Patients with Sepsis and Prior Diabetes Mellitus of Different Body Mass Indexes

Sepsis remains a critical concern in healthcare, and its management is complicated when patients have pre-existing diabetes and varying body mass indexes (BMIs). This retrospective multicenter observational study, encompassing data from 15,884 sepsis patients admitted between 2012 and 2017, investigates the relationship between peak glucose levels and peak glycemic gap in the first 3 days of ICU admission, and their impact on mortality. The study reveals that maintaining peak glucose levels between 141-220 mg/dL is associated with improved survival rates in sepsis patients with diabetes. Conversely, peak glycemic gaps exceeding 146 mg/dL are linked to poorer survival outcomes. Patients with peak glycemic gaps below -73 mg/dL also experience inferior survival rates. In terms of predicting mortality, modified Sequential Organ Failure Assessment-Peak Glycemic Gap (mSOFA-pgg) scores outperform traditional SOFA scores by 6.8% for 90-day mortality in overweight patients. Similarly, the modified SOFA-Peak Glucose (mSOFA-pg) score demonstrates a 17.2% improvement over the SOFA score for predicting 28-day mortality in underweight patients. Importantly, both mSOFA-pg and mSOFA-pgg scores exhibit superior predictive power compared to traditional SOFA scores for patients at high nutritional risk. These findings underscore the importance of glycemic control in sepsis management and highlight the potential utility of the mSOFA-pg and mSOFA-pgg scores in predicting mortality risk, especially in patients with diabetes and varying nutritional statuses.

Association of stress hyperglycemia with clinical outcomes in patients with ST-elevation myocardial infarction undergoing percutaneous coronary intervention: a cohort study

BACKGROUND

In recent years, several studies have demonstrated that stress hyperglycemia is significantly associated with poor prognosis in patients diagnosed with acute coronary syndrome (ACS). In the present study, we aimed to investigate the potential associations between various markers of stress hyperglycemia, such as admission blood glucose (ABG), fasting blood sugar (FBS), and stress hyperglycemia ratio (SHR) with different definitions, and the occurrence of adverse cardiovascular events in patients diagnosed with ST-elevation myocardial infarction (STEMI) who have undergone percutaneous coronary intervention (PCI).

METHODS

Our study enrolled a total of 1099 patients diagnosed with STEMI who underwent PCI from 2016 to 2021. The primary outcomes of this study were in-hospital death and all-cause mortality.

RESULTS

Stress hyperglycemia was associated with a higher incidence of in-hospital death (ABG OR: 1.27 95% CI 1.19-1.36; FBS OR: 1.25 95% CI 1.16-1.35; SHR1 OR: 1.61 95% CI 1.21-2.14; SHR2 OR: 1.57, 95%CI 1.22-2.01; SHR3 OR: 1.59, 95%CI 1.24-2.05) and all-cause mortality (ABG HR: 1.10, 95% CI 1.07-1.14; FBS HR: 1.12, 95 CI 1.07-1.17; SHR1 HR: 1.19 95% CI 1.03-1.39; SHR2 HR: 1.28, 95%CI 1.14-1.44; SHR3 HR: 1.29, 95%CI 1.14-1.45) after adjusting for ischemic time, age, gender, BMI, hypertension, hyperlipidemia, diabetes mellitus (DM), current smoking history, chronic kidney disease (CKD), previous history of coronary artery disease (CAD), atrial fibrillation (AF), heart failure (HF), stroke, cancer, culprit vessel, multi-vessel disease. These associations exhibited a non-linear, J-shaped pattern, wherein the risk significantly increased when the ABG and FBS levels exceeded 5mmol/L. Moreover, the inflection point for SHR was estimated to be 1.2.

CONCLUSIONS

Stress hyperglycemia was significantly associated with an increased risk of in-hospital death and all-cause mortality in STEMI patients treated with PCI. Stress hyperglycemia should be considered a high-risk prognostic marker in all STEMI patients, regardless of with or without diabetes.

Open Abdomen in Elderly Patients With Surgical Sepsis: Predictors of Mortality

INTRODUCTION

Elderly patients are frequently presenting with emergency surgical conditions. The open abdomen technique is widely used in abdominal emergencies needing rapid control of intrabdominal contamination. However, specific predictors of mortality identifying candidates for comfort care are understudied.

METHODS

The 2013-2017 the American College of Surgeons-National Surgical Quality Improvement Program database was queried for emergent laparotomies performed in geriatric patients with sepsis or septic shock in whom fascial closure was delayed. Patients with acute mesenteric ischemia were excluded. The primary outcome was 30-d mortality. Univariable analysis, followed by multivariable logistic regression, was performed. Mortality was computed for combinations of the five predictors with the highest odds ratios (OR).

RESULTS

A total of 1399 patients were identified. The median age was 73 (69-79) y, and 54.7% were female. 30-d mortality was 50.6%. In the multivariable analysis, the most important predictors were as follows: American Society of Anesthesiologists status 5 (OR = 4.80, 95% confidence interval [CI], 1.85-12.49 P = 0.002), dialysis dependence (OR = 2.65, 95% CI 1.54-4.57, P < 0.001), congestive hearth failure (OR = 2.53, 95% CI 1.52-4.21, P < 0.001), disseminated cancer (OR = 2.61, 95% CI 1.55-4.38, P < 0.001), and preoperative platelet count of <100,000 cells/μL (OR = 1.87, 95% CI 1.15-3.04, P = 0.011). The presence of two or more of these factors resulted in over 80% mortality. The absence of all these risk factors results in a survival rate of 62.1%.

CONCLUSIONS

In elderly patients, surgical sepsis or septic shock requiring an open abdomen for surgical management is highly lethal. The presence of several combinations of preoperative comorbidities is associated with a poor prognosis and can identify patients who can benefit from timely initiation of palliative care.

Undernutrition Scored Using the CONUT Score with Hypoglycemic Status in ICU-Admitted Elderly Patients with Sepsis Shows Increased ICU Mortality

This study aimed to clarify whether the influence of undernutrition status and the degree of glycemic disorders affected the prognosis of patients with sepsis. A total of 307 adult patients with sepsis were retrospectively enrolled and analyzed. Characteristics, including nutrition status, calculated according to the Controlling Nutritional Status (CONUT) score of survivors and non-survivors, were examined. The independent prognostic factors of these patients with sepsis were extracted using multivariable logistic regression analysis. The CONUT scores in three glycemic categories were compared. Most patients with sepsis (94.8%) in the study had an undernutrition status according to their CONUT scores. High CONUT scores (odds ratio, 1.214; p = 0.002), indicating a poor nutritional status, were associated with high mortality. The CONUT scores in the hypoglycemic group were significantly higher than those in other groups with an undernutrition status (vs. hyperglycemic, p < 0.001; vs. intermediate glycemic, p = 0.006). The undernutrition statuses of patients with sepsis in the study scored using the CONUT were independent predictors of prognostic factors.

Association between type II diabetes mellitus and 90-day mortality in a large multicenter prospectively collected cohort. A FROG ICU post-hoc study

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.

Early Lactate Clearance as a Determinant of Survival in Patients with Sepsis: Findings from a Low-resource Country

Background

Single lactate measurements have been reported to have prognostic significance, however, there is a lack of data in local literature from Pakistan. This study was done to determine prognostic role of lactate clearance in sepsis patients being managed in our lower-middle income country.

Methods

This prospective cohort study was conducted from September 2019-February 2020 at the Aga Khan University Hospital, Karachi. Patients were enrolled using consecutive sampling and categorized based on their lactate clearance status. Lactate clearance was defined as decrease by 10% or greater in repeat lactate from the initial measurement (or both initial and repeat levels <=2.0 mmol/L).

Results

A total 198 patients were included in the study, 51% (101) were male. Multi-organ dysfunction was reported in 18.6% (37), 47.7% (94) had single organ dysfunction, and 33.8% (67) had no organ dysfunction. Around 83% (165) were discharged and 17% (33) died. There were missing data for 25.8% (51) of the patients for the lactate clearance, whereas 55% (108) patients had early lactate clearance and 19.7% (39) had delayed lactate clearance.On univariate analysis, mortality rate was higher in patients with delayed lactate clearance (38.4% vs 16.6%) and patients were 3.12 times (OR = 3.12; [95% CI: 1.37-7.09]) more likely to die as compared with early lactate clearance. Patients with delayed lactate clearance had higher organ dysfunction (79.4% vs 60.1%) and were 2.56 (OR = 2.56; [95% CI: 1.07-6.13]) times likely to have organ dysfunction. On multivariate analysis, after adjusting for age and co-morbids, patients with delayed lactate clearance were 8 times more likely to die than patients with early lactate clearance [aOR = 7.67; 95% CI:1.11-53.26], however, there was no statistically significant association between delayed lactate clearance [aOR = 2.18; 95% CI: 0.87-5.49)] and organ dysfunction.

Conclusion

Lactate clearance is a better determinant of sepsis and septic shock effective management. Early lactate clearance is related to better outcomes in septic patients.

Association of Blood Glucose Level and Glycemic Variability With Mortality in Sepsis Patients During ICU Hospitalization

Background

There was considerable debate regarding the effect of mean blood glucose (MBG) and glycemic variability (GV) on the mortality of septic patients. This retrospective cohort study aimed to assess the association between MBG and GV with ICU mortality of sepsis patients and to explore the optimal MBG range.

Methods

Sepsis patients were enrolled from the Medical Information Mart for Intensive Care IV database (MIMIC-IV). MBG and glycemic coefficient of variation (GluCV) were, respectively, calculated to represent the overall glycemic status and GV during ICU stay. The associations between MBG, GluCV, and ICU mortality of the septic patients were assessed by using multivariate logistic regression in different subgroups and the severity of sepsis. Restricted cubic splines evaluated the optimal MBG target.

Results

A total of 7,104 adult sepsis patients were included. The multivariate logistic regression results showed that increased MBG and GluCV were significantly correlated with ICU mortality. The adjusted odds ratios were 1.14 (95% CI 1.09-1.20) and 1.05 (95% CI 1.00-1.12). However, there was no association between hyperglycemia and ICU mortality among diabetes, liver disease, immunosuppression, and hypoglycemia patients. And the impact of high GluCV on ICU mortality was not observed in those with diabetes, immunosuppression, liver disease, and non-septic shock. The ICU mortality risk of severe hyperglycemia (≧200 mg/dl) and high GluCV (>31.429%), respectively, elevated 2.30, 3.15, 3.06, and 2.37, 2.79, 3.14-folds in mild (SOFA ≦ 3), middle (SOFA 3-7), and severe group (SOFA ≧ 7). The MBG level was associated with the lowest risk of ICU mortality and hypoglycemia between 120 and 140 mg/dl in the subgroup without diabetes. For the diabetic subset, the incidence of hypoglycemia was significantly reduced when the MBG was 140-190 mg/dl, but a glycemic control target effectively reducing ICU mortality was not observed.

Conclusion

MBG and GluCV during the ICU stay were associated with all-cause ICU mortality in sepsis patients; however, their harms are not apparent in some particular subgroups. The impact of hyperglycemia and high GV on death increased with the severity of sepsis. The risk of ICU mortality and hypoglycemia in those with no pre-existing diabetes was lower when maintaining the MBG in the range of 120-140 mg/dl.

Impact of Oxygen Saturation on Mortality in Obese and Non-obese Critically Ill Patients With Mechanical Ventilation: A Retrospective Observational Study

Background

The main aim of this study was to evaluate the effect of oxygen saturation on mortality in critically ill patients with mechanical ventilation according to obesity status.

Methods

We conducted an observational study in mechanically ventilated patients admitted to the ICU retrospectively. Demographic, arterial blood gas, ventilator setting, interventions, and peripheral oxygen saturation (Spo₂) during the first 24 h were recorded and analyzed between non-obese and obese patients. The main exposure included Spo₂, time-weighted mean Spo₂ (TWM-Spo₂), and proportion of time spent in different Spo₂ (PTS-Spo₂) levels. The primary outcome was hospital mortality. We used multivariable logistic regression models to assess the relationship between Spo₂ and mortality, as well as the interaction between PTS-Spo₂ and obesity status.

Results

A total of 25,100 patients were included, of which 10,564 (42%) were obese patients. After adjusting for confounders, compared with TWM-Spo₂ of 94–98%, TWM-Spo₂ of < =88% (OR 3.572; CI [2.343, 5.455]; p < 0.001) and of 89–93% (OR 1.514; CI [1.343, 1.706]; p < 0.001) were both associated with higher risk of mortality. PTS-Spo₂ of 99–100% was associated with increased risk of mortality for obese patients (OR 1.028; 95% CI 1.010–1.046; p = 0.002; P_{interaction =} 0.001), while PTS-Spo₂ of 89–93% was associated with increased risk of mortality (OR 1.089; 95% CI 1.051–1.128; p < 0.001; P_{interaction =} 0.001) for non-obese patients.

Conclusions

For obese and non-obese critically ill patients with mechanical ventilation, the impact of oxygen saturation on hospital mortality is different.

Impact of diabetes mellitus on outcomes of patients with sepsis: an updated systematic review and meta-analysis

BACKGROUND

The effect of concurrent diabetes on the outcome of sepsis is not conclusively known. A meta-analysis published in 2017 indicated that diabetes did not influence the mortality of patients with sepsis but increased the risk of acute renal injury. In view of publication of several new studies in recent years, there is a need for updated evidence.

METHODS

A systematic search was conducted using the PubMed, Scopus, Embase, and Google Scholar databases. Studies that were done in patients with sepsis, were observational in design- either cohort or case-control or analysed retrospective data were considered for inclusion. Statistical analysis was performed using STATA software.

RESULTS

A total of 21 studies were included. The risk of in-hospital mortality (RR 0.98, 95% CI 0.93, 1.04) and mortality at latest follow up i.e., within 90 days of discharge (RR 0.94, 95% CI 0.86, 1.04) among diabetic and non-diabetic subjects was statistically similar. There was an increased risk of in-hospital mortality among those with high blood glucose level at admission (RR 1.45, 95% CI 1.01, 2.09). Among those who were diabetic, the risk of acute renal failure (RR 1.54, 95% CI 1.34, 1.78) was higher than non-diabetics. The risk of respiratory failure, adverse cardiac events, need for additional hospitalization post-discharge and length of hospital stay was similar among diabetics and non-diabetics.

CONCLUSIONS

Diabetes is not associated with poor survival outcomes in patients with sepsis but is associated with increased risk of acute renal failure. High blood glucose levels, irrespective of the diabetes status, are associated with increased risk of in-hospital mortality. Findings underscore the need for better evaluation of renal function in diabetic patients with concurrent sepsis.

Association between hyperglycemia and adverse clinical outcomes of sepsis patients with diabetes

BACKGROUND

Hyperglycemia is one of the poor prognostic factors in critical ill sepsis patients with diabetes. We aimed to assess the interaction between admission glucose level and clinical endpoints in sepsis patients with diabetes admitted in the intensive care unit (ICU).

METHODS

Data from the Medical Information Mart Intensive Care III database were used in this study. The study primary endpoint was 28-day mortality after ICU admission. Multivariate Cox regression models were used to explore the association between admission glucose level and the primary endpoint.

RESULTS

We included 3,500 sepsis patients with diabetes. Of participants with no hyperglycemia, mild hyperglycemia, and severe hyperglycemia, no differences were evident in hospital mortality, ICU mortality, or 28-day mortality (all P >0.05). The multivariable Cox regression analysis demonstrated that severe hyperglycemia did not increase the risk of 28-day mortality (hazard ratio [HR]=1.06, 95% confidence interval [CI]: 0.86-1.31, P=0.5880). Threshold effects analysis identified the inflection points for 28-day mortality as 110 mg/dl and 240 mg/dl. The HRs for 28-day mortality were 0.980 in the <110 mg/dl and 1.008 in the >240 mg/dl. A short-term survival advantage was observed in the 110-240 mg/dl group compared with that in the <110 mg/dl group; meanwhile, no adverse hazard was detected in the >240 mg/dl group. In the stratified analyses, the association effect between the three glucose groups (<110 mg/dl, 110-240 mg/dl, and ≥240 mg/dl) and 28-day mortality was consistent in terms of different sequential organ failure assessment (SOFA) scores and infection sites. The 28-day mortality of the 110-240 mg/dl group with a SOFA score of ≥10 was lower than that of the <110 mg/dl group (HR=0.61, 95% CI: 0.38-0.98).

CONCLUSION

Admission hyperglycemia was not a risk factor for short-term prognosis in critical ill sepsis patients with diabetes; a lower admission blood glucose level was associated with increased risk of poor prognosis. The potential benefit of higher admission glucose level on 28-day mortality in patients with a more severe condition remains a concern.

Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage

BACKGROUND AND PURPOSE

We evaluated the effect of persistent hyperglycemia on outcomes in 1000 patients with intracerebral hemorrhage enrolled within 4.5 hours of symptom onset.

METHODS

We defined moderate and severe hyperglycemia based on serum glucose levels ≥140 mg/dL-<180 and ≥180 mg/dL, respectively, measured at baseline, 24, 48, and 72 hours. Persistent hyperglycemia was defined by 2 consecutive (24 hours apart) serum glucose levels. We evaluated the relationship between moderate and severe hyperglycemia and death or disability (defined by modified Rankin Scale score of 4-6) at 90 days in the overall cohort and in groups defined by preexisting diabetes.

RESULTS

In the multivariate analysis, both moderate (odds ratio, 1.8 [95% CI, 1.1-2.8]) and severe (odds ratio, 1.8 [95% CI, 1.2-2.7]) hyperglycemia were associated with higher 90-day death or disability after adjusting for Glasgow Coma Scale score, hematoma volume, presence or absence of intraventricular hemorrhage, hyperlipidemia, cigarette smoking, and hypertension (no interaction between hyperglycemia and preexisting diabetes, P=0.996). Among the patients without preexisting diabetes, both moderate (odds ratio, 1.8 [95% CI, 1.0-3.2]) and severe (odds ratio, 2.0 [95% CI, 1.1-3.7]) hyperglycemia were associated with 90-day death or disability after adjusting for above mentioned potential confounders. Among the patients with preexisting diabetes, moderate and severe hyperglycemia were not associated with 90-day death or disability.

CONCLUSIONS

Persistent hyperglycemia, either moderate or severe, increased the risk of death or disability in nondiabetic patients with intracerebral hemorrhage.

REGISTRATION

URL: https://www.clinicaltrials.gov; Unique identifier: NCT01176565.

Admission Blood Glucose Is Associated With the 30-Days Mortality in Septic Patients: A Retrospective Cohort Study

Background: Sepsis, as one of the severe diseases, is frequently observed in critically ill patients, especially concurrent with diabetes. Whether admission blood glucose is associated with the prognosis, and outcome of septic patients is still debatable.

Methods: We retrospectively reviewed and analyzed the demographic characteristics of septic patients in the Medical Information Mart for Intensive Care III (MIMIC III, version 1.4) between June 2001 and October 2012. The Chi-square and Fisher's exact tests were used for the comparison of qualitative variables among septic patients with different glucose levels and the 30-day mortality in septic patients with diabetes or not. Univariate and stepwise multivariate Cox regression analyses were used to determine the risk factors for 30-day mortality. Kaplan-Meier analysis was conducted to reveal the different 30-day survival probabilities in each subgroup.

Results: A total of 2,948 septic patients (910 cases with diabetes, 2,038 cases without diabetes) were ultimately included in the study. The 30-day mortality was 32.4% (956/2,948 cases) in the overall population without any difference among diabetic and non-diabetic septic patients (p = 1.000). Admission blood glucose levels <70 mg/dl were only observed to be significantly associated with the 30-day mortality of septic patients without diabetes (hazard ratio (HR) = 2.48, p < 0.001). After adjusting for confounders, age >65 years (HR = 1.53, p = 0.001), the Sequential Organ Failure Assessment (SOFA) score >5 (HR = 2.26, p < 0.001), lactic acid >2 mmol/L (Lac, HR = 1.35, p = 0.024), and platelet abnormality (<100 k/ul: HR = 1.49; >300 k/ul: HR = 1.36, p < 0.001) were the independent risk factors for 30-day mortality in septic patients with diabetes. In non-diabetes population, age >65 years (HR = 1.53, p < 0.001), non-White or non-Black patients (HR = 1.30, p = 0.004), SOFA score >5 (HR = 1.56, p < 0.001), blood glucose <70 mg/dl (HR = 1.91, p = 0.003), anion gap (AG) >2 mmol/L (HR = 1.60, p < 0.001), Lac (HR = 1.61, p < 0.001), urea nitrogen >21 mg/dl (HR = 1.45, p = 0.001), alanine aminotransferase (ALT, HR = 1.31, p = 0.009), total bilirubin >1.2 mg/dl (HR = 1.20, p = 0.033), and low hemoglobin (HR = 1.34, p = 0.001) were the independent risk factors for 30-day mortality.

Conclusions: Our results indicate admission blood glucose, especially in terms of <70 mg/dl, is the key signaling in predicting the worse 30-day survival probability of septic patients without diabetes, which could help clinicians to make a more suitable and precise treatment modality in dealing with septic patients.

Individualised versus conventional glucose control in critically-ill patients: the CONTROLING study-a randomized clinical trial

Purpose

Hyperglycaemia is an adaptive response to stress commonly observed in critical illness. Its management remains debated in the intensive care unit (ICU). Individualising hyperglycaemia management, by targeting the patient’s pre-admission usual glycaemia, could improve outcome.

Methods

In a multicentre, randomized, double-blind, parallel-group study, critically-ill adults were considered for inclusion. Patients underwent until ICU discharge either individualised glucose control by targeting the pre-admission usual glycaemia using the glycated haemoglobin A1c level at ICU admission (IC group), or conventional glucose control by maintaining glycaemia below 180 mg/dL (CC group). A non-commercial web application of a dynamic sliding-scale insulin protocol gave to nurses all instructions for glucose control in both groups. The primary outcome was death within 90 days.

Results

Owing to a low likelihood of benefit and evidence of the possibility of harm related to hypoglycaemia, the study was stopped early. 2075 patients were randomized; 1917 received the intervention, 942 in the IC group and 975 in the CC group. Although both groups showed significant differences in terms of glycaemic control, survival probability at 90-day was not significantly different (IC group: 67.2%, 95% CI [64.2%; 70.3%]; CC group: 69.6%, 95% CI [66.7%; 72.5%]). Severe hypoglycaemia (below 40 mg/dL) occurred in 3.9% of patients in the IC group and in 2.5% of patients in the CC group (p = 0.09). A post hoc analysis showed for non-diabetic patients a higher risk of 90-day mortality in the IC group compared to the CC group (HR 1.3, 95% CI [1.05; 1.59], p = 0.018).

Conclusion

Targeting an ICU patient’s pre-admission usual glycaemia using a dynamic sliding-scale insulin protocol did not demonstrate a survival benefit compared to maintaining glycaemia below 180 mg/dL.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06526-8.

Application of Peak Glucose Range and Diabetes Status in Mortality Risk Stratification in Critically Ill Patients with Sepsis

The effects of diabetes and glucose on the outcomes of patients with sepsis are somewhat conflicting. This retrospective study enrolled 1214 consecutive patients with sepsis, including a subpopulation of 148 patients with immune profiles. The septic patients were stratified according to their Diabetes mellitus (DM) status or peak glucose level (three-group tool; P1: ≤140 mg/dL, P2: 141–220 mg/dL, P3: >220 mg/dL) on day 1. Although the DM group had a lower hazard ratio (HR) for 90-day mortality compared to non-DM patients, the adjusted HRs were insignificant. The modified sequential organ failure assessment-glucose (mSOFA-g) score can predict 90-day survival in patients with and without diabetes (β = 1.098, p < 0.001; β = 1.202, p < 0.001). The goodness of fit of the mSOFA-g score was 5% higher than the SOFA score of the subgroup without diabetes. The SOFA score and human leukocyte antigen-D-related (HLA-DR) expression were comparable between the groups. The P3 group had lower HLA-DR expression on days 1 and 3 and a higher 90-day mortality. The three-group tool was useful for predicting 90-day mortality in patients with separate Kaplan-Meier survival curves and mortality HRs in the construction and validation cohorts. The peak glucose level, instead of diabetes status, can be used as an easy adjunctive tool for mortality risk stratification in critically ill septic patients.

Type 2 diabetes mellitus and sepsis: state of the art, certainties and missing evidence

Diabetes and sepsis are important causes of morbidity and mortality worldwide, and diabetic patients represent the largest population experiencing post-sepsis complications and rising mortality. Dysregulated immune pathways commonly found in both sepsis and diabetes contribute to worsen the host response in diabetic patients with sepsis. The impact of diabetes on mortality from sepsis is still controversial. Whereas a substantial proportion of severe infections can be attributed to poor glycemic control, treatment with insulin, metformin and thiazolidinediones may be associated with lower incidence and mortality for sepsis. It has been suggested that chronic exposure to high glucose might enhance immune adaptation, leading to reduced mortality rate in septic diabetic patients. On the other hand, higher risk of acute kidney injury has been extensively documented and a suggested lower risk of acute respiratory distress syndrome has been recently questioned. Additional investigations are ongoing to confirm the protective role of some anti-diabetic treatments, the occurrence of acute organ dysfunction, and the risk/benefit of less stringent glycemic control in diabetic patients experiencing sepsis. Based on a MEDLINE/PubMed search from inception to December 31, 2020, the aim of this review is therefore to summarize the strengths and weaknesses of current knowledge on the interplay between diabetes and sepsis.

Incidence and Impact of Dysglycemia in Patients with Sepsis Under Moderate Glycemic Control

ABSTRACT

Glycemic control strategies for sepsis have changed significantly over the last decade, but their impact on dysglycemia and its associated outcomes has been poorly understood. In addition, there is controversy regarding the detrimental effects of hyperglycemia in sepsis. To evaluate the incidence and risks of dysglycemia under current strategy, we conducted a preplanned subanalysis of the sepsis cohort in a prospective, multicenter FORECAST study. A total of 1,140 patients with severe sepsis, including 259 patients with pre-existing diabetes, were included. Median blood glucose levels were approximately 140 mg/dL at 0 h and 72 h indicating that blood glucose was moderately controlled. The rate of initial and late hyperglycemia was 27.3% and 21.7%, respectively. The rate of early hypoglycemic episodes during the initial 24 h was 13.2%. Glycemic control was accompanied by a higher percentage of initial and late hyperglycemia but not with early hypoglycemic episodes, suggesting that glycemic control was targeted at excess hyperglycemia. In nondiabetic patients, late hyperglycemia (hazard ratio, 95% confidence interval; p-value: 1.816, 1.116-2.955, 0.016) and early hypoglycemic episodes (1.936, 1.180-3.175, 0.009) were positively associated with in-hospital mortality. Further subgroup analysis suggested that late hyperglycemia and early hypoglycemic episodes independently, and probably synergistically, affect the outcomes. In diabetic patients, however, these correlations were not observed. In conclusion, a significantly high incidence of dysglycemia was observed in our sepsis cohort under moderate glycemic control. Late hyperglycemia in addition to early hypoglycemia was associated with poor outcomes at least in nondiabetic patients. More sophisticated approaches are necessary to reduce the incidence of these serious complications.

Factors Associated with Survival in Patients Undergoing Invasive Mechanical Ventilation in an Intensive Care Unit in Colombia, 2017-2018: A Retrospective Cohort Study

BACKGROUND

Critically ill patients are admitted to intensive care units so they can be comprehensively managed and provided with services not covered in general hospital wards, with the aim to increase their chances of survival. These procedures include invasive mechanical ventilation.

OBJECTIVE

The aim of this study was to identify the factors associated with survival in critically ill patients who required invasive mechanical ventilation in an intensive care unit of a tertiary-level hospital in Colombia.

METHODS

This was a retrospective follow-up study of a cohort of adult patients who required invasive mechanical ventilation in an intensive care unit in San José de Buga Hospital, between 2017 and 2018. Sociodemographic, clinical, and pharmacological variables were identified. Using Cox regression, variables associated with survival and complications were identified.

RESULTS

A total of 357 patients were analyzed. The average age was 64.8 ± 18.9 years, and 52.9% were male. The most frequent diagnoses were sepsis/septic shock (38.4%) and trauma (17.4%). The main factors associated with shorter survival were advanced age (HR 0.97; 95% CI 0.96-0.99), a diagnosis of septic shock (HR 0.29; 95% CI 0.18-0.48) or diabetes mellitus at admission (HR 0.57; 95% CI 0.33-0.98), a healthcare-associated infection (HR 0.51; 95% CI 0.33-0.80), and the need for vasopressors (HR 0.36; 95% CI 0.22-0.59). The administration of systemic corticosteroids was associated with a higher probability of survival (HR 1.93; 95% CI 1.15-3.25).

CONCLUSIONS

The use of systemic corticosteroids was associated with a greater probability of survival in critically ill patients who required invasive mechanical ventilation in an intensive care unit. The identification of the variables associated with a higher risk of dying should allow care protocols to be improved, thereby extending the life expectancy of these patients.

The association of diabetes and hyperglycemia with sepsis outcomes: a population-based cohort analysis

The independent association of diabetes and hyperglycemia on the outcomes of sepsis remains unclear. We conducted retrospective cohort analyses of outcomes among patients with community-onset sepsis admitted to Shamir Medical Center, Israel (08-12/2016). Statistical associations were queried by Cox and logistic regressions, controlled for by matched propensity score analyses. Among 1527 patients with community-onset sepsis, 469 (30.7%) were diabetic. Diabetic patients were significantly older, with advanced complexity of comorbidities, and were more often exposed to healthcare environments. Despite statistically significant univariable associations with in-hospital and 90-day mortality, the adjusted Hazard Ratios (aHR) were 1.21 95% CI 0.8-1.71, p = 0.29 and 1.13 95% CI 0.86-1.49, p = 0.37, respectively. However, hyperglycemia at admission (i.e., above 200 mg/dl (was independently associated with: increased in-hospital mortality, aHR 1.48 95% CI 1.02-2.16, p = 0.037, 30-day mortality, aHR 1.8 95% CI 1.12-2.58, p = 0.001), and 90-day mortality, aHR 1.68 95% CI 1.24-2.27, p = 0.001. This association was more robust among diabetic patients than those without diabetes. In this study, diabetes was not associated with worse clinical outcomes in community-onset sepsis. However, high glucose levels at sepsis onset are independently associated with a worse prognosis, particularly among diabetic patients. Future trials should explore whether glycemic control could impact the outcomes and should be part of the management of sepsis, among the general adult septic population.

Diabetes on sepsis outcomes in non-ICU patients: A cohort study and review of the literature

AIMS

We sought to determine whether primary outcomes differ between non-ICU septic patients with and without type 2 diabetes (T2D).

METHODS

This study utilized the Hellenic Sepsis Study Group Registry, collecting nationwide data for sepsis patients since 2006, and classified patients upon presence or absence of T2D. Patients were perfectly matched for a) Sepsis 3 definition criteria (including septic shock) b) gender, c) age, d) APACHE II score and e) Charlson's comorbidity index (CCI). Independent sample t-test and chi-square t-test was used to compare prognostic indices and primary outcomes.

RESULTS

Of 4320 initially included non-ICU sepsis patients, 812 were finally analysed, following match on criteria. Baseline characteristics were age 76 [±10.3] years, 46% male, APACHE II 15.5 [±6], CCI 5.1 [±1.8], 24% infection, 63.8% sepsis and 12.2% septic shock. No significant difference was noted between two groups in qSOFA, SOFA, or suPAR1 levels (p = 0.7, 0.1 & 0.3) respectively. Primary sepsis syndrome resolved in 70.9% of cases (p = 0.9), while mortality was 24% in 28-days time. Cause of death was similar between patients with and without T2D (sepsis 17.8% vs 15.8%, heart event 3.7% vs 3.2%, CNS event 0.5% vs 0.5%, malignancy 0.7% vs 2% respectively, p = 0.6).

CONCLUSIONS

DM does not appear to negatively affect outcomes in septic patients not requiring ICU.

Association between comorbid diabetes mellitus and prognosis of patients with sepsis in the intensive care unit: a retrospective cohort study

Background

Sepsis patients hospitalized in the intensive care unit (ICU) often have comorbid diabetes mellitus (DM). However, the clinical impact of DM on the clinical outcomes of critically ill sepsis patients has yet to be determined. Therefore, the current study aimed to analyze the association of comorbid DM with the prognosis of sepsis patients in the ICU.

Methods

Data of patients with sepsis and comorbid DM were obtained from a large-scale intensive care database. The primary outcome was 28-day mortality after ICU admission. Associations of comorbid DM with the primary outcome were assessed using a multivariable Cox regression model. Different adjusted models, such as the propensity score method, were used to determine the prognosis of the patients.

Results

Overall, 12,321 sepsis patients were enrolled, including 3,509 (28.48%) with comorbid DM. After adjusting and matching, we found that comorbid DM was not an independent risk factor for 28-day mortality in critically ill sepsis patients and was even associated with lower mortality. Propensity score matching showed a dramatically lower 28-day mortality for sepsis patients with comorbid DM in comparison to patients without comorbid DM [hazard ratio (HR): 0.86, 95% confidence interval (CI): 0.77–0.97, P=0.0167]. The relationship of comorbid DM with 28-day mortality was broadly consistent for all subgroup variables. In the stratified analysis, a significant interaction was observed only for glucose concentration (P<0.0001). Patients with comorbid DM and a glucose level of 140–200 mg/dL (7.8–11.1 mmol/L) or ≥200 mg/dL (11.1 mmol/L) had a significantly lower 28-day mortality rate (HR 0.83, 95% CI: 0.71–0.98, P=0.0250 and HR: 0.49, 95% CI: 0.38–0.64, P<0.0001, respectively).

Conclusions

Critically ill patients with sepsis and comorbid DM were not found to have increased 28-day mortality compared to those without comorbid DM, and may even have a lower risk of mortality. Notably, this association remained in the setting of hyperglycemia.

Stress Hyperglycemia and Mortality in Subjects With Diabetes and Sepsis

Objectives:

Poor glycemic control is associated with mortality in critical patients with diabetes. The aim of the study was to assess the predicting value of stress hyperglycemia in patients with diabetes following hospital admission for sepsis.

Design:

Retrospective observational study.

Setting:

Adult, emergency department, and critical care in a district hospital.

Patients:

In a 10-year retrospective analysis of sepsis-related hospitalizations in the emergency department, we carried out a secondary analysis of 915 patients with diabetes (males, 54.0%) in whom both fasting glucose at entry and glycosylated hemoglobin were available.

Interventions:

None.

Measurements and Main Results:

Patients’ mean age was 79.0 (sd 11.0), glucose at admission was 174.0 mg/dL (74.3 mg/dL), and glycosylated hemoglobin was 7.7% (1.7%). Stress hyperglycemia was defined by the stress hyperglycemia ratio, that is, fasting glucose concentration at admission divided by the estimated average glucose derived from glycosylated hemoglobin. A total of 305 patients died (33.3%) in hospital. Factors associated with in-hospital case fatality rate were tested by multivariable logistic model. Ten variables predicting outcomes in the general population were confirmed in the presence of diabetes (male sex, older age, number of organ dysfunction diagnoses, in particular cardiovascular dysfunction, infection/parasitic, circulatory, respiratory, digestive diseases diagnosis, and Charlson Comorbidity Index). In addition, also glycemic control (glycosylated hemoglobin: odds ratio, 1.17; 95% CI, 1.15–1.40) and stress hyperglycemia (stress hyperglycemia ratio: 5.25; 3.62–7.63) were significant case fatality rate predictors. High stress hyperglycemia ratio (≥ 1.14) significantly increased the discriminant capacity (area under the receiver operating characteristic curve, 0.864; se, 0.013; p < 0.001).

Conclusions:

Stress hyperglycemia, even in the presence of diabetes, is predictive of mortality following admission for sepsis. Stress hyperglycemia ratio may be used to refine prediction of an unfavorable outcome.

Is it time to abandon glucose control in critically ill adult patients?

PURPOSE OF REVIEW

To summarize the advances in literature that support the best current practices regarding glucose control in the critically ill.

RECENT FINDINGS

There are differences between patients with and without diabetes regarding the relationship of glucose metrics during acute illness to mortality. Among patients with diabetes, an assessment of preadmission glycemia, using measurement of Hemoglobin A1c (HgbA1c) informs the choice of glucose targets. For patients without diabetes and for patients with low HgbA1c levels, increasing mean glycemia during critical illness is independently associated with increasing risk of mortality. For patients with poor preadmission glucose control the appropriate blood glucose target has not yet been established. New metrics, including stress hyperglycemia ratio and glycemic gap, have been developed to describe the relationship between acute and chronic glycemia.

SUMMARY

A 'personalized' approach to glycemic control in the critically ill, with recognition of preadmission glycemia, is supported by an emerging literature and is suitable for testing in future interventional trials.

Updates in Glycemic Management in the Hospital

PURPOSE OF REVIEW

To provide an update of glycemic management during metabolic stress related to surgery or critical illness.

RECENT FINDINGS

There is a clear association between severe hyperglycemia, hypoglycemia, and high glycemic variability and poor outcomes of postoperative or critically ill patients. However, the impressive beneficial effects of tight glycemic management (TGM) by intensive insulin therapy reported in one study were never reproduced. Hence, the recommendation of TGM is now replaced by more liberal blood glucose (BG) targets (< 180 mg/dL or 10 mM). Recent data support the concept of targeting individualized blood glucose (BG) values according to the presence of diabetes mellitus/chronic hyperglycemia, the presence of brain injury, and the time from injury. A more liberal glycemic management goal is currently advised during metabolic stress and could be switched to individualized glycemic management once validated by prospective trials.

An elevated glycemic gap predicts adverse outcomes in diabetic patients with necrotizing fasciitis

Background

Diabetes is the most common comorbidity of necrotizing fasciitis (NF), but the effect of stress-induced hyperglycemia (SIH) on diabetic patients with NF has never been investigated. The aim of this study was to assess whether SIH, as determined by the glycemic gap between admission glucose levels and A_1C-derived average glucose levels, predicts adverse outcomes in diabetic patients hospitalized with NF.

Methods

We retrospectively reviewed the glycemic gap and clinical outcomes in 252 diabetic patients hospitalized due to NF from 2011 to 2018 in a single medical center in Taiwan. A receiver operating characteristic (ROC) curve was used to analyze the optimal cutoff values for predicting adverse outcomes. Univariate and multivariate logistic regression analyses were employed to identify significant predictors of adverse outcomes.

Results

In total, 194 diabetic NF patients were enrolled. Compared with patients without adverse outcomes, patients with adverse outcomes had significantly higher glycemic gaps, Acute Physiology and Chronic Health Evaluation (APACHE) II scores and C-reactive protein (CRP) levels; lower albumin and hemoglobin levels; greater incidence of limb loss; and longer hospital and intensive care unit stays. The glycemic gap positively correlates with the laboratory risk indicator for NF scores, APACHE II scores and CRP levels. A glycemic gap of 146 mg/dL was the optimal cutoff value for predicting adverse outcomes using the ROC curve. Compared with patients with glycemic gaps ≤146 mg/dL, those with glycemic gaps >146 mg/dL had higher APACHE II scores and incidence rates of adverse outcomes, especially bacteremia and acute kidney injury. Multivariate analysis revealed that a glycemic gap >146 mg/dL and APACHE II score >15 were independent predictors of adverse outcomes, while the presence of hyperglycemia at admission was not.

Conclusions

An elevated glycemic gap was significantly independently associated with adverse outcomes in diabetic NF patients. Further prospective studies are warranted to validate the role of the glycemic gap in NF patients with diabetes.

Sepsis patients with complication of hypoglycemia and hypoalbuminemia are an early and easy identification of high mortality risk

Either hypoglycemia or hypoalbuminemia alone is an independent condition associated with increased risk of mortality in critical illness. This study evaluates whether the mortality risk increases in septic patients if these conditions are combined. Patients admitted to our hospital from 2008 to 2015 who satisfied the definition of sepsis were targeted (n = 336). We classified cases into three groups based on blood glucose (BG) level measured at admission: hypoglycemia (Hypo-G; BG < 80 mg/dl), intermediate glycemia (Inter-G; 80-199 mg/dl), and hyperglycemia (Hyper-G; ≥ 200 mg/dl) group, and then estimated mortality. We also compared the clinical data of these glycemic groups in combination with hypoalbuminemia (Hypo-A) or Inter-G with non-hypoalbuminemia (Inter-G + Nonhypo-A), as a secondary analysis. Diagnostic cut-off level of Hypo-A (< 2.8 mg/dl) was determined using the ROC curve between blood albumin and mortality. In Hypo-G group (n = 40), APACHE II/SOFA scores are significantly higher than in the Inter-G (n = 196) and Hyper-G groups (n = 100). Mortality is 52.5% in the Hypo-G and 60.0% in the Hypo-G with Hypo-A (Hypo-G + Hypo-A) groups. Significantly higher APACHE II or SOFA scores and mortality are observed in the Hypo-G + Hypo-A group compared to the Inter-G + Nonhypo-A group. A higher mortality risk is observed in cases with Hypo-G + Hypo-A (OR 5.065) than those with Hypo-G (OR 3.503), Inter-G (OR 1.175), Hyper-G (OR 1.756) or Hypo-A (OR 3.243), calculated by a single logistic-regression analysis. Hypo-G + Hypo-A in patients with sepsis is related to higher ICU mortality. Physicians should be keenly aware of these conditions to provide immediate intensive treatment after admission of septic patients.

Nationwide observational study of mortality from complicated intra-abdominal infections and the role of bacterial cultures

BACKGROUND

The benefit of taking intra-abdominal cultures during source control procedures in patients with complicated intra-abdominal infection (CIAI) is unknown. The aim of this study was to evaluate whether intra-abdominal cultures reduce the mortality rate of CIAI.

METHODS

The Japanese Diagnosis Procedure Combination database was used to identify adult patients with CIAI who had undergone source control procedures on the first day of admission to hospital between April 2014 and March 2016. In-hospital mortality was compared between patients who did and those who did not have intra-abdominal cultures taken. A generalized linear mixed-effect logistic regression model and a random intercept per hospital were used to adjust for baseline confounders and institutional differences. Subgroup analyses were also performed according to disease cause, site of onset and severity of CIAI.

RESULTS

Intra-abdominal cultures were taken from 16 303 of 41 495 included patients. Multivariable logistic regression analysis showed that patients with intra-abdominal cultures had a significantly lower mortality than those without (odds ratio 0·85, 95 per cent c.i. 0·77 to 0·95). Subgroup analyses revealed statistically significant differences in mortality between patients with and without cultures among those with lower intestinal perforation, biliary tract infection/perforation, healthcare-associated CIAI and high-risk community-acquired CIAI.

CONCLUSIONS

Intra-abdominal cultures obtained during source control procedures may reduce in-hospital mortality, especially in patients with lower intestinal perforation, biliary tract infection/perforation, or healthcare-associated or high-risk community-acquired CIAI.

Glucose Activates Vagal Control of Hyperglycemia and Inflammation in Fasted Mice

Sepsis is a leading cause of death in hospitalized patients. Many experimental treatments may have failed in clinical trials for sepsis, in part, because they focused on immune responses of healthy animals that did not mimic the metabolic settings of septic patients. Epidemiological studies show an association between metabolic and immune alterations and over 1/3 of septic patients are diabetic, but the mechanism linking these systems is unknown. Here, we report that metabolic fasting increased systemic inflammation and worsened survival in experimental sepsis. Feeding and administration of glucose in fasted mice activated the vagal tone without affecting blood pressure. Vagal stimulation attenuated hyperglycemia and serum TNF levels in sham but only hyperglycemia in splenectomized mice. Vagal stimulation induced the production of dopamine from the adrenal glands. Experimental diabetes increased hyperglycemia and systemic inflammation in experimental sepsis. Fenoldopam, a specific dopaminergic type-1 agonist, attenuated hyperglycemia and systemic inflammation in diabetic endotoxemic mice. These results indicate that glucose activates vagal control of hyperglycemia and inflammation in fasted septic mice via dopamine.

Linagliptin Attenuates the Cardiac Dysfunction Associated With Experimental Sepsis in Mice With Pre-existing Type 2 Diabetes by Inhibiting NF-κB

The mortality rate of patients who develop sepsis-related cardiac dysfunction is high. Many disease conditions (e.g., diabetes) increase the susceptibility to infections and subsequently sepsis. Activation of the NF-κB pathway plays a crucial role in the pathophysiology of sepsis-associated cardiac dysfunction and diabetic cardiomyopathy. The effect of diabetes on outcomes in patients with sepsis is still highly controversial. We here hypothesized that type 2 diabetes (T2DM) augments the cardiac (organ) dysfunction associated with sepsis, and that inhibition of the NF-κB pathway with linagliptin attenuates the cardiac (organ) dysfunction in mice with T2DM/sepsis. To investigate this, 10-week old male C57BL/6 mice were randomized to receive normal chow or high fat diet (HFD), 60% of calories derived from fat). After 12 weeks, mice were subjected to sham surgery or cecal ligation and puncture (CLP) for 24 h. At 1 hour after surgery, mice were treated with linagliptin (10 mg/kg, i.v.), IKK-16 (1 mg/kg, i.v.), or vehicle (2% DMSO, 3 ml/kg, i.v.). Mice also received analgesia, fluids and antibiotics at 6 and 18 h after surgery. Mice that received HFD showed a significant increase in body weight, impairment in glucose tolerance, reduction in ejection fraction (%EF), and increase in alanine aminotransferase (ALT). Mice on HFD subjected to CLP showed further reduction in %EF, increase in ALT, developed acute kidney dysfunction and lung injury. They also showed significant increase in NF-κB pathway, iNOS expression, and serum inflammatory cytokines compared to sham surgery group. Treatment of HFD-CLP mice with linagliptin or IKK-16 resulted in significant reductions in (i) cardiac, liver, kidney, and lung injury associated with CLP-sepsis, (ii) NF-κB activation and iNOS expression in the heart, and (iii) serum inflammatory cytokine levels compared to HFD-CLP mice treated with vehicle. Our data show that pre-existing type 2 diabetes phenotype worsens the organ dysfunction/injury associated with CLP-sepsis in mice. Most notably, inhibition of NF-κB reduces the organ dysfunction/injury associated with sepsis in mice with pre-existing T2DM.

Dopaminergic Control of Inflammation and Glycemia in Sepsis and Diabetes

Most preclinical treatments for sepsis failed in clinical trials in part because the experimental models of sepsis were performed on healthy animals that do not mimic septic patients. Here, we report that experimental diabetes worsens glycemia, inflammation, and mortality in experimental sepsis. Diabetes increases hyperglycemia, systemic inflammation, and mortality in sepsis. Diabetes exacerbates serum tumor necrosis factor (TNF) levels in sepsis by increasing splenic TNF production. Both serum from diabetic mice and glucose increase cytokine production in splenocytes. Anti-inflammatory treatments cannot control hyperglycemia and are less effective in diabetic patients. By contrast, dopaminergic agonist type-1, fenoldopam, attenuates hyperglycemia, and systemic inflammation in diabetic septic mice by inhibiting splenic p65NF-kB phosphorylation. Fenoldopam inhibits TNF production in splenocytes even at high glucose concentrations and inhibits the canonical NF-kB pathway by inhibiting p65RelA and p50NF-kB1 phosphorylation without affecting the non-canonical NF-kB proteins. Treatment with fenoldopam rescues diabetic mice from established polymicrobial peritonitis even when the treatment is started after the onset of sepsis. These results suggest that dopaminergic agonists can control hyperglycemia, systemic inflammation and provide therapeutic advantages for treating diabetic patients with sepsis in a clinically relevant time frame.

Early glycemia and mortality in critically ill septic patients: Interaction with insulin-treated diabetes

PURPOSE

To investigate the relationship between dysglycemia and hospital mortality in patients with and without a preadmission diagnosis of insulin treated diabetes mellitus (ITDM).

MATERIALS AND METHODS

An observational multicentre cohort study using the ANZICS-APD database on adult patients admitted to ICU with sepsis between January 1st 2006 and December 31st 2015. Four domains of dysglycemia were investigated (highest, mean and lowest blood glucose levels and glycemic variability: the absolute difference between the highest and lowest level). The association between a preadmission diagnosis of ITDM and hospital mortality in each domain was analysed.

RESULTS

We studied 90,644 septic patients including 5127 patients with ITDM. We found that septic ICU patients with ITDM have lower adjusted hospital mortality with higher peak blood glucose levels in the first 24 h while non-ITDM patients have increased mortality (interaction p 0.012). We found that this significant difference was replicated when assessing glycemic variability (interaction p 0.048).

CONCLUSIONS

Septic patients with a pre-existing diagnosis of ITDM show a different relationship between hospital mortality and highest glucose levels and glycemic variability in the first 24 h than those without ITDM. These findings provide a rationale for an ITDM-specific approach to the management of dysglycemia.