Acute glucose elevation is highly predictive of infection and outcome in critically injured trauma patients. Ann Surg. 2010;252:597-602. [PMID: 20881765 DOI: 10.1097/sla.0b013e3181f4e499]

Stress-Induced Hyperglycemia is a Risk Factor for Surgical-Site Infections in Nondiabetic Patients with Open Leg Fractures

Background

Nondiabetic patients with open leg fractures who have elevated blood glucose levels on arrival in the emergency department have an increased risk of surgical-site infections (SSIs).

Objective

This study evaluates the association between the incidence of SSIs in nondiabetic patients with an open leg fracture and blood glucose levels registered on arrival in the ER. We also analyzed the correlation between patients' days of hospital stay and the incidence of SSIs and the time elapsed between the damage control with external fixation and final fixation and the incidence of SSI.

Methods

We retrospectively studied nondiabetic patients admitted to our emergency unit from 2017 to 2021 with a diagnosis of open leg fracture consecutively treated. Based on the diagnosis of SSIs, all enrolled patients were divided into two groups based on the developed (group A) or not developed (group B) SSIs within 1 year after surgery. All patients enrolled in the study underwent damage control within 24 hours after admission to the ER. At stabilization of general clinical and local wound conditions, all patients underwent definitive surgery.

Results

We enrolled 80 patients. In group A, glycemia on arrival in the ER was on average 148.35 ± 19.59 mg/dl, and in group B, it was 122.61 ± 22.22 mg/dl (p value: 0.0001). In group A, glycemia in the first postoperative day was on average 113.81 ± 21.07 mg/dl, and in group B, it was 99.02 ± 17.60 mg/dl (p value: 0.001). In group A, the average hospitalization was 57.92 ± 42.43 days, and in group B, it was 18.41 ± 14.21 days (p value: 0.01). Through Youden's J, we therefore analyzed the value with the highest sensitivity and specificity which proved to be 132 mg/dl.

Conclusion

Our findings show that nondiabetic patients with SIH have a significantly increased risk of SSIs compared to patients without SIH within 1 year after surgery. Patients with open leg fractures with SIH have a significantly higher average hospital stay than patients without SIH. Further studies are needed to confirm 132 mg/dl of blood glucose levels as a value to stratify the risk of SSIs in these patients.

A Retrospective Cohort Study: Predicting 90-Day Mortality for ICU Trauma Patients with a Machine Learning Algorithm Using XGBoost Using MIMIC-III Database

Objective

The aim of this study was to develop and validate a machine learning-based predictive model that predicts 90-day mortality in ICU trauma patients.

Methods

Data of patients with severe trauma were extracted from the Medical Information Mart for Intensive Care III (MIMIC-III) database. The performances of mortality prediction models generated using nine machine learning extreme gradient boosting (XGBoost), logistic regression, random forest, AdaBoost, multilayer perceptron (MLP) neural networks, support vector machine (SVM), light gradient boosting machine (GBM), k nearest neighbors (KNN) and gaussian naive bayes (GNB). The performance of the model was evaluated in terms of discrimination, calibration and clinical application.

Results

We found that the accuracy, sensitivity, specificity, PPV, NPV and F1 score of our proposed XGBoost model were 82.8%, 79.7%, 77.6%, 51.2%, 91.5% and 0.624, respectively. Among the nine models, the XGBoost model performed best. Compared with traditional logistic regression, the calibration curves of the XGBoost model and decision curve analysis (DCA) performed well.

Conclusion

Our study shows that the XGBoost model outperforms other machine learning models in predicting 90-day mortality in trauma patients. It can be used to assist clinicians in the early identification of mortality risk factors and early intervention to reduce mortality.

Association between time in range 70-180 mg/dl in early stage and severity with in patients acute pancreatitis

BACKGROUND

It is not well understood whether glucose control in the early stage of acute pancreatitis(AP) is related to outcome. This study aimed to investigate the association between blood glucose time in range (TIR) of 70-180 mg/dL in the first 72 h(h) on admission and the progression of AP.

METHODS

Individuals admitted with AP to the Gastroenterology Department of the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University between January 2017 and December 2021 were included and retrospectively evaluated. The percentage of TIR between 70 and 180 mg/dL in the first 72 h was calculated. According to the progress of AP at discharge, patients were divided into mild pancreatitis(MAP), and moderately severe acute pancreatitis (MSAP), or severe acute pancreatitis (SAP) groups. We examined the association between TIR or TIR ≥ 70% and AP severity using logistic regression models stratified by a glycosylated hemoglobin (HbA1c) level of 6.5%. Receiver operating characteristic (ROC) curves were generated to assess the ability of the TIR to predict MSAP or SAP.

RESULTS

A total of 298 individuals were included, of whom 35 developed MSAP or SAP. Logistic regression analyses indicated that TIR was independently associated with the incidence of more serious AP (odds ratio [OR] = 0.962, 95% CI = 0.941-0.983, p = 0.001). This association remained significant in individuals with HbA1c levels ≤ 6.5% (OR = 0.928, 95% CI = 0.888-0.969, p = 0.001). A TIR ≥ 70% was independently associated with reduced severity only in people with well-antecedent controls (OR = 0.238; 95% CI = 0.071-0.802; p = 0.020). TIR was not powerful enough to predict the severity of AP in both patients with poor antecedent glucose control (AUC = 0.641) or with HbA1c < 6.5% (AUC = 0.668).

CONCLUSIONS

TIR was independently associated with severity in patients with AP, particularly those with good antecedent glucose control.

Impact of early enteral nutrition on ventilator associated pneumonia in intubated severe trauma patients: A propensity score-matched study

Background

Early enteral nutrition (EN) is recommended for critically ill patients. However, the impact of early EN on intubated severe trauma patients remains unclear.

Methods

Severely traumatized adult patients who received invasive mechanical ventilation (MV) for more than 48 h during intensive care unit (ICU) stay at our institution between 2017 and 2022 were retrospectively included. Early EN was defined as EN initiation ≤48 h from ICU admission and late EN >48 h. Propensity score matching (PSM) analysis was used to compare outcomes between the groups. The primary endpoint was the incidence of ventilator-associated pneumonia (VAP). Multivariable logistic regression analysis was performed to identify independent predictors of delayed EN.

Results

For final analysis, 337 intubated severe trauma patients were available, including 204 (60.5%) in the early EN group and 133 (39.5%) in the late EN group. After PSM, early EN patients had a lower incidence of VAP (12.9 vs. 25.8%, p = 0.026) and a shorter length of hospital stay (21 vs. 24 days, p = 0.015) compared to late EN patients. There was no demonstrable difference in mortality between the two groups. Abdominal trauma, massive blood transfusion, and serum albumin were identified as independent risk factors for delayed EN.

Conclusion

Early EN decreased the VAP rate and reduced the length of hospital stay in invasively ventilated patients with severe trauma. Abdominal injury, massive blood transfusion and low albumin were associated with delayed EN.

Admission Hyperglycemia Is a Risk Factor for Deep Surgical-Site Infection in Orthopaedic Trauma Patients

OBJECTIVES

To evaluate the association of admission blood glucose ≥200 mg/dL and surgical site infection in orthopaedic trauma surgery.

DESIGN

Retrospective, case control study.

SETTING

Academic trauma center.

PATIENTS

Four hundred sixty-five nondiabetic, noncritically ill orthopaedic trauma patients with an extremity, pelvic, or acetabular fracture and requiring open reduction and internal fixation or intramedullary nailing.

INTERVENTION

None.

MAIN OUTCOME MEASUREMENTS

Ninety-day deep surgical site infection.

RESULTS

Admission blood glucose ≥200 mg/dL was significantly associated with the primary outcome (8/128, 6.3% vs. 35/337, 1.8%; P = 0.01). Multivariable logistic regression modeling demonstrated that admission blood glucose ≥200 mg/dL was a significant risk factor for deep surgical site infections [odds ratio (OR): 4.7, 95% confidence interval (CI) 1.4-15.7], after controlling for male gender (OR: 1.8, 95% CI: 1.1-3.1), prior drug or alcohol abuse (OR: 1.9, 95% CI 0.9-4.0), open fracture (OR: 6.4, 95% CI 3.7-11.0), and fracture region (upper extremity OR: reference; pelvis/hip OR: 3.9, 95% CI 1.6-9.7; femur OR: 2.0, 95% CI 0.88-4.8; tibia/ankle OR: 3.3, 95% CI 1.7-6.2; and foot OR: 2.7, 95% CI 1.2-6.3).

CONCLUSIONS

Admission glucose ≥200 mg/dL was a significant independent risk factor for 90-day deep surgical site infections in orthopaedic trauma patients and may serve as an important marker for infection risk.

LEVEL OF EVIDENCE

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

Recommendations of the Italian society for infectious and tropical diseases (SIMIT) for adult vaccinations

Vaccination prevents 2-3 million deaths worldwide every year. Nevertheless, vaccine-preventable diseases (VPDs) still cause a considerable number of deaths especially in subjects belonging to "risk groups." These are represented by older adults, immunocompromised individuals and all subjects with underlying chronic medical conditions (cardiovascular, pulmonary, renal and liver chronic diseases, diabetes, immunodeficiency disorders). They have a weaker immune system and, if infected, are more likely to develop severe complications of their condition or of the preventable-infectious disease. This document summarizes the recommendations for vaccination of the main Global Institutional Organizations and analyses the risks of comorbidities associated with infectious disease and the benefits of vaccination for each specific group. The document provides a clear, practical and authoritative guide to adult vaccination.

Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia

Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.

The Bitter and the Sweet: Relationship of Lactate, Glucose, and Mortality After Severe Blunt Trauma

BACKGROUND

Hyperglycemia is associated with mortality after trauma; however, few studies have simultaneously investigated the association of depth of shock and acute hyperglycemia. We evaluated lactate, as a surrogate measure for depth of shock, and glucose levels on mortality following severe blunt trauma. We hypothesize that measurements of both lactate and glucose are associated with mortality when considered simultaneously.

METHODS

This is a retrospective cohort study at a single academic trauma center. Inclusion criteria are age 18-89 years, blunt trauma, injury severity score (ISS) ≥15, and transferred from the scene of injury. All serum blood glucose and lactate values were analyzed within the first 24 hours of admission. Multiple metrics of glucose and lactate were calculated: first glucose (Glucadm) and lactate (Lacadm) at hospital admission, mean 24-hour after hospital admission glucose (Gluc24-hMean) and lactate (Lac24-hMean), maximum 24-hour after hospital admission glucose (Gluc24-hMax) and lactate (Lac24-hMax), and time-weighted 24-hour after hospital admission glucose (Gluc24-hTW) and lactate (Lac24-hTW). Primary outcome was in-hospital mortality. Multivariable logistic regression modeling assessed the odds ratio (OR) of mortality, after adjusting for confounding variables.

RESULTS

A total of 1439 trauma patients were included. When metrics of both glucose and lactate were analyzed, after adjusting for age, ISS, and admission shock index, only lactate remained significantly associated with mortality: Lacadm (OR, 1.28; 95% confidence interval [CI], 1.13-1.44); Lac24-hMean (OR, 1.86; 95% CI, 1.52-2.28); Lac24-hMax (OR, 1.39; 95% CI, 1.23-1.56); and Lac24-hTW (OR, 1.86; 95% CI, 1.53-2.26).

CONCLUSIONS

Lactate is associated with mortality in severely injured blunt trauma patients, after adjusting for injury severity, age, and shock index. However, we did not find evidence for an association of glucose with mortality after adjusting for lactate.

Blood Glucose Levels Combined with Triage Revised Trauma Score Improve the Outcome Prediction in Adults and in Elderly Patients with Trauma

INTRODUCTION

This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma.

METHODS

This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient's death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score.

RESULTS

Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001.

CONCLUSIONS

Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years.

Investigating the mechanism of impact and differential effect of the Quality Premium scheme on antibiotic prescribing in England: a longitudinal study

BACKGROUND

In 2017, approximately 73% of antibiotics in England were prescribed from primary care practices. It has been estimated that 9%-23% of antibiotic prescriptions between 2013 and 2015 were inappropriate. Reducing antibiotic prescribing in primary care was included as one of the national priorities in a financial incentive scheme in 2015-2016.

AIM

To investigate whether the effects of the Quality Premium (QP), which provided performance-related financial incentives to clinical commissioning groups (CCGs), could be explained by practice characteristics that contribute to variations in antibiotic prescribing.

DESIGN & SETTING

Longitudinal monthly prescribing data were analysed for 6251 primary care practices in England from April 2014 to March 2016.

METHOD

Linear generalised estimating equations models were fitted, examining the effect of the 2015-2016 QP on the number of antibiotic items per specific therapeutic group age-sex related prescribing unit (STAR-PU) prescribed, adjusting for seasonality and months since implementation. Consistency of effects after further adjustment for variations in practice characteristics were also examined, including practice workforce, comorbidities prevalence, prescribing rates of non-antibiotic drugs, and deprivation.

RESULTS

Antibiotics prescribed in primary care practices in England reduced by -0.172 items per STAR-PU (95% confidence interval [CI] = -0.180 to -0.171) after 2015-2016 QP implementation, with slight increases in the months following April 2015 (+0.014 items per STAR-PU; 95% CI = +0.013 to +0.014). Adjusting the model for practice characteristics, the immediate and month-on-month effects following implementation remained consistent, with slight attenuation in immediate reduction from -0.172 to -0.166 items per STAR-PU. In subgroup analysis, the QP effect was significantly greater among the top 20% prescribing practices (interaction p<0.001). Practices with low workforce and those with higher diabetes prevalence had greater reductions in prescribing following 2015-2016 QP compared with other practices (interaction p<0.001).

CONCLUSION

In high-prescribing practices, those with low workforce and high diabetes prevalence had more reduction following the QP compared with other practices, highlighting the need for targeted support of these practices and appropriate resourcing of primary care.

Morbidity and mortality of Hispanic trauma patients with diabetes mellitus

PURPOSE

DM and trauma are leading causes of death in Hispanic patients, yet the interaction between them remains obscure. We aimed to assess the complications and in-hospital mortality rate of Hispanic diabetic trauma patients.

METHODS

A retrospective cohort study was carried out using data from the Puerto Rico Trauma Hospital databank. Patients were matched based on gender, age, mechanism of injury, Glasgow Coma Scale, and Injury Severity Score using propensity-score matching. From 2000 to 2014, a total of 1134 patients with DM were compared to 1134 patients who did not have DM. The outcomes measured were hospital and TICU lengths of stay, days on mechanical ventilation, complications, and in-hospital mortality rate. A logistic regression model was carried out to evaluate the relationship of DM with complications and mortality after trauma.

RESULTS

Hispanic patients with DM had longer hospital and TICU stays and required mechanical ventilation for extended periods. Complications, predominantly of an infectious nature, were more common among DM patients than they were among non-DM patients: 31.3% in the DM group vs. 11.6% in the non-DM group (OR 3.46; 95% CI 2.77-4.31). Despite an increase in the number of complications, DM was not associated with higher in-hospital mortality rates.

CONCLUSIONS

DM is associated with a twofold increase in complications in Hispanic diabetic trauma patients, which may account for their longer hospital and TICU stays. This indicates that diabetic Hispanic trauma patients may need earlier and more aggressive intervention to reduce their risk of developing complications.

The clinical significance of hyperglycemia in nondiabetic critically ill multiple trauma patients

BACKGROUND

Information is inconsistent regarding the clinical role of acute elevations of blood glucose level secondary to hospital-acquired infections in nondiabetic critically ill patients during an intensive care unit stay. In this study we investigated the clinical significance of hyperglycemia related to new episodes of ventilator-associated pneumonia in nondiabetic critically ill multiple trauma intensive care unit patients.

MATERIALS AND METHODS

We analyzed the clinical data of 202 critically ill multiple trauma patients with no history of previous diabetes who developed a new ventilator-associated pneumonia episode during their intensive care unit stay. We used a time-from-event analysis method to assess whether acute changes in blood glucose levels that occurred prior to the onset of ventilator-associated pneumonia episodes had a different prognostic significance from those that occurred during such episodes. Glucose levels and other laboratory data were recorded for up to 5 days before ventilator-associated pneumonia events and for 5 days following these events.

RESULTS

Patients who required insulin therapy for persistent hyperglycemia related to a new ventilator-associated pneumonia event had a longer period of intensive care unit stay and a higher intensive care unit mortality rate than patients who did not require insulin for blood glucose control (p < 0.008 and <0.001 respectively). In addition, older age, administration of parenteral nutrition, and elevated mean blood glucose level parameters on the day following the day of diagnosis of a new ventilator-associated pneumonia episode were found to be independent risk factors for intensive care unit mortality.

CONCLUSION

Our study suggests that persistent hyperglycemia in nondiabetic critically ill patients, even treated by early insulin therapy, is an adverse prognostic factor of considerable clinical significance.

Continuous glucose monitoring in the ICU: clinical considerations and consensus

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

Glycemic management in critically ill patients

Hyperglycemia associated with critical illness, also called “stress hyperglycemia” or “stress diabetes”, is a consequence of many pathophysiologic hormonal responses including increased catecholamines, cortisol, glucagon, and growth hormone. Alterations in multiple biochemical pathways result in increased hepatic and peripheral insulin resistance with an uncontrolled activation of gluconeogenesis and glycogenolysis. Hyperglycemia has a negative impact on the function of the immune system, on the host response to illness or injury, and on infectious and overall outcomes. The degree of glucose elevation is associated with increased disease severity. Large randomized controlled trials including the Van den Berghe study, the NICE-SUGAR trial, VISEP and GLUCONTROL have shown that the control of glucose levels in critically ill patients has implications on outcome and that both hyperglycemia and hypoglycemia are detrimental and should be avoided. Glucose variability has also been shown to be detrimental. Aggressive glucose control strategies have changed due to the concerns of hypoglycemia and therefore intermediate target glucose control strategies are most often adopted. Different patient populations may vary with regards to optimal glucose targets, timing and approach for glucose control, and with regards to the prognostic significance of glucose excursions and variability. Medical, surgical, and trauma patients may benefit at different rates from glucose control and the approach may need to be adapted to various medical settings and to correspond to the workflow of health providers. Effect modifiers for the success of insulin therapy for hyperglycemia include the methods of nutritional supplementation and exogenous glucose administration. Further research is required to improve insulin protocols for glucose control, to further define glucose targets, and to enhance the accuracy of glucose measuring technologies.

Results of a near continuous glucose monitoring technology in surgical intensive care and trauma

INTRODUCTION

Near-continuous glucose monitoring is expected to increase time in range (TIR) of 80-120mg/dL and to avoid hypoglycemia without increasing workload. We investigated a near-continuous glucose monitor in surgical critically ill and trauma patients.

METHODS

Patients were enrolled at a surgical intensive care unit associated with a level 1 trauma center. Glucose measurements were compared to the gold standard Yellow Springs Instrument (YSI). The technology withdraws 0.13mL of blood every 15min from a central venous line, centrifuges the sample, and uses mid-infrared spectroscopy to measure glucose. We plotted a Clarke Error Grid, calculated Mean Absolute Relative Deviation (MARD) to analyze trend accuracy, and we present a Bland Altman plot of device versus standard glucose measurements.

RESULTS

24 patients were enrolled. One patient was withdrawn due to poor blood return from central venous line. A total of 347 glucose measurements from 23 patients were compared to the gold standard. 94.8% of the data points were in zone A of the Clarke Error Grid and 5.2% in zone B. The MARD was 8.02%. The majority of data points achieved the benchmark for accuracy. The remaining 5.2% are clinically benign. The MARD was below 10%. The Bland Altman plot shows good agreement between the device and reference glucose measurements. There were no device related adverse events.

CONCLUSION

Our data suggests that near continuous monitoring via infrared spectroscopy is safe and accurate for use in critically ill surgical and trauma patients. A large scale multi-center study is underway to confirm these findings.

Diabetes and infection: assessing the association with glycaemic control in population-based studies

Diabetes is a leading cause of morbidity and mortality. The global burden of diabetes is rising because of increased obesity and population ageing. Although preventive and treatment measures are well documented for macrovascular and microvascular complications, little such guidance exists for infections in people with diabetes, despite evidence suggesting greater susceptibility to infections, and worse outcomes. In particular, few studies have characterised the relation between glycaemic control and infectious disease, which we discuss in this Review. Some large population-based observational studies have reported strong associations between higher HbA1c and infection risks for both type 1 and type 2 diabetes. However, studies are contradictory, underpowered, or do not control for confounders. Evidence suggests that better glycaemic control might reduce infection risk, but further longitudinal studies with more frequent measures of HbA1c are needed. Older people (aged 70 years or older) with diabetes are at increased risk of complications, including infectious diseases. There is more uncertainty about appropriate glycaemic control targets in this age group, and evidence suggests that glycaemic control is often neglected. Robust evidence from cohorts with sufficient numbers of older people would help to develop clinically relevant guidelines and targets to reduce mortality, morbidity, and antibiotic use, and to improve quality of life.

One-step electrochemical fabrication of a nickel oxide nanoparticle/polyaniline nanowire/graphene oxide hybrid on a glassy carbon electrode for use as a non-enzymatic glucose biosensor

A non-enzymatic glucose biosensor was developed by the one-step electrodeposition fabrication of nickel oxide nanoparticles/polyaniline nanowire hybrids on a graphene oxide/glassy carbon electrode.

Diabetes-specific enteral nutrition formula in hyperglycemic, mechanically ventilated, critically ill patients: a prospective, open-label, blind-randomized, multicenter study

INTRODUCTION

Although standard enteral nutrition is universally accepted, the use of disease-specific formulas for hyperglycemic patients is still controversial. This study examines whether a high-protein diabetes-specific formula reduces insulin needs, improves glycemic control and reduces ICU-acquired infection in critically ill, hyperglycemic patients on mechanical ventilation (MV).

METHODS

This was a prospective, open-label, randomized (web-based, blinded) study conducted at nine Spanish ICUs. The patient groups established according to the high-protein formula received were: group A, new-generation diabetes-specific formula; group B, standard control formula; group C, control diabetes-specific formula. Inclusion criteria were: expected enteral nutrition ≥5 days, MV, baseline glucose >126 mg/dL on admission or >200 mg/dL in the first 48 h. Exclusion criteria were: APACHE II ≤10, insulin-dependent diabetes, renal or hepatic failure, treatment with corticosteroids, immunosuppressants or lipid-lowering drugs and body mass index ≥40 kg/m(2). The targeted glucose level was 110-150 mg/dL. Glycemic variability was calculated as the standard deviation, glycemic lability index and coefficient of variation. Acquired infections were recorded using published consensus criteria for critically ill patients. Data analysis was on an intention-to-treat basis.

RESULTS

Over a 2-year period, 157 patients were consecutively enrolled (A 52, B 53 and C 52). Compared with the standard control formula, the new formula gave rise to lower insulin requirement (19.1 ± 13.1 vs. 23.7 ± 40.1 IU/day, p <0.05), plasma glucose (138.6 ± 39.1 vs. 146.1 ± 49.9 mg/dL, p <0.01) and capillary blood glucose (146.1 ± 45.8 vs. 155.3 ± 63.6 mg/dL, p <0.001). Compared with the control diabetes-specific formula, only capillary glucose levels were significantly reduced (146.1 ± 45.8 vs. 150.1 ± 41.9, p <0.01). Both specific formulas reduced capillary glucose on ICU day 1 (p <0.01), glucose variability in the first week (p <0.05), and incidences of ventilator-associated tracheobronchitis (p <0.01) or pneumonia (p <0.05) compared with the standard formula. No effects of the nutrition formula were produced on hospital stay or mortality.

CONCLUSIONS

In these high-risk ICU patients, both diabetes-specific formulas lowered insulin requirements, improved glycemic control and reduced the risk of acquired infections relative to the standard formula. Compared with the control-specific formula, the new-generation formula also improved capillary glycemia.

TRIAL REGISTRATION

Clinicaltrials.gov NCT1233726 .

Insulin resistance increases before ventilator-associated pneumonia in euglycemic trauma patients

BACKGROUND

Hyperglycemia caused by stress-induced insulin resistance is associated with both infection and mortality in critically injured patients. The onset of infection may increase stress-induced insulin resistance, leading to hyperglycemia. Hyperglycemia has been shown to precede the diagnosis of ventilator-associated pneumonia (VAP) in critically injured adults and has been suggested to have potential diagnostic importance. However, glycemic control (GC) protocols in critically ill patients limit the development of hyperglycemia despite increasing insulin resistance. Our computer-assisted GC protocol achieves excellent GC, limiting infection-related hyperglycemia while capturing prospectively all glucose values, insulin infusion rates, and the multiplier (M) used to calculate the insulin rate. We hypothesized that surrogate measures of insulin resistance, the insulin infusion rate and multiplier M, would increase prior to the clinical suspicion of VAP, even in euglycemic critically injured patients.

METHODS

All critically injured patients (2,656) on the computerized glycemic control protocol were included in the analysis and categorized by those developing VAP and those without pneumonia on days 3-10 of their intensive care unit (ICU) stay. Median blood glucose concentration (BG), insulin infusion rate (IDR), and multiplier (M) [Insulin Drip Rate=M*(BG-60)] were determined for VAP patients (n=329) and non-infected ventilated (NIV) patients (n=2,327) on each day of mechanical ventilation. The day of VAP diagnosis according to U.S. Centers for Disease Control and Prevention (CDC) criteria was defined as day zero and VAP patients matched with NIV patients according to ventilator day from -10 to +10. Comparisons were conducted using the Mann-Whitney U test.

RESULTS

Baseline characteristics between VAP and NIV groups did not differ. Measures of insulin resistance increased from the time of injury in both groups. Patients with VAP had significantly greater change in both measures of insulin resistance, IDR and M, in the 48 hours preceding the diagnosis of VAP. These changes occurred despite the fact that the computer-assisted GC protocol achieved lower glucose values in VAP patients for the majority of study days.

CONCLUSIONS

Measures of insulin resistance increase in the two days prior to the clinical suspicion of VAP for critically injured patients on the GC protocol. These changes occur despite the protocol maintaining euglycemia. This data suggests that markers of insulin resistance may provide clinically useful information in the early diagnosis of VAP.

Insulin Resistance in Critically Injured Adults: Contribution of Pneumonia, Diabetes, Nutrition, and Acuity

PURPOSE

Changes in insulin resistance (IR) cause stress-induced hyperglycemia after trauma, but the numerous factors involved in IR have not been delineated clearly. We hypothesized that a statistical model could help determine the relative contribution of different clinical co-variates to IR in critically injured patients.

PATIENTS AND METHODS

We retrospectively studied 726 critically injured patients managed with a computer-assisted glycemic protocol at an academic level I trauma center (639 ventilated controls without pneumonia (VWP) and 87 patients with ventilator-associated pneumonia (VAP). Linear regression using age, gender, body mass index (BMI), diabetes mellitus, pneumonia, and glycemic provision was used to estimate M, a marker of IR that incorporates both the serum blood glucose concentration (BG) and insulin dose.

RESULTS

Increasing M (p<0.001) was associated with age (1.62%; 95% confidence interval [CI] 1.27%-1.97% per decade), male gender (9.78%; 95% CI 8.28%-12.6%), BMI (4.32% [95% CI 4.02%-4.62%] per 5 points), diabetes mellitus (21.2%; 95% CI 19.2%-23.2%), pneumonia (10.9%; 95% CI 9.31%-12.6%), and glycemic provision (27.3% [95% CI 6.6%-28.1%] per 100 g of glucose). Total parenteral nutrition was associated with a decrease in M of 10.3%; 95% CI 8.52%-12.1%; p<0.001.

CONCLUSIONS

Clinical factors can be used to construct a model of IR. Prospective validation might enable early detection and treatment of infection or other conditions associated with increased IR.

Essentials of sepsis management

Despite remarkable advances in the knowledge of infection and human response to it, sepsis continues to be one of the most common challenges surgeons and critical care providers face. Surgeons confront the problem of infection every day, in treating established infections or reacting to a consequence of surgical intervention. Infections after surgery continue to be a problem despite massive efforts to prevent them. Patients rely on the surgeon's ability to recognize infection and treat it. Also, preventing nosocomial infection and antibiotic resistance is a primary responsibility. This article describes diagnostic and therapeutic measures for sepsis in the perioperative surgical patient.

Lower blood glucose and variability are associated with earlier recovery from renal injury caused by episodic urinary tract infection in advanced type 2 diabetic chronic kidney disease

PURPOSE

In our previous study, type 2 diabetic chronic kidney disease (CKD) patients with glomerular filtration rates of <30 mL/min upon hospitalization for urinary tract infection (UTI) were at a risk for acute kidney injury. This study aimed to clarify the effect of glucose and its variability on renal outcomes during admission for the treatment of UTI.

MATERIALS AND METHODS

Based on the date of renal recovery (RIFLE criteria: acute kidney injury occurred within 1-7 days and was sustained over 1 day), we divided these patients into early- (≤9 days, Group A) and late-recovery (>9 days, Group B) groups. The differences in the continuous and categorical variables of the two groups were assessed separately. The mean glucose levels and their variability (using the standard deviation and the coefficient of standard deviation) were compared at the fasting, midday pre-meal, evening pre-meal, and evening post-meal time points during hospitalization. We have organized the manuscript in a manner compliant with the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement.

RESULTS

Acute kidney injury occurred within the two groups (p = 0.007 and p = 0.001, respectively). The early-morning blood glucose levels (149.7±44.0 mg/dL) and average blood glucose levels (185.6±52.0 mg/dL) were better in Group A (p = 0.01, p = 0.02). Group A patients also had lower glucose variability than Group B at the different time points (p<0.05). Group A also had earlier renal recovery. More relevant pathogens were identified from blood in Group B (p = 0.038).

CONCLUSIONS

Early-morning fasting and mean blood glucose levels and their variability can be good indicators of severe infection and predictors of renal outcome in type 2 diabetic patients with CKD and UTI.

Outcomes of polytrauma patients with diabetes mellitus

BACKGROUND

The impact of diabetes mellitus in patients with multiple system injuries remains obscure. This study was designed to increase knowledge of outcomes of polytrauma in patients who have diabetes mellitus.

METHODS

Data from the Trauma Audit and Research Network was used to identify patients who had suffered polytrauma during 2003 to 2011. These patients were filtered to those with known outcomes, then separated into those with diabetes, those known to have other co-morbidities but not diabetes and those known not to have any co-morbidities or diabetes. The data were analyzed to establish if patients with diabetes had differing outcomes associated with their diabetes versus the other groups.

RESULTS

In total, 222 patients had diabetes, 2,558 had no past medical co-morbidities (PMC), 2,709 had PMC but no diabetes. The diabetic group of patients was found to be older than the other groups (P <0.05). A higher mortality rate was found in the diabetic group compared to the non-PMC group (32.4% versus 12.9%), P <0.05). Rates of many complications including renal failure, myocardial infarction, acute respiratory distress syndrome, pulmonary embolism and deep vein thrombosis were all found to be higher in the diabetic group.

CONCLUSIONS

Close monitoring of diabetic patients may result in improved outcomes. Tighter glycemic control and earlier intervention for complications may reduce mortality and morbidity.

β(2)-Adrenoreceptor blockade improves early posttrauma hyperglycemia and pulmonary injury in obese rats

Early hyperglycemia after trauma increases morbidity and mortality. Insulin is widely used to control posttrauma glucose, but this treatment increases the risk of hypoglycemia. We tested a novel method for early posttrauma hyperglycemia control by suppressing hepatic glycogenolysis via β2-adrenoreceptor blockade [ICI-118551 (ICI)]. We have shown that, after severe trauma, obese Zucker (OZ) rats, similar to obese patients, exhibit increased acute lung injury compared with lean Zucker (LZ) rats. We hypothesized that OZ rats exhibit a greater increase in early posttrauma glucose compared with LZ rats, with the increased posttrauma hyperglycemia suppressed by ICI treatment. Orthopedic trauma was applied to both hindlimbs in LZ and OZ rats. Fasting plasma glucose was then monitored for 6 h with or without ICI (0.2 mg·kg(-1)·h(-1) iv.) treatment. One day after trauma, plasma IL-6 levels, lung neutrophil numbers, myeloperoxidase (MPO) activity, and wet-to-dry weight ratios were measured. Trauma induced rapid hepatic glycogenolysis, as evidenced by decreased liver glycogen levels, and this was inhibited by ICI treatment. Compared with LZ rats, OZ rats exhibited higher posttrauma glucose, IL-6, lung neutrophil infiltration, and MPO activity. Lung wet-to-dry weight ratios were increased in OZ rats but not in LZ rats. ICI treatment reduced the early hyperglycemia, lung neutrophil retention, MPO activity, and wet-to-dry weight ratio in OZ rats to levels comparable with those seen in LZ rats, with no effect on blood pressure or heart rate. These results demonstrate that β2-adrenoreceptor blockade effectively reduces the early posttrauma hyperglycemia, which is associated with decreased lung injury in OZ rats.

Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries

BACKGROUND

Hyperglycemia in nondiabetic patients outside the intensive care unit is not well defined. We evaluated the relationship of hyperglycemia and surgical site infection (SSI) in stable nondiabetic patients with orthopedic injuries.

METHODS

We conducted a prospective observational cohort study at a single academic Level 1 trauma center over 9 months (Level II evidence for therapeutic/care management). We included patients 18 years or older with operative orthopedic injuries and excluded patients with diabetes, corticosteroid use, multisystem injuries, or critical illness. Demographics, medical comorbidities (American Society of Anesthesiologists class), body mass index, open fractures, and number of operations were recorded. Fingerstick glucose values were obtained twice daily. Hyperglycemia was defined as a fasting glucose value greater than or equal to 125 mg/dL or a random value greater than or equal to 200 mg/dL on more than one occasion before the diagnosis of SSI. Glycosylated hemoglobin level was obtained from hyperglycemic patients; those with glycosylated hemoglobin level of 6.0 or greater were considered occult diabetic patients and were excluded. SSI was defined by a positive intraoperative culture at reoperation within 30 days of the index case.

RESULTS

We enrolled 171 patients. Of these 171, 40 (23.4%) were hyperglycemic; 7 of them were excluded for occult diabetes. Of the 164 remaining patients, 33 were hyperglycemic (20.1%), 50 had open fractures (6 Type I, 22 Type II, 22 Type III), and 12 (7.3%) had SSI. Hyperglycemic patients were more likely to develop SSI (7 of 33 [21.2%] vs. 5 of 131 [3.8%], p = 0.003). Open fractures were associated with SSI (7 of 50 [14%] vs. 5 of 114 [4.4%], p = 0.047) but not hyperglycemia (10 of 50 [20.0%] vs. 23 of 114 [20.2%], p = 0.98). There was no significant difference between infected and noninfected patients in terms of age, sex, race, American Society of Anesthesiologists class, obesity (body mass index > 29), tobacco use, or number of operations.

CONCLUSION

Stress hyperglycemia was associated with SSI in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. Further prospective randomized studies are necessary to identify optimal treatment of hyperglycemia in the noncritically ill trauma population.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Glycated hemoglobin A: A predictor of outcome in trauma admissions to intensive care unit

Background and Aim:

Although large studies have demonstrated the association between hyperglycemia and adverse intensive care unit (ICU) outcomes, it is yet unclear which subset of patients benefit from tight sugar control in ICU. Recent evidence suggests that stress induced hyperglycemia (SIH) and co-incidentally detected diabetes mellitus are different phenomena with different prognoses. Differentiating SIH from diabetic hyperglycemia is challenging in ICU settings. We followed a cohort of trauma patients admitted to a surgical intensive care unit (SICU) to evaluate if initial glycated hemoglobin A (HbA₁c) level predicts the outcome of admission.

Materials and Methods:

A cohort of 120 consecutive admissions to SICU following trauma were recruited and admission blood sugar and HbA₁c were measured. Outcomes were prospectively measured by blinded ICU doctors. A logistic regression model was developed to assess if HbA₁c predicts poor outcomes in these settings.

Results:

Nearly 24% of the participants had HbA₁c ≥ 6. Those with HbA₁c ≥ 6 had 3.14 times greater risk of poor outcome at the end of hospital stay when compared to those with HbA₁c < 6 and this risk increased to an odds ratio of 4.57 on adjusting for other significant predictors: Acute Physiology and Chronic Health Evaluation II, injury severity score, admission blood sugar and age at admission.

Conclusions:

Substantial proportion of trauma admissions has underlying diabetes. HbA₁c, a measure of pre admission glycaemic status is an important predictor of ICU outcome in trauma patients.

The clinical significance of an elevated postoperative glucose value in nondiabetic patients after colorectal surgery: evidence for the need for tight glucose control?

OBJECTIVES

To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery.

METHODS

Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center. Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and/or based on HbA1C levels. The association between any elevated postoperative random glucose value (hyperglycemia: >125 mg/dL) and level of elevation (>125 mg/dL or >200 mg/dL) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed.

RESULTS

Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7% patients experienced hyperglycemia. Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity (blood loss). Hyperglycemia was associated with infectious and noninfectious complications and mortality, the rates of these complications increasing parallel to the degree of hyperglycemia. Hyperglycemia was independently associated with septic complications (P = 0.024).

CONCLUSIONS

Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients. Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality; this risk is related to the degree of glucose elevation. These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients.

Coagulation system changes associated with susceptibility to infection in trauma patients

BACKGROUND

Infection following trauma is associated with increased morbidity and mortality and is common following severe hemorrhage. There is a strong interaction between the coagulation and immunity. The objective of this study was to establish if there was an association between changes in coagulation status after hemorrhage and the subsequent incidence of infection.

METHODS

Prospective cohort study of adult injured patients presenting to a major trauma center during a 2-year period. Blood was drawn at 24 hours following admission and analyzed using functional thromboelastography testing and laboratory defined tests of coagulation and blood count. Patients were followed up for infectious episodes while in the hospital using Center for Disease Control definitions.

RESULTS

A total of 158 patients were recruited; 71 (45%) developed infection and were older (44 years vs. 32 years, p = 0.01) and more severely injured (Injury Severity Score [ISS], 25 vs.10; p < 0.01). White blood cell counts at 24 hours were normal, and there was no difference between groups (both 9.6 × 10/(9)L). Protein C was lower in those with infection (70.2 IU/dL vs. 83.3 IU/dL, p = 0.02), with a dose-dependent increase in infection as levels of protein C decreased. Plasmin activation at 24 hours was also strongly associated with infection plasmin-antiplasmin (infection vs. no infection, 6,156 μg/L vs. 3,324 μg/L, p = 0.03). The infection cohort had overall 12% lower procoagulant levels (varied between factor VIII 6.4% and factor II 16.2%).

CONCLUSION

There is a strong association between the status of the coagulation system after 24 hours and the development of infection following trauma. Improved early coagulation management may decrease infection rates in this patient group.

LEVEL OF EVIDENCE

Prognostic prospective study, level III.

Blood glucose levels as an adjunct for prehospital field triage

OBJECTIVE

Elevated blood glucose levels (BGL) are known to be part of the physiologic response to stress following physical trauma. We aimed to study whether a measured BGL might help improve accuracy of field triage.

METHODS

We conducted a retrospective study using the Israel Defense Forces Trauma Registry. BGLs were determined upon hospital arrival and were not available to medical providers in the field.

RESULTS

There were 706 casualties in the registry who had a recorded BGL upon hospital arrival. Sixty percent (18/30) of casualties who had a BGL ≥200 mg/dL had been triaged in the field as severely wounded, whereas 11% (71/651) of casualties who had a BGL <200 mg/dL had been triaged as severely wounded. For predicting an Injury Severity Score >15, the positive likelihood ratio using field triage of severe was 11, using BGL ≥200 mg/dL was 8, and using a combination of the two tests was 26. For predicting the need for intensive care unit (ICU) admission, the ratios were 8, 13, and 23, respectively.

CONCLUSIONS

Elevated BGL improved prediction of high Injury Severity Score and ICU use among casualties triaged as severe. If future research using BGL measured in the field yields similar results, combining BGL with standard field triage may allow for more accurate identification of casualties who need acute field intervention, have major injury, or require ICU admission.

Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients

OBJECTIVE

To evaluate the literature and identify important aspects of insulin therapy that facilitate safe and effective infusion therapy for a defined glycemic end point.

METHODS

Where available, the literature was evaluated using Grades of Recommendation, Assessment, Development, and Evaluation (GRADE) methodology to assess the impact of insulin infusions on outcome for general intensive care unit patients and those in specific subsets of neurologic injury, traumatic injury, and cardiovascular surgery. Elements that contribute to safe and effective insulin infusion therapy were determined through literature review and expert opinion. The majority of the literature supporting the use of insulin infusion therapy for critically ill patients lacks adequate strength to support more than weak recommendations, termed suggestions, such that the difference between desirable and undesirable effect of a given intervention is not always clear.

RECOMMENDATIONS

The article is focused on a suggested glycemic control end point such that a blood glucose ≥ 150 mg/dL triggers interventions to maintain blood glucose below that level and absolutely <180 mg/dL. There is a slight reduction in mortality with this treatment end point for general intensive care unit patients and reductions in morbidity for perioperative patients, postoperative cardiac surgery patients, post-traumatic injury patients, and neurologic injury patients. We suggest that the insulin regimen and monitoring system be designed to avoid and detect hypoglycemia (blood glucose ≤ 70 mg/dL) and to minimize glycemic variability.Important processes of care for insulin therapy include use of a reliable insulin infusion protocol, frequent blood glucose monitoring, and avoidance of finger-stick glucose testing through the use of arterial or venous glucose samples. The essential components of an insulin infusion system include use of a validated insulin titration program, availability of appropriate staffing resources, accurate monitoring technology, and standardized approaches to infusion preparation, provision of consistent carbohydrate calories and nutritional support, and dextrose replacement for hypoglycemia prevention and treatment. Quality improvement of glycemic management programs should include analysis of hypoglycemia rates, run charts of glucose values <150 and 180 mg/dL. The literature is inadequate to support recommendations regarding glycemic control in pediatric patients.

CONCLUSIONS

While the benefits of tight glycemic control have not been definitive, there are patients who will receive insulin infusion therapy, and the suggestions in this article provide the structure for safe and effective use of this therapy.

Stress-induced hyperglycemia as a risk factor for surgical-site infection in nondiabetic orthopedic trauma patients admitted to the intensive care unit

OBJECTIVES

The aim of this study was to evaluate the association between stress-induced hyperglycemia and infectious complications in nondiabetic orthopedic trauma patients admitted to the intensive care unit (ICU).

DESIGN

: This study was a retrospective review.

SETTING

The study was conducted at an academic level-1 trauma center.

PATIENTS

One hundred and eighty-seven consecutive trauma patients with isolated orthopedic injuries were studied.

INTERVENTION

: Blood glucose values during initial hospitalization were evaluated. The admission blood glucose (BG) and hyperglycemic index (HGI) were determined for each patient.

MAIN OUTCOME MEASURES

Perioperative infectious complications: pneumonia, urinary tract infection (UTI), surgical-site infection (SSI), sepsis were the outcome measures.

RESULTS

An average of 21.5 BG values was obtained for each patient. The mean ICU and hospital length of stay was 4.0 ± 4.9 and 10.0 ± 8.1 days, respectively. Infections were recorded in 43 of 187 patients (23.0%) and SSIs specifically documented in 16 patients (8.6%). Open fractures were not associated with SSI (8/83, 9.6% vs. 8/104, 7.7%). There was no difference in admission BG or HGI and infection. However, there was a significant difference in HGI when considering SSI alone (2.1 ± 1.7 vs. 1.2 ± 1.1). Patients with an SSI received a greater amount of blood transfusions (14.9 ± 12.1 vs. 4.9 ± 7.6). No patient was diagnosed with a separate infection (ie, pneumonia, UTI, bacteremia) before SSI. There was no significant difference in injury severity score among patients with an SSI (11.1 ± 4.0 vs. 9.6 ± 3.0). Multivariable regression testing with HGI as a continuous variable demonstrated a significant relationship (odds ratio: 1.8, 95% confidence interval: 1.3-2.5) with SSI after adjusting for blood transfusions (odds ratio: 1.1, 95% confidence interval: 1.1-1.2).

CONCLUSIONS

: Stress-induced hyperglycemia demonstrated a significant independent association with SSIs in nondiabetic orthopedic trauma patients who were admitted to the ICU.

LEVEL OF EVIDENCE

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

Steroid modulation of cytokine release and desmosine levels in bilateral total knee replacement: a prospective, double-blind, randomized controlled trial

BACKGROUND

The perioperative inflammatory response as measured by elevated levels of interleukin-6 (IL-6) has been linked to acute respiratory distress syndrome, postoperative confusion, and fever. Because of the extent of surgery,patients undergoing bilateral total knee arthroplasty may be at high risk of complications. We had found a significant decrease in IL-6 in patients having bilateral total knee replacement who received two doses of 100 mg of hydrocortisone eight hours apart; however, by twenty-four hours, IL-6 levels were equal to those in the group that received a placebo. In the present study, we investigated whether the administration of three doses would reduce IL-6 levels at twenty-four hours and affect other outcomes such as desmosine level, a marker of lung injury.

METHODS

After institutional review board approval, a total of thirty-four patients (seventeen patients and seventeen control subjects) were enrolled in this double-blind, randomized, placebo-controlled study. Three doses of intravenous hydrocortisone (100 mg) or placebo were given eight hours apart. Urinary desmosine levels were obtained at baseline and at one and three days postoperatively. The level of IL-6 was measured at baseline and at six, ten, twenty-four, and forty-eight hours postoperatively. Pain scores, presence of fever, and functional outcomes were recorded.

RESULTS

The level of IL-6 increased in both groups, but was significantly higher in the control group, peaking at twenty-four hours (mean and standard deviation, 623.74 ± 610.35 pg/mL versus 148.13 ± 119.35 pg/mL; p = 0.006). Urinary desmosine levels significantly increased by twenty-four hours in the control group, but remained unchanged in the study group (134.75 ± 67.88 pmol/mg and 79.45 ± 46.30 pmol/mg, respectively; p = 0.006). Pain scores at twenty-four hours were significantly lower in the study group (1.4 ± 0.9 versus 2.4 ± 1.2; p = 0.01) as was the presence of fever (11.8%versus 47.1%; p = 0.03). Range of motion at the knee was significantly greater in the study group (81.6 ± 11.6 versus 70.6 ± 14.0 in the right knee [p = 0.02] and 81.4 ± 11.3 versus 73.4 ± 9.4 in the left knee [p = 0.03]).

CONCLUSIONS

Hydrocortisone (100 mg) given over three doses, each eight hours apart, decreased and maintained a lower degree of inflammation with bilateral total knee replacement as measured by IL-6 level. Corticosteroids decreased the prevalence of fever, lowered visual analog pain scores, and improved knee motion. The significantly lower values of desmosine in the study group suggest that this treatment may be protective against lung injury.

Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery

BACKGROUND

The impact of perioperative hyperglycemia in orthopaedic surgery is not well defined. We hypothesized that hyperglycemia is an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes at hospital admission.

METHODS

Patients eighteen years of age or older with isolated orthopaedic injuries requiring acute operative intervention were studied. Patients with diabetes, injuries to other body systems, a history of corticosteroid use, or admission to the intensive care unit were excluded. Blood glucose values were obtained, and hyperglycemia was defined in two ways. First, patients with two or more blood glucose levels of ≥200 mg/dL were identified. Second, the hyperglycemic index, a validated measure of overall glucose control during hospitalization, was calculated for each patient. A hyperglycemic index of ≥1.76 (equivalent to ≥140 mg/dL) was considered to indicate hyperglycemia. The primary outcome was thirty-day surgical-site infection. Multivariable logistic regression models evaluating the effect of the markers of hyperglycemia, after controlling for open fractures, were constructed.

RESULTS

Seven hundred and ninety patients were identified. There were 268 open fractures (33.9%). Twenty-one thirty-day surgical-site infections (2.7%) were recorded. Age, race, comorbidities, injury severity, and blood transfusion were not associated with the primary outcome. Of the 790 patients, 294 (37.2%) had more than one glucose value of ≥200 mg/dL. This factor was associated with thirty-day surgical-site infection, with thirteen (4.4%) of the 294 patients with that indication of hyperglycemia having a surgical-site infection versus eight (1.6%) of the 496 patients without more than one glucose value of ≥200 mg/dL (p = 0.02). One hundred and thirty-four (17.0%) of the 790 patients had a hyperglycemic index of ≥1.76, and this was also associated was thirty-day surgical-site infection (ten [7.5%] of 134 versus eleven [1.7%] of 656; p < 0.001). Multivariable logistic regression models demonstrated that two or more blood glucose levels of ≥200 mg/dL was a risk factor for thirty-day surgical-site infection (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.1 to 6.7) after adjustment for open fractures (OR: 3.2, 95% CI: 1.3 to 7.8). A second model demonstrated that a hyperglycemic index of ≥1.76 was an independent risk factor for surgical-site infection (OR: 4.9, 95% CI: 2.0 to 11.8) after controlling for open fractures (OR: 3.3, 95% CI: 1.4 to 8.3).

CONCLUSIONS

Hyperglycemia was an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes.

The place for glycemic control in the surgical patient

BACKGROUND

Hyperglycemia is common in surgical patients and is associated with adverse outcomes. Conflicting data exist regarding the best method and the value of glycemic control in various patient populations. The contributions to hyperglycemia and the components of its control are complex and overlapping and likely contribute to the documented variation in outcomes. We provide an overview of the physiologic contributors to hyperglycemia and its control, review the differences in the major randomized trial results, and summarize the data regarding glycemic control in surgical patients.

METHODS

Major reviews of the pathophysiology of hyperglycemia in surgical patients, large randomized trials in critically ill and peri-operative populations, and meta-analyses were reviewed. Summations are provided for the critically ill population and for the peri-operative group.

RESULTS

A substantial physiologic rationale exists for the control of hyperglycemia in surgical patients during critical illness and in the peri-operative period. Randomized, controlled studies are limited predominately to critically ill populations. The data support controlling hyperglycemia to a serum glucose concentration <200 mg/dL, but the absolute target range remains controversial and studied inadequately. The data indicate the benefit of tight glycemic control using insulin to achieve a target of 80-110 mg/dL (intensive insulin therapy [IIT]) vs. a liberal target of 180-200 mg/dL in critically ill surgical patients, although hypoglycemia is more common with IIT. Inadequate studies are available in the peri-operative period to draw conclusions about non-critically ill surgical patients, but the weight of the data suggests control to < 200 mg/dL likely is beneficial.

CONCLUSIONS

Surgical patients benefit from maintaining serum glucose concentrations <200 mg/dL. Intensive insulin therapy (80-110 mg/dL), which appears beneficial in critically ill surgical patients but requires frequent measurement of glucose to avoid hypoglycemia. Further studies are needed to determine the appropriate target range and the influence of nutritional provision and other factors on outcome.