Mild hypoglycemia is independently associated with increased mortality in the critically ill

Estimating risk of consequences following hypoglycaemia exposure using the Hypo-RESOLVE cohort: a secondary analysis of pooled data from insulin clinical trials

AIMS/HYPOTHESIS

Whether hypoglycaemia increases the risk of other adverse outcomes in diabetes remains controversial, especially for hypoglycaemia episodes not requiring assistance from another person. An objective of the Hypoglycaemia REdefining SOLutions for better liVEs (Hypo-RESOLVE) project was to create and use a dataset of pooled clinical trials in people with type 1 or type 2 diabetes to examine the association of exposure to all hypoglycaemia episodes across the range of severity with incident event outcomes: death, CVD, neuropathy, kidney disease, retinal disorders and depression. We also examined the change in continuous outcomes that occurred following a hypoglycaemia episode: change in eGFR, HbA1c, blood glucose, blood glucose variability and weight.

METHODS

Data from 84 trials with 39,373 participants were pooled. For event outcomes, time-updated Cox regression models adjusted for age, sex, diabetes duration and HbA1c were fitted to assess association between: (1) outcome and cumulative exposure to hypoglycaemia episodes; and (2) outcomes where an acute effect might be expected (i.e. death, acute CVD, retinal disorders) and any hypoglycaemia exposure within the last 10 days. Exposures to any hypoglycaemia episode and to episodes of given severity (levels 1, 2 and 3) were examined. Further adjustment was then made for a wider set of potential confounders. The within-person change in continuous outcomes was also summarised (median of 40.4 weeks for type 1 diabetes and 26 weeks for type 2 diabetes). Analyses were conducted separately by type of diabetes.

RESULTS

The maximally adjusted association analysis for type 1 diabetes found that cumulative exposure to hypoglycaemia episodes of any level was associated with higher risks of neuropathy, kidney disease, retinal disorders and depression, with risk ratios ranging from 1.55 (p=0.002) to 2.81 (p=0.002). Associations of a similar direction were found when level 1 episodes were examined separately but were significant for depression only. For type 2 diabetes cumulative exposure to hypoglycaemia episodes of any level was associated with higher risks of death, acute CVD, kidney disease, retinal disorders and depression, with risk ratios ranging from 2.35 (p<0.0001) to 3.00 (p<0.0001). These associations remained significant when level 1 episodes were examined separately. There was evidence of an association between hypoglycaemia episodes of any kind in the previous 10 days and death, acute CVD and retinal disorders in both type 1 and type 2 diabetes, with rate ratios ranging from 1.32 (p=0.017) to 2.68 (p<0.0001). These associations varied in magnitude and significance when examined separately by hypoglycaemia level. Within the range of hypoglycaemia defined by levels 1, 2 and 3, we could not find any evidence of a threshold at which risk of these consequences suddenly became pronounced.

CONCLUSIONS/INTERPRETATION

These data are consistent with hypoglycaemia being associated with an increased risk of adverse events across several body systems in diabetes. These associations are not confined to severe hypoglycaemia requiring assistance.

Hypoglycemia in non-diabetic in-patients at a teaching referral hospital in Iran

Purpose

This study aims to investigate comorbidities, clinical features, laboratory values, and diagnoses in non-diabetic patients experiencing hypoglycemic episodes.

Methods

A retrospective observational study was conducted at Shariati Hospital in Iran from 2016 to 2023. Seventy-four non-diabetic patients admitted with a diagnosis of hypoglycemia were included, while patients with diabetes were excluded. Demographic data, symptoms, and biochemical assessments were obtained from the hospital information system. Hypoglycemic episodes were identified based on low measured blood glucose, recorded medications for hypoglycemia treatment, or recorded codes indicating hypoglycemia. Hypoglycemia was defined as blood glucose below 70 mg/dL (3.9 mmol/L) along with two other criteria of the Whipple triad. Statistical analysis was performed using SPSS software (version 26).

Results

Among the enrolled patients, 63.5% were female, and 13.5% were elderly (≥ 65 years). The most common comorbidities observed were cardiovascular disease (20.3%), psychological disorders (20.3%), hypothyroidism (14.9%), and hypertension (8.1%). The prevalent symptoms included weakness, loss of consciousness, sweating, palpitations, dizziness, and tremors. Non-diabetic hypoglycemia was caused by factitious disorders, insulinoma, organ failure, and infection, respectively.

Conclusion

Due to the diverse range of clinical symptoms, hypoglycemia in non-diabetic patients may be diagnosed late, leading to misdiagnoses such as psychological disorders or seizures. It is crucial to consider the possibility of hypoglycemia in non-diabetic patients and determine its underlying cause. Given the poor prognosis associated with hypoglycemia, timely interventions are essential.

SCH772984 ameliorates lipopolysaccharide-induced hypoglycemia in mice through reversing MEK/ERK/Foxo1-mediated gluconeogenesis suppression

Lipopolysaccharide (LPS) results in a lethal hypoglycemic response. However, the main molecular mechanism involved in LPS-induced glucose metabolism disorder is poorly understood. This study intends to investigate the signaling pathways involved in LPS-induced hypoglycemia and potential efficacy of extracellular signal-regulated kinase (ERK) inhibitor SCH772984. The effects of LPS and SCH772984 on gluconeogenesis, glucose absorption, and glycogenolysis were evaluated by pyruvate tolerance test, oral glucose tolerance test, and glucagon test, respectively. After a single intraperitoneal injection of 0.5 mg/kg LPS, the mice's blood glucose levels and gluconeogenesis ability were significantly lower than that of control group. Besides, mRNA and protein expression of glucose-6-phosphatase (G6Pase) and phosphoenolpyruvate carboxykinase (PEPCK) decreased significantly after LPS treatment. LPS induced the phosphorylation of ERK1/2, MEK1/2 (mitogen-activated protein kinase), and Foxo1 while inhibited Foxo1 expression in the nucleus, indicating an important role of the MEK/ERK/Foxo1 signaling in the inhibition of gluconeogenesis by LPS. Furthermore, SCH772984 elevated blood glucose, increased the G6Pase and PEPCK expression, and inhibited pERK1/2 and pFoxo1 expression in LPS-induced mice. In summary, LPS inhibited gluconeogenesis and induced hypoglycemia through the MEK/ERK/Foxo1 signal pathway, and ERK inhibitor could effectively reverse decreased blood glucose in mice with LPS treatment. These findings provide a novel therapeutic target for LPS-induced hypoglycemia.

Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit

Background

Sepsis is one of the major causes of admission to the pediatric intensive care unit (PICU), as well as a primary cause of poor outcomes. Glycemic variation may occur because of sepsis resulting in either hypoglycemia or hyperglycemia. Measuring the random blood glucose (RBG) level of patients presenting with sepsis in PICU is an easy way to assess their prognosis.

Objectives

A prospective study was done from February 2023 to June 2023 to evaluate the relation between the outcome of pediatric septic patients and blood glucose level upon PICU admission.

Patients and methods

One hundred three children diagnosed with sepsis underwent clinical assessment upon admission to the PICU and initial labs including blood glucose levels were done. Pediatric Sequential Organ Failure Assessment (pSOFA) was calculated for every patient. The outcome of sepsis including length of stay, review of body systems, and mortality was documented.

Results

Hypoglycemic patients had the highest percentage of non-survivors (20.4%). They had a higher pSOFA score with a median of 11 (interquartile range-IQR 7-15), shorter PICU stay with a median of 2 (IQR 1-6) days, lower RBG with a median of 95 (45-120), a higher percentage of ventilation (55.1%), and a higher percentage of inotropic support (87.8%) with statistical significance with p-value (< 0.001, < 0.001, 0.001, < 0.001, 0.002), respectively.

Conclusion

Critically ill patients with abnormal random blood sugar (RBS) had a higher possibility of non-survival particularly those with hypoglycemia. Accordingly, RBS measurement is a rapid and cheap method that could be used in any emergency and as an early indicator to detect outcome.

How to cite this article

Mohamed AO, Abd El-Megied MA, Hosni YA. Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(10):754-758.

Perioperative glycemic management in adults presenting for elective cardiac and non-cardiac surgery

Perioperative dysglycemia is associated with adverse outcomes in both cardiac and non-cardiac surgical patients. Hyperglycemia in the perioperative period is associated with an increased risk of postoperative infections, length of stay, and mortality. Hypoglycemia can induce neuronal damage, leading to significant cognitive deficits, as well as death. This review endeavors to summarize existing literature on perioperative dysglycemia and provides updates on pharmacotherapy and management of perioperative hyperglycemia and hypoglycemia in surgical patients.

Association of the time in targeted blood glucose range of 3.9-10 mmol/L with the mortality of critically ill patients with or without diabetes

Purpose

The relationship between the TIR and mortality may be influenced by the presence of diabetes and other glycemic indicators. The purpose of this study was to investigate the relationship between TIR and in-hospital mortality in diabetic and non-diabetic patients in ICU.

Methods

A total of 998 patients with severe diseases in the ICU were selected for this retrospective analysis. The TIR is defined as the percentage of time spent in the target blood glucose range of 3.9-10.0 mmol/L within 24 h. The relationship between TIR and in-hospital mortality in diabetic and non-diabetic patients was analyzed. The effect of glycemic variability was also analyzed.

Results

The binary logistic regression model showed that there was a significant association between the TIR and the in-hospital death of severely ill non-diabetic patients. Furthermore, TIR≥70% was significantly associated with in-hospital death (OR = 0.581, P = 0.003). The study found that the coefficient of variation (CV) was significantly associated with the mortality of severely ill diabetic patients (OR = 1.042, P = 0.027).

Conclusions

Both diabetic and non-diabetic critically ill patients should control blood glucose fluctuations and maintain blood glucose levels within the target range, it may be beneficial in reducing mortality.

Model-based subcutaneous insulin for glycemic control of pre-term infants in the neonatal intensive care unit

Hyperglycaemia is a common problem in neonatal intensive care units (NICUs). Achieving good control can result in better outcomes for patients. However, good control is difficult, where poor control and resulting hypoglycaemia reduces outcomes and confounds results. Clinically validated models can provide good control, and subcutaneous insulin delivery can provide more options for insulin therapy for clinicians. However, this combination has only been significantly utilised in adult outpatient diabetes, but could hold benefit for treating NICU infants. This research combines a well-validated NICU metabolic model with subcutaneous insulin kinetics models to assess the feasibility of a model-based approach. Clinical data from 12 very/extremely pre-mature infants was collected for an average study duration of 10.1 days. Blood glucose, interstitial and plasma insulin, as well as subcutaneous and local insulin were modelled, and patient-specific insulin sensitivity profiles were identified for each patient. Modelling error was low, where the cohort median [IQR] mean percentage error was 0.8 [0.3 3.4] %. For external validation, insulin sensitivity was compared to previous NICU cohorts using the same metabolic model, where overall levels of insulin sensitivity were similar. Overall, the combined system model accurately captured observed glucose and insulin dynamics, showing the potential for a model-based approach to glycaemic control using subcutaneous insulin in this cohort. The results justify further model validation and clinical trial research to explore a model-based protocol.

Accuracy of a Risk Alert Threshold for ICU Hypoglycemia: Retrospective Analysis of Alert Performance and Association With Clinical Deterioration Events

OBJECTIVES

To quantify the accuracy of and clinical events associated with a risk alert threshold for impending hypoglycemia during ICU admissions.

DESIGN

Retrospective electronic health record review of clinical events occurring greater than or equal to 1 and less than or equal to 12 hours after the hypoglycemia risk alert threshold was met.

SETTING

Adult ICU admissions from June 2020 through April 2021 at the University of Virginia Medical Center.

PATIENTS

Three hundred forty-two critically ill adults that were 63.5% male with median age 60.8 years, median weight 79.1 kg, and median body mass index of 27.5 kg/m2.

INTERVENTIONS

Real-world testing of our validated predictive model as a clinical decision support tool for ICU hypoglycemia.

MEASUREMENTS AND MAIN RESULTS

We retrospectively reviewed 350 hypothetical alerts that met inclusion criteria for analysis. The alerts correctly predicted 48 cases of level 1 hypoglycemia that occurred greater than or equal to 1 and less than or equal to 12 hours after the alert threshold was met (positive predictive value = 13.7%). Twenty-one of these 48 cases (43.8%) involved level 2 hypoglycemia. Notably, three myocardial infarctions, one medical emergency team call, 19 deaths, and 20 arrhythmias occurred greater than or equal to 1 and less than or equal to 12 hours after an alert threshold was met.

CONCLUSIONS

Alerts generated by a validated ICU hypoglycemia prediction model had a positive predictive value of 13.7% for real-world hypoglycemia events. This proof-of-concept result suggests that the predictive model offers clinical value, but further prospective testing is needed to confirm this.

Hypoglycemia is associated with a higher risk of mortality and arrhythmias in ST-elevation myocardial infarction, irrespective of diabetes

Aims

We aimed to assess the impact of hypoglycemia in ST-elevation myocardial infarction (STEMI).

Background

Hypoglycemia increases the risk of mortality in patients with diabetes and high cardiovascular risk.

Methods

We used the National Inpatient Sample (2005–2017) database to identify adult patients with STEMI as the primary diagnosis. The secondary diagnosis was hypoglycemia. We compared cardiovascular and socio-economic outcomes between STEMI patients with and without hypoglycemia and assessed temporal trends.

Results

Hypoglycemia tends to complicate 0.17% of all cases hospitalized for STEMI. The mean age (±SD) of STEMI patients hospitalized with hypoglycemia decreased from 67 ± 15 in 2005 to 63 ± 12 in 2017 (p = 0.046). Mortality was stable with time, but the prevalence of ventricular tachycardia, ventricular fibrillation, acute renal failure, cardiogenic shock, total charges, and length of stay (LOS) increased with time (p < 0.05 for all). Compared to non-hypoglycemic patients, those who developed hypoglycemia were older and more likely to be black; only 6.7% had diabetes compared to 28.5% of STEMI patients (p = 0.001). Cardiovascular events were more likely to occur in hypoglycemia: mortality risk increased by almost 2.5-fold (adjusted OR = 2.625 [2.095–3.289]). There was a higher incidence of cardiogenic shock (adjusted OR = 1.718 [1.387–2.127]), atrial fibrillation (adjusted OR = 1.284 [1.025–1.607]), ventricular fibrillation (adjusted OR = 1.799 [1.406–2.301]), and acute renal failure (adjusted OR = 2.355 [1.902–2.917]). Patients who developed hypoglycemia were less likely to have PCI (OR = 0.596 [0.491–0.722]) but more likely to have CABG (OR = 1.792 [1.391–2.308]). They also had a longer in-hospital stay and higher charges/stay.

Conclusion

Hypoglycemia is a rare event in patients hospitalized with STEMI. However, it was found to have higher odds of mortality, arrhythmias, and other comorbidities, irrespective of diabetes.

Divergent effect of blood glucose dysregulation on long-term clinical outcome in acute decompensated heart failure: A reappraisal in contemporary practice

BACKGROUND

The prognostic implication of elevated or decreased blood glucose (BG) level in acute decompensated heart failure (ADHF) has been still controversial. Indices of stress hyperglycemia, expressed by the ratio of BG and chronic BG control, has been reported to be associated with poor outcome in different disease population. We sought to assess BG at admission and %ΔBG, an index of BG deviation from estimated average BG calculated from glycated hemoglobin (HbA1c), on the long-term outcome in ADHF patients.

METHODS AND RESULTS

The West Tokyo Heart Failure (WET-HF) Registry is a prospective multicenter registry enrolling consecutive hospitalized ADHF patients. Among the patients (N = 3078, 77 [67-84] years, male 59%), BG at admission discriminated the long-term (1000 days) incidence of ADHF rehospitalization, but not cardiac death. BG at admission showed a U-shape relationship with the long-term incidence of ADHF rehospitalization after adjustment for covariates. Especially, in patients with HbA1c ≥ 6.5%, the lowest quartile showed the highest risk of ADHF rehospitalization. On the contrary, %ΔBG showed U-shape relationship with the long-term incidence of cardiac death after discharge, rather than ADHF rehospitalization after adjustment for covariates. In addition, elevated %ΔBG was associated with the long-term risk of sudden cardiac death (SCD) even after adjustment for covariates.

CONCLUSIONS

For ADHF patients, BG at admission and %ΔBG might be a simple, useful tool for predicting and stratifying long-term risk of cardiac events. Especially, elevated %ΔBG might be an important in predicting hard events such as cardiac death or SCD.

Evaluation of the Efficacy of a Hypoglycemia Protocol to Treat Severe Hypoglycemia

PURPOSE

The purpose of this quality improvement project was to evaluate the efficacy of the facility's Hypoglycemia Protocol when treating severe hypoglycemia (defined as blood glucose < 50 mg/dL).

DESCRIPTION

The diabetes clinical nurse specialists conducted a retrospective chart review of diabetic inpatients with severe hypoglycemia who were treated per the Hypoglycemia Protocol from October 1, 2017, through April 30, 2019. The primary outcome was achievement of euglycemia (defined as blood glucose ≥ 80 mg/dL) 15 to 30 minutes post treatment with either oral carbohydrates or intravenous dextrose.

OUTCOME

Two hundred twenty-two patients received treatment with oral carbohydrates versus 120 patients who received intravenous dextrose. Fifty patients receiving oral carbohydrates versus 106 patients receiving intravenous dextrose achieved euglycemia after 1 treatment. Compared with treatment with intravenous dextrose, the odds ratio of the rise in blood glucose to 80 mg/dL or greater within 15 to 30 minutes post treatment for a patient given oral carbohydrate was decreased by 97.2%.

CONCLUSION

Intravenous dextrose was more efficacious than oral carbohydrate treatment in patients with diabetes experiencing severe hypoglycemia. In response, the Hypoglycemia Protocol was revised to increase oral carbohydrate treatment for severe hypoglycemia and to expedite escalation from oral to intravenous treatment.

Association Between Glycemic Gap and Mortality in Critically Ill Patients with Diabetes

OBJECTIVES

Dysglycemia is associated with poor outcomes in critically ill patients,which is uncertain in patients with diabetes regarding to the situation of glucose control before hospitalization. This study was aimed to investigate the effect of the difference between the level of blood glucose during ICU stay and before admission to ICU upon the outcomes of critically ill patients with diabetes.

METHOD

Patients with diabetes expected to stay for more than 24hs were enrolled, HbA1c was converted to A1C-derived average glucose (ADAG) by the equation: ADAG  =  [ (HbA1c * 28.7) - 46.7 ] * 18^-1, blood glucose were measured four times a day during the first 7 days after admission, the mean glucose level(MGL) and SOFA (within 3, 5, and 7days) were calculated for each person, GAP_adm and GAP_mean was calculated as admission blood glucose and MGL minus ADAG, the incidence of moderate hypoglycemia(MH), severe hypoglycemia (SH), total dosage of glucocorticoids and average daily dosage of insulin, duration of renal replacement therapy(RRT), ventilator-free hours, and non-ICU days were also collected. Patients were divided into survival group and nonsurvival group according to survival or not at 28-day, the relationship between GAP and mortality were analyzed.

RESULTS

431 patients were divided into survival group and nonsurvival group. The two groups had a comparable level of HbA1c, the nonsurvivors had greater APACHE II, SOFA, GAP_adm, GAP_mean-3, GAP_mean-5, GAP_mean-7 and higher MH and SH incidences. Less duration of ventilator-free, non-ICU stay and longer duration of RRT were recorded in the nonsurvival group. GAP_mean-5 had the greatest predictive power with an AUC of 0.807(95%CI: 0.762-0.851), the cut-off value was 3.6 mmol/L (sensitivity 77.7% and specificity 76.6%). The AUC was increased to 0.852(95%CI: 0.814-0.889) incorporated with SOFA₅ (NRI  =  11.34%).

CONCLUSION

Glycemic GAP between the MGL within 5 days and ADAG was independently associated with 28-day mortality of critically ill patients with diabetes. The predictive power was optimized with addition of SOFA₅.

Relative Hypoglycemia is Associated with Delirium in Critically Ill Patients with Diabetes: A Cohort Study

PURPOSE

Critically ill patients with premorbid diabetes can suffer from relative hypoglycemia (RHG), falling below the normal blood glucose (BG) target. However, these events have not been well defined or studied. In the present study, we aimed to explore the incidence and clinical significance of RHG events in critically ill patients with diabetes.

PATIENTS AND METHODS

Patients with a history of diabetes who stayed in the intensive care unit (ICU) for more than three days with at least 12 BG recordings were retrospectively included in the study. A BG level > 30% below the estimated average according to patient hemoglobin A1c measured at admission was defined as a single RHG event. Outcomes were compared between patients with and those without RHG events.

RESULTS

In total, 113 patients were included in the final analysis. RHG was detected in 73 patients (64.6%). Those who experienced RHG events had a significantly higher incidence of ICU delirium. They also had a higher risk of 28-day mortality, but this was not statistically significant. However, patients with a higher frequency of RHG events did have a significantly higher risk of overall mortality (57.1% for more than four events vs 15.4% for three to four events, P=0.006 and 15.1% for one to two events, P=0.003).

CONCLUSION

In conclusion, RHG is a common finding in critically ill patients with diabetes and is associated with mortality and the occurrence of delirium.

Relationship between blood glucose variability and muscle composition in ICU patients receiving nutrition support: A pilot study

BACKGROUND AND AIMS

Many critically ill patients experience increased blood glucose variability (BGV). The objective of the current pilot study was to assess the relationship between muscle composition (defined as average Hounsfield units (HU)) among ICU patients with an abdominal CT scan within seven days of intubation, and BGV (defined as coefficient of variation (CV)) calculated from blood glucose levels measured each morning while intubated.

METHODS

The first serum blood glucose measurement obtained each day during intubation was recorded, blood glucose CV ((mean/SD)∗100) was calculated. Cross-sectional muscle area (CSA; cm²) at the third lumbar region was identified using the -29 to +150 HU range; muscle composition was calculated as the average HU. BGV predictors were determined using linear regression.

RESULTS

Eighty-two patients were included (53% female), with a median age of 64 (25th, 75 percentile (IQR): 51, 70) years. The median CV was 29% (IQR: 20, 37); 40% of subjects required insulin. The median CSA was 100.4 cm² (IQR: 84.0, 120.8) and muscle composition was 20.4 HU (IQR: 12.2, 29.4). Patients received only 36% of estimated calorie requirements. Insulin administration, history of diabetes, and muscle composition were significant BGV predictors.

CONCLUSION

Among these adult intubated ICU patients, higher muscle composition was associated with lower BGV. Future research is needed to corroborate these findings, determine other factors associated with poor muscle quality, and identify methods to describe muscle composition for all ICU patients.

Effect of glycemic gap upon mortality in critically ill patients with diabetes

AIMS/INTRODUCTION

Hyperglycemia, hypoglycemia, and blood glucose fluctuation are associated with the outcome in critically ill patients, but the target of blood glucose control is debatable especially in patients with diabetes regarding the status of blood glucose control before admission to ICU. This study aimed to investigate the association between the glycemic gap which is calculated as the mean blood glucose level during the first 7 days after admission to ICU minus the A1C-derived average glucose and the outcome of critically ill patients with diabetes.

METHOD

This study was undertaken in two intensive care units (ICUs) with a total of 30 beds. Patients with diabetes who were expected to stay for more than 24 h were enrolled, the HbA1c was tested within 3 days after admission and converted to the A1C-derived average glucose (ADAG) by the equation: ADAG = [(HbA1c * 28.7) - 46.7 ] * 18-1 , arterial blood glucose measurements were four per day routinely during the first 7 days after admission, the APACHE II score within the first 24 h, the mean blood glucose level (MGL), standard deviation (SD), and coefficient of variation (CV) during the first 7 days were calculated for each person, the GAPadm and GAPmean were calculated as the admission blood glucose and MGL minus the ADAG, respectively, the incidence of moderate hypoglycemia (MH) and severe hypoglycemia (SH), the total dosage of glucocorticoids and average daily dosage of insulin within 7 days, the duration of renal replacement therapy (RRT), ventilator-free hours, and non-ICU stay days within 28 days were also collected. The enrolled patients were divided into a survival group and a nonsurvival group according to survival or not at 28 days and 1 year after admission, and the relationship between parameters derived from blood glucose and mortality in the enrolled critically ill patients was explored.

RESULTS

Five hundred and two patients were enrolled and divided into a survival group (n = 310) and a nonsurvival group (n = 192). It was shown that the two groups had a comparable level of HbA1c, the nonsurvivors had a greater APACHE II, MGL, SD, CV, GAPadm , GAPmean , and a higher incidence of hypoglycemia. A lesser duration of ventilator-free, non-ICU stay, and a longer duration of RRT were recorded in the nonsurvival group, who received a lower carbohydrate intake, a higher daily dosage of insulin and glucocorticoid. GAPmean had the greatest predictive power with an AUC of 0.820 (95%CI: 0.781-0.850), the cut-off value was 3.60 mmol/L (sensitivity 78.2% and specificity 77.3%). Patients with a low GAPmean tended to survive longer than the high GAPmean group 1 year after admission.

CONCLUSIONS

Glycemic GAP between the mean level of blood glucose within the first 7 days after admission to ICU and the A1C-derived average glucose was independently associated with a 28 day mortality of critically ill patients with diabetes, the predictive power extended to 1 year. The incidence of hypoglycemia was associated with mortality either.

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.

Glycemic lability index and mortality in critically ill patients-A multicenter cohort study

BACKGROUND

Emerging evidence indicates a relationship between glycemic variability during intensive care unit (ICU) admission and death. We assessed whether mean glucose, hypoglycemia occurrence, or premorbid glycemic control modified this relationship.

METHODS

In this retrospective, multicenter cohort study, we included adult patients admitted to five ICUs in Australia and Sweden with available preadmission glycated hemoglobin A1c (HbA1c) and three or more glucose readings. We calculated the glycemic lability index (GLI), a measure of glycemic variability, and the time-weighted average blood glucose (TWA-BG) from all glucose readings. We used logistic regression analysis with adjustment for hypoglycemia and admission characteristics to assess the independent association of GLI (above vs. below cohort median) and TWA-BG (above vs. below cohort median) with hospital mortality.

RESULTS

Among 2305 patients, 859 (37%) had diabetes, median GLI was 40 [mmol/L]² /h/week, median TWA-BG was 8.2 mmol/L, 171 (7%) developed hypoglycemia, and 371 (16%) died. The adjusted odds ratio for death was 1.61 (95% CI, 1.19-2.15; P = .002) for GLI above versus below median and 1.06 (95% CI, 0.80-1.41; P = .67) for TWA-BG above versus below median. The relationship between GLI and mortality was not modified by TWA-BG (P [interaction] = 0.66), a history of diabetes (P [interaction] = 0.89) or by HbA1c ≥52 mmol/mol (vs. <52 mmol/mol) (P [interaction] = 0.29).

CONCLUSION

In adult patients admitted to an ICU in Sweden and Australia, a high GLI was associated with increased hospital mortality irrespective of the level of mean glycemia, hypoglycemia occurrence, or premorbid glycemic control. These findings support the assessment of interventions to reduce glycemic variability during critical illness.

Birkenfeld A, Sponholz C, A. Müller U, von Loeffelholz C. Blood Sugar Targets in Surgical Intensive Care—Management and Special Considerations in Patients With Diabetes

BACKGROUND

30-80% of patients being treated in intensive care units in the perioperative period develop hyperglycemia. This stress hyperglycemia is induced and maintained by inflammatory-endocrine and iatrogenic stimuli and generally requires treatment. There is uncertainty regarding the optimal blood glucose targets for patients with diabetes mellitus.

METHODS

This review is based on pertinent publications retrieved by a selective search in PubMed and Google Scholar.

RESULTS

Patients in intensive care with pre-existing diabetes do not benefit from blood sugar reduction to the same extent as metabolically healthy individuals, but they, too, are exposed to a clinically relevant risk of hypoglycemia. A therapeutic range from 4.4 to 6.1 mmol/L (79-110 mg/dL) cannot be justified for patients with diabetes mellitus. The primary therapeutic strategy in the perioperative setting should be to strictly avoid hypoglycemia. Neurotoxic effects and the promotion of wound-healing disturbances are among the adverse consequences of hyperglycemia. Meta-analyses have shown that an upper blood sugar limit of 10 mmol/L (180 mg/dL) is associated with better outcomes for diabetic patients than an upper limit of less than this value. The target range of 7.8-10 mmol/L (140-180 mg/dL) proposed by specialty societies for hospitalized patients with diabetes seems to be the best compromise at present for optimizing clinical outcomes while avoiding hypoglycemia. The method of choice for achieving this goal in intensive care medicine is the continuous intravenous administration of insulin, requirng standardized, high-quality monitoring conditions.

CONCLUSION

Optimal blood sugar control for diabetic patients in intensive care meets the dual objectives of avoiding hypoglycemia while keeping the blood glucose concentration under 10 mmol/L (180 mg/dL). Nutrition therapy in accordance with the relevant guidelines is an indispensable pre - requisite.

Combined glucocorticoid resistance and hyperlactatemia contributes to lethal shock in sepsis

Sepsis is a potentially lethal syndrome resulting from a maladaptive response to infection. Upon infection, glucocorticoids are produced as a part of the compensatory response to tolerate sepsis. This tolerance is, however, mitigated in sepsis due to a quickly induced glucocorticoid resistance at the level of the glucocorticoid receptor. Here, we show that defects in the glucocorticoid receptor signaling pathway aggravate sepsis pathophysiology by lowering lactate clearance and sensitizing mice to lactate-induced toxicity. The latter is exerted via an uncontrolled production of vascular endothelial growth factor, resulting in vascular leakage and collapse with severe hypotension, organ damage, and death, all being typical features of a lethal form of sepsis. In conclusion, sepsis leads to glucocorticoid receptor failure and hyperlactatemia, which collectively leads to a lethal vascular collapse.

Metabolic Alterations in Sepsis

Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection”. Contrary to the older definitions, the current one not only focuses on inflammation, but points to systemic disturbances in homeostasis, including metabolism. Sepsis leads to sepsis-induced dysfunction and mitochondrial damage, which is suggested as a major cause of cell metabolism disorders in these patients. The changes affect the metabolism of all macronutrients. The metabolism of all macronutrients is altered. A characteristic change in carbohydrate metabolism is the intensification of glycolysis, which in combination with the failure of entering pyruvate to the tricarboxylic acid cycle increases the formation of lactate. Sepsis also affects lipid metabolism—lipolysis in adipose tissue is upregulated, which leads to an increase in the level of fatty acids and triglycerides in the blood. At the same time, their use is disturbed, which may result in the accumulation of lipids and their toxic metabolites. Changes in the metabolism of ketone bodies and amino acids have also been described. Metabolic disorders in sepsis are an important area of research, both for their potential role as a target for future therapies (metabolic resuscitation) and for optimizing the current treatment, such as clinical nutrition.

Critical illness myopathy precedes hyperglycaemia and high glucose variability

BACKGROUND

Critical Illness Myopathy (CIM) is a serious ICU complication, and dysglycaemia is widely regarded as a risk factor. Although glucose variability (GV) has been independently linked to ICU mortality, an association with CIM has not been investigated. This study examines the relationship between CIM and GV.

METHODS

Retrospective investigation including ICU patients with SOFA ≥8, mechanical ventilation, and CIM diagnostics. Glucose readings were collected every 6 h throughout the first week of treatment, when CIM is thought to develop. GV was measured using standard deviation (SD), coefficient of variability (CV), mean absolute glucose (MAG), mean amplitude of glycaemic excursions (MAGE), and mean of daily difference (MODD).

RESULTS

74 patients were included, and 50 (67.6%) developed CIM. Time on glycaemic target (70-179 mg/dL), caloric and insulin intakes, mean, maximum and minimum blood glucose values were similar for all patients until the 5th day, after which CIM patients exhibited higher mean and maximum glucose levels. Significantly higher GV in CIM patients were observed on day 5 (SD, CV, MAG, MAGE), day 6 (MODD), and day 7 (SD, CV, MAG).

CONCLUSIONS

CIM patients developed transient increases in GV and hyperglycaemia only late in the first week, suggesting that myopathy precedes dysglycaemia.

Insulin sensitivity in critically ill patients: are women more insulin resistant?

Background

Glycaemic control (GC) in intensive care unit is challenging due to significant inter- and intra-patient variability, leading to increased risk of hypoglycaemia. Recent work showed higher insulin resistance in female preterm neonates. This study aims to determine if there are differences in inter- and intra-patient metabolic variability between sexes in adults, to gain in insight into any differences in metabolic response to injury. Any significant difference would suggest GC and randomised trial design should consider sex differences to personalise care.

Methods

Insulin sensitivity (SI) levels and variability are identified from retrospective clinical data for men and women. Data are divided using 6-h blocks to capture metabolic evolution over time. In total, 91 male and 54 female patient GC episodes of minimum 24 h are analysed. Hypothesis testing is used to determine whether differences are significant (P < 0.05), and equivalence testing is used to assess whether these differences can be considered equivalent at a clinical level. Data are assessed for the raw cohort and in 100 Monte Carlo simulations analyses where the number of men and women are equal.

Results

Demographic data between females and males were all similar, including GC outcomes (safety from hypoglycaemia and high (> 50%) time in target band). Females had consistently significantly lower SI levels than males, and this difference was not clinically equivalent. However, metabolic variability between sexes was never significantly different and always clinically equivalent. Thus, inter-patient variability was significantly different between males and females, but intra-patient variability was equivalent.

Conclusion

Given equivalent intra-patient variability and significantly greater insulin resistance, females can receive the same benefit from safe, effective GC as males, but may require higher insulin doses to achieve the same glycaemia. Clinical trials should consider sex differences in protocol design and outcome analyses.

Insulin sensitivity in critically ill patients: are women more insulin resistant?

BACKGROUND

Glycaemic control (GC) in intensive care unit is challenging due to significant inter- and intra-patient variability, leading to increased risk of hypoglycaemia. Recent work showed higher insulin resistance in female preterm neonates. This study aims to determine if there are differences in inter- and intra-patient metabolic variability between sexes in adults, to gain in insight into any differences in metabolic response to injury. Any significant difference would suggest GC and randomised trial design should consider sex differences to personalise care.

METHODS

Insulin sensitivity (SI) levels and variability are identified from retrospective clinical data for men and women. Data are divided using 6-h blocks to capture metabolic evolution over time. In total, 91 male and 54 female patient GC episodes of minimum 24 h are analysed. Hypothesis testing is used to determine whether differences are significant (P < 0.05), and equivalence testing is used to assess whether these differences can be considered equivalent at a clinical level. Data are assessed for the raw cohort and in 100 Monte Carlo simulations analyses where the number of men and women are equal.

RESULTS

Demographic data between females and males were all similar, including GC outcomes (safety from hypoglycaemia and high (> 50%) time in target band). Females had consistently significantly lower SI levels than males, and this difference was not clinically equivalent. However, metabolic variability between sexes was never significantly different and always clinically equivalent. Thus, inter-patient variability was significantly different between males and females, but intra-patient variability was equivalent.

CONCLUSION

Given equivalent intra-patient variability and significantly greater insulin resistance, females can receive the same benefit from safe, effective GC as males, but may require higher insulin doses to achieve the same glycaemia. Clinical trials should consider sex differences in protocol design and outcome analyses.

Considerations for Insulin-Treated Type 2 Diabetes Patients During Hospitalization: A Narrative Review of What We Need to Know in the Age of Second-Generation Basal Insulin Analogs

With the availability of second-generation basal insulin analogs, insulin degludec (100 and 200 units/ml [degludec]) and insulin glargine 300 units/ml (glargine U300), clinicians now have long-acting, efficacious treatment options with stable pharmacokinetic profiles and associated low risks of hypoglycemia that may be desirable for many patients with type 2 diabetes. In this narrative review, we summarize the current evidence on glycemic control in hospitalized patients and review the pharmacokinetic properties of degludec and glargine U300 in relation to the challenges these may pose during the hospitalization of patients with type 2 diabetes who are receiving outpatient regimens involving these newer insulins. Their increased use in clinical practice requires that hospital healthcare professionals (HCPs) have appropriate protocols to transfer patients from these second-generation insulins to formulary insulin on admission, and ensure the safe discharge of patients and transition back to degludec or glargine U300. However, there is no guidance available on this. Based on the authors' clinical experience, we identify key issues to consider when arranging hospital care of such patients. We also summarize the limited available evidence on the potential utility of these second-generation basal insulin analogs in the non-critical inpatient setting and identify avenues for future research. To address current knowledge gaps, it is important that HCPs are educated about the differences between standard formulary insulins and second-generation insulins, and the importance of clear communication during patient transitions.

Risk Factors for Hypoglycemia with the Use of Enteral Glyburide in Neurocritical Care Patients

OBJECTIVE

Intravenous glyburide has demonstrated safety when used for attenuation of cerebral edema, although safety data are lacking for enteral glyburide when used for this indication. We aimed to determine the prevalence of and risk factors for hypoglycemia in neurocritical care patients receiving enteral glyburide.

METHODS

We performed a retrospective case-control chart review (hypoglycemia vs. no hypoglycemia) of adult patients who received enteral glyburide for prevention or treatment of cerebral or spinal cord edema. Hypoglycemia was defined as a blood glucose <55.8 mg/dL. Descriptive statistics were used, with multivariate analysis to measure the association of risk factors and outcomes. Logistic regression was applied to outcomes with an exposure. Potential confounders were evaluated using the t-test or the Wilcoxon rank-sum test for continuous variables, and the χ² test or the Fisher exact test for categorical variables.

RESULTS

Seventy-one patients (60.6% men, median age 60 years) were included. The majority received 2.5 mg of enteral glyburide twice daily. Diagnoses included tumors (35.2%), intracerebral hemorrhage (28.2%), postspinal surgery (12.7%), and ischemic stroke (12.7%). Hypoglycemia occurred in 17 (23.9%) patients. Multivariate analysis identified admission serum creatinine (odds ratio, 27.2; [1.661, 445.3]; P < 0.05) as a risk factor for hypoglycemia, whereas body mass index >30 (odds ratio, 0.085; [0.008, 0.921]; P < 0.05) was protective.

CONCLUSIONS

Hypoglycemic episodes are common following enteral glyburide in neurocritical care patients. Both patients with and without diabetes mellitus are at risk of hypoglycemia. Elevated admission serum creatinine may increase the risk of hypoglycemia when utilizing glyburide for prevention or treatment of cerebral or spinal cord edema.

Etiology and prognosis for dogs with abnormal blood glucose concentrations evaluated in an emergency room

OBJECTIVE

To determine the prevalence of glucose abnormalities in nondiabetic dogs presenting to a veterinary emergency room (ER) and their association with underlying disease processes, previous glucocorticoid administration, and overall mortality.

DESIGN

Single-center, retrospective study from January 2013 to December 2014.

SETTING

University Teaching Hospital.

ANIMALS

A total of 660 dogs presenting to an ER with a blood glucose concentration measured within 6 hours of presentation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records from dogs with a blood glucose concentration measured within 6 hours of hospital admission were reviewed. Medications administered prior to blood sampling, the presence of shock, final clinical diagnosis, and survival were recorded. Hypoglycemia and hyperglycemia were defined as a blood glucose <4.4 mmol/L (80 mg/dL) and >6.7 mmol/L (120 mg/dL), respectively. Diabetic patients were removed from analysis. Hyperglycemia was found in 40.1% of dogs, whereas hypoglycemia was present in 9.0%. Hyperglycemia was most often associated with gastrointestinal disease, trauma, neoplasia, and respiratory disease. The most common diseases associated with hypoglycemia were sepsis, gastrointestinal disease, and neoplasia. Dogs in shock or with hyperlactatemia had higher blood glucose values than dogs with normal perfusion and plasma lactate concentrations (P = 0.016 and P < 0.0001, respectively). Mortality was higher in dogs with hyperglycemia (33.2%, P = 0.03) or hypoglycemia (44.6%, P = 0.0024) compared to those with normoglycemia (24.9%).

CONCLUSION

Dysglycemia in nondiabetic dogs evaluated in an ER was associated with a higher mortality rate than dogs in the same population with normoglycemia. Hyperglycemia in this population was common and may represent a stress response.

Electronic Measurement of a Clinical Quality Measure for Inpatient Hypoglycemic Events: A Multicenter Validation Study

BACKGROUND

Hypoglycemia related to antidiabetic drugs (ADDs) is important iatrogenic harm in hospitalized patients. Electronic identification of ADD-related hypoglycemia may be an efficient, reliable method to inform quality improvement.

OBJECTIVE

Develop electronic queries of electronic health records for facility-wide and unit-specific inpatient hypoglycemia event rates and validate query findings with manual chart review.

METHODS

Electronic queries were created to associate blood glucose (BG) values with ADD administration and inpatient location in 3 tertiary care hospitals with Patient-Centered Outcomes Research Network (PCORnet) databases. Queries were based on National Quality Forum criteria with hypoglycemia thresholds <40 and <54 mg/dL, and validated using a stratified random sample of 321 BG events. Sensitivity and specificity were calculated with manual chart review as the reference standard.

RESULTS

The sensitivity and specificity of queries for hypoglycemia events were 97.3% [95% confidence interval (CI), 90.5%-99.7%] and 100.0% (95% CI, 92.6%-100.0%), respectively for BG <40 mg/dL, and 97.7% (95% CI, 93.3%-99.5%) and 100.0% (95% CI, 95.3%-100.0%), respectively for <54 mg/dL. The sensitivity and specificity of the query for identifying ADD days were 91.8% (95% CI, 89.2%-94.0%) and 99.0% (95% CI, 97.5%-99.7%). Of 48 events missed by the queries, 37 (77.1%) were due to incomplete identification of insulin administered by infusion. Facility-wide hypoglycemia rates were 0.4%-0.8% (BG <40 mg/dL) and 1.9%-3.0% (BG <54 mg/dL); rates varied by patient care unit.

CONCLUSIONS

Electronic queries can accurately identify inpatient hypoglycemia. Implementation in non-PCORnet-participating facilities should be assessed, with particular attention to patient location and insulin infusions.

Risk and reward: extending stochastic glycaemic control intervals to reduce workload

Background

STAR is a model-based, personalised, risk-based dosing approach for glycaemic control (GC) in critically ill patients. STAR provides safe, effective control to nearly all patients, using 1–3 hourly measurement and intervention intervals. However, the average 11–12 measurements per day required can be a clinical burden in many intensive care units. This study aims to significantly reduce workload by extending STAR 1–3 hourly intervals to 1 to 4-, 5-, and 6-hourly intervals, and evaluate the impact of these longer intervals on GC safety and efficacy, using validated in silico virtual patients and trials methods. A Standard STAR approach was used which allowed more hyperglycaemia over extended intervals, and a STAR Upper Limit Controlled approach limited nutrition to mitigate hyperglycaemia over longer intervention intervals.

Results

Extending STAR from 1–3 hourly to 1–6 hourly provided high safety and efficacy for nearly all patients in both approaches. For STAR Standard, virtual trial results showed lower % blood glucose (BG) in the safe 4.4–8.0 mmol/L target band (from 83 to 80%) as treatment intervals increased. Longer intervals resulted in increased risks of hyper- (15% to 18% BG > 8.0 mmol/L) and hypo- (2.1% to 2.8% of patients with min. BG < 2.2 mmol/L) glycaemia. These results were achieved with slightly reduced insulin (3.2 [2.0 5.0] to 2.5 [1.5 3.0] U/h) and nutrition (100 [85 100] to 90 [75 100] % goal feed) rates, but most importantly, with significantly reduced workload (12 to 8 measurements per day). The STAR Upper Limit Controlled approach mitigated hyperglycaemia and had lower insulin and significantly lower nutrition administration rates.

Conclusions

The modest increased risk of hyper- and hypo-glycaemia, and the reduction in nutrition delivery associated with longer treatment intervals represent a significant risk and reward trade-off in GC. However, STAR still provided highly safe, effective control for nearly all patients regardless of treatment intervals and approach, showing this unique risk-based dosing approach, modulating both insulin and nutrition, to be robust in its design. Clinical pilot trials using STAR with different measurement timeframes should be undertaken to confirm these results clinically.

Individualizing Glycemic Control in the Critically Ill

Hyperglycemia is a common phenomenon in critically ill patients, even in those without diabetes. Two landmark studies established the benefits of tight glucose control (blood glucose target 80-110 mg/dL) in surgical and medical patients. Since then, literature has consistently demonstrated that both hyperglycemia and hypoglycemia are independently associated with increased morbidity and mortality in a variety of critically ill patients. However, tight glycemic control has subsequently come into question due to risks of hypoglycemia and increased mortality. More recently, strategies targeting euglycemia (blood glucose ≤180 mg/dL) have been associated with improved outcomes, although the risk of hypoglycemia remains. More complex targets (ie, glycemic variability and time within target glucose range) and the impact of individual patient characteristics (ie, diabetic status and prehospital glucose control) have more recently been shown to influence the relationship between glycemic control and outcomes in critically ill patients. Although our understanding has increased, the optimal glycemic target is still unclear and glucose management strategies may require adjustment for individual patient characteristics. As glucose management increases in complexity, we realize that traditional means of using meters and strips and paper insulin titration algorithms are potential limitations to our success. To achieve these complex goals for glycemic control, the use of continuous or near-continuous glucose monitoring combined with computerized insulin titration algorithms may be required. The purpose of this review is to discuss the evidence surrounding the various domains of glycemic control and the emerging data supporting the need for individualized glucose targets in critically ill patients.

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.

Hypoglycemia during Short-Term Intensive Insulin Therapy and Its Association with Long-Term Glycemic Remission in Patients with Newly Diagnosed Type 2 Diabetes

BACKGROUND

Short-term intensive insulin therapy induces long-term glycemic remission in half of patients with newly diagnosed type 2 diabetes. The concomitant hypoglycemia needs further analysis.

METHODS

We collected data from three randomized trials conducted with the same inclusion and exclusion criteria at our institution from 2002 to 2015. Continuous subcutaneous insulin infusion (CSII) was provided to achieve the glycemic goals within a week and then maintained for 14 days. Hypoglycemia episodes during short-term treatment and the one-year drug-free glycemic remission were observed.

RESULTS

A total of 244 patients were included. The per day episode of mild hypoglycemia (3.0-3.9 mmol/L) was higher in the remission group than in the nonremission group (0.26 ± 0.20 vs. 0.18 ± 0.21, P = 0.005). However, a moderate hypoglycemia episode (<3.0 mmol/L) per day was insignificantly lower in the remission group (0.02 ± 0.04 vs. 0.03 ± 0.04, P = 0.005). However, a moderate hypoglycemia episode (<3.0 mmol/L) per day was insignificantly lower in the remission group (0.02 ± 0.04 vs. 0.03 ± 0.04, P = 0.005). However, a moderate hypoglycemia episode (<3.0 mmol/L) per day was insignificantly lower in the remission group (0.02 ± 0.04 vs. 0.03 ± 0.04, P = 0.005). However, a moderate hypoglycemia episode (<3.0 mmol/L) per day was insignificantly lower in the remission group (0.02 ± 0.04 vs. 0.03 ± 0.04.

CONCLUSIONS

Mild hypoglycemic episodes during the continuing insulin dose reduction period indicate a long-term drug-free euglycemic remission in patients with newly diagnosed type 2 diabetes. However, the insulin dosage should be reduced even more quickly in the future treatment to decrease the potential harms.

The Impact of Serum Glucose on the Predictive Value of Serum Lactate for Hospital Mortality in Critically Ill Surgical Patients

Background

Lactate has been widely used as a risk indicator of outcomes in critically ill patients due to its ready measurement and good predictive ability. However, the interconnections between lactate metabolism and glucose metabolism have not been sufficiently explored, yet. In this study, we aimed to investigate whether glucose levels could influence the predictive ability of lactate and design a more comprehensive strategy to assess the in-hospital mortality of critically ill patients.

Methods

We analyzed the clinical data of 293 critically ill patients. The primary outcome was in-hospital mortality. The logistic regression analysis and the area under the receiver operating characteristic curve (AUROC) were applied to evaluate the predictive ability of lactate in association with glucose.

Results

The lactate level showed significant association with in-hospital mortality, and its predictive ability was also comparable to other prognostic scores such as the SOFA score and APACHE II score. We further divided 293 patients into three groups based on glucose levels: low-glucose group (<7 mmol/L), medium-glucose group (7-9 mmol/L), and high-glucose group (>9 mmol/L). The lactate level was associated with in-hospital mortality in the low- and high- glucose groups, but not in the medium-glucose group, whereas the SOFA score and APACHE II score were associated with in-hospital mortality in all three glucose groups. The AUROC of lactate in the medium-glucose group was also the lowest among the three glucose groups, indicating a decrease in its predictive ability.

Conclusions

Our findings demonstrated that the predictive ability of lactate to assess in-hospital mortality could be influenced by glucose levels. In the medium glucose level (i.e., 7-9 mmol/L), lactate was inadequate to predict in-hospital mortality and the SOFA score; the APACHE II score should be utilized as a complementation in order to obtain a more accurate prediction.

Diabetes, Glycemic Control, and Risk of Infection Morbidity and Mortality: A Cohort Study

Objective

Diabetic patients have an elevated risk of infection, but the optimal level of glycemic control with the lowest infection risk remains unclear, especially among the elderly. We aimed to investigate the relation between fasting plasma glucose (FPG) level and risk of infection-related morbidity and mortality.

Method

The participants were from a community-based health screening program in northern Taiwan during 2005–2008 (n = 118 645) and were followed up until 2014. Incidence of hospitalization for infection and infection-related death was ascertained from the National Health Insurance Database and National Death Registry. Cox proportional hazards regression modelling was used to estimate the hazard ratio (HR) between FPG and risk of infection.

Results

During a median follow-up of 8.1 years, the incidence rate of hospitalization for any infection was 36.33 and 14.26 per 1000 person-years among diabetics and nondiabetics, respectively, in the total study population, but increased to 70.02 and 45.21 per 1000 person-years, respectively, in the elderly. In the Cox regression analysis, the adjusted HR comparing diabetics to nondiabetics was 1.59 (95% confidence interval [CI], 1.52–1.67) for any hospitalization for infection and 1.71 (95% CI, 1.36–2.16) for infection-related mortality. The hazard for infection morbidity and mortality was higher at both extremes (<90 and >200 mg/dl) of FPG. The excess risk associated with FPG ≤ 90 mg/dl was attenuated after controlling for multiple comorbidities.

Conclusions

Poor glycemic control (FPG > 200 mg/dl) was associated with a higher risk of infection-related morbidity and mortality, especially in the elderly population where the baseline infection risk was high.

Diabetes, dysglycemia, and vascular surgery

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Glucose Management Technologies for the Critically Ill

Hyperglycemia is common in the intensive care unit (ICU) both in patients with and without a previous diagnosis of diabetes. The optimal glucose range in the ICU population is still a matter of debate. Given the risk of hypoglycemia associated with intensive insulin therapy, current recommendations include treating hyperglycemia after two consecutive glucose >180 mg/dL with target levels of 140-180 mg/dL for most patients. The optimal method of sampling glucose and delivery of insulin in critically ill patients remains elusive. While point of care glucose meters are not consistently accurate and have to be used with caution, continuous glucose monitoring (CGM) is not standard of care, nor is it generally recommended for inpatient use. Intravenous insulin therapy using paper or electronic protocols remains the preferred approach for critically ill patients. The advent of new technologies, such as electronic glucose management, CGM, and closed-loop systems, promises to improve inpatient glycemic control in the critically ill with lower rates of hypoglycemia.

The practice of glycaemic control in intensive care units: A multicentre survey of nursing and medical professionals

AIMS AND OBJECTIVES

To determine the views of nurses and physicians working in intensive care units (ICU) about the aims of glycaemic control and use of their protocols.

BACKGROUND

Evidence about the optimal aims and methods for glycaemic control in ICU is controversial, and current local protocols guiding practice differ between ICUs, both nationally and internationally. The views of professionals on glycaemic control can influence their practice.

DESIGN

Cross-sectional, multicentre, survey-based study.

METHODS

An online short survey was sent to all physicians and nurses of seven ICUs, including questions on effective glycaemic control, treatment of hypoglycaemia and deviations from protocols' instructions. STROBE reporting guidelines were followed.

RESULTS

Over half of the 40 respondents opined that a patient spending <75% admission time within the target glycaemic levels constituted poor glycaemic control. Professionals with more than 5 years of experience were more likely to rate a patient spending 50%-74% admission time within target glycaemic levels as poor than less experienced colleagues. Physicians were more likely to rate a patient spending <50% admission time within target as poor than nurses. There was general agreement on how professionals would rate most deviations from their protocols. Nurses were more likely to rate insulin infusions restarted late and incorrect dosage of rescue glucose as major deviations than physicians. Most professionals agreed on when they would treat hypoglycaemia.

CONCLUSIONS

When surveyed on various aspects of glycaemic control, ICU nurses and physicians often agreed, although there were certain areas of disagreement, in which their profession and level of experience seemed to play a role.

RELEVANCE TO CLINICAL PRACTICE

Differing views on glycaemic control amongst professionals may affect their practice and, thus, could lead to health inequalities. Clinical leads and the multidisciplinary ICU team should assess and, if necessary, address these differing opinions.

Management of Endocrine Emergencies in the ICU

Endocrine emergencies are frequent in critically ill patients and may be the cause of admission or can be secondary to other critical illness. The ability to anticipate endocrine abnormalities such as adrenal excess or , hypothyroidism, can mitigate their duration and severity. Hyperglycemic crisis may trigger hospital and intensive care unit (ICU) admission and may be life threatening. Recognition and safe treatment of severe conditions such as acute adrenal insufficiency, thyroid crisis, and hypoglycemia and hyperglycemic crisis may be lifesaving. Electrolyte abnormalities such as hypercalcemia and hypocalcemia may have underlying endocrine causes, and may be treated differently with recognition of those disorders- electrolyte replacement alone may not be adequate for efficient resolution. Sodium disorders are common in the ICU and are generally related to altered water balance however may be related to pituitary abnormalities in selected patients, and recognition may improve treatment effectiveness and safety.

Role of the Diabetes Educator in Inpatient Diabetes Management

It is the position of American Association of Diabetes Educators (AADE) that all inpatient interdisciplinary teams include a diabetes educator to lead or support improvement efforts that affect patients hospitalized with diabetes or hyperglycemia. This not only encompasses patient and family education but education of interdisciplinary team members and achievement of diabetes-related organizational quality metrics and performance outcomes.

Improved outcome of patients with diabetes mellitus with good glycemic control in the cardiac intensive care unit: a retrospective study

Background

Diabetes mellitus (DM) is a prevalent metabolic disease characterized by chronic hyperglycemia. A primary burden of DM is related to its long-term complications, which have been shown to impact the course of hospitalization and to influence patients’ outcome.

Aim

To assess the role of in-hospital glucose control on length of stay, 30-days and 1-year mortality.

Methods

This is a retrospective study that included patients admitted to the cardiac intensive care unit (CICU) of the Edith Wolfson Medical Centre between 01 January, 2010 and 31 December 2013. Blood glucose was measured by glucometer and fed into an interactive database. Glucose status was referred to as controlled when more than 50% of a given patients glucose values were between 71 and 200 mg/dL. Chisquared tests were used to assess the distribution of categorical variables, while the ttest was applied for continuous variables. A multivariate logistic regression model was used to analyze the association between glucose control and mortality. Cox regression was conducted to assess survival and 1-year mortality.

Results

2466 patients were admitted to the CICU over the study period, of which 370 had concomitant diabetes mellitus. Controlled glucose status was associated with shorter length of hospital stay (1.6 ± 1.7 versus 2.6 ± 3.0, p < 0.001), reduced 30-day mortality (0.7% versus 4.6%, p < 0.001), and improved 1-year mortality (2.2% versus 7.5%, p < 0.001). Moreover, attainment of glucose control was independently associated with a significant decrease in 1-year mortality (OR = 0.371, 95% CI 0.140–0.988, p = 0.047).

Conclusion

In-hospital control of glucose parameters is associated with shorter length of hospital stay, and lowered 30-day and 1-year mortality. An effort to maintain glucose levels within reference ranges is warranted in critically ill patients to reduce mortality.

Intensive glucose control for critically ill patients: an updated meta-analysis

This meta-analysis aims to update the evidence for the effects of intensive glucose control (IGC) on the outcomes among critically ill patients. We performed a systematic literature review from inception through December, 2017 by two independent authors by searching PubMed, EMBASE and Cochrane Library. Randomized clinical trials of the effects of IGC compared with conventional glucose control were selected. Random-effect models were applied to calculate summary relative risks (RRs) for the related outcomes. Of 4247 records identified, we abstracted data from 27 relevant trials for meta-analysis. Compared with patients receiving conventional glucose control (controls), patients with IGC did not have significantly decreased risk of short-term mortality (in-hospital mortality or intensive care unit (ICU) mortality) (RR 0.99, 95% CI 0.92-1.06) or 3- to 6-month mortality (RR 1.02, 95% CI 0.97-1.08). These results remained constant among different study settings including surgical ICUs, medical ICUs or mixed ICUs. Similarly, we also found that patients with IGC did not have significantly lower risk of sepsis (RR 1.00, 95% CI 0.89-1.11) or new need for dialysis (RR 0.97, 95% CI 0.84-1.11). However, patients with IGC had almost 4-fold increase in risk of hypoglycemia (RR 4.86, 95% CI 3.16-7.46). In conclusion, in this updated meta-analysis of published trials, critically ill patients receiving IGC were found to be at neutral risk for short-term or 3- 6-month mortality, risk of sepsis or new need for dialysis, but at higher risk of hypoglycemia.

Systematic review of incretin therapy during peri-operative and intensive care

Background

Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) are incretin hormones. By lowering blood glucose in a glucose-dependent manner, incretin-based therapies represent a novel and promising intervention to treat hyperglycaemia in hospital settings. We performed a systematic review of the literature for all current applications of incretin-based therapies in the peri-operative and critical care settings.

Methods

We searched MEDLINE, the Cochrane Library, and Embase databases for all randomised controlled trials using exogenous GLP-1, GLP-1 receptor agonists, exogenous GIP and dipeptidyl peptidase IV inhibitors in the setting of adult peri-operative care or intensive care. We defined no comparator treatment. Outcomes of interest included blood glucose, frequency of hypoglycaemia and insulin administration.

Results

Of the 1190 articles identified during the initial literature search, 38 fulfilled criteria for full-text review, and 19 single-centre studies were subsequently included in the qualitative review. Of the 18 studies reporting glycaemic control, improvement was reported in 15, defined as lower glucose concentrations in 12 and as reduced insulin administration (with similar glucose concentrations) in 3. Owing to heterogeneity, meta-analysis was possible only for the outcome of hypoglycaemia. This revealed an incidence of 7.4% in those receiving incretin-based therapies and 6.8% in comparator groups (P = 0.94).

Conclusions

In small, single-centre studies, incretin-based therapies lowered blood glucose and reduced insulin administration without increasing the incidence of hypoglycaemia.

Trial registration

PROSPERO, CRD42017071926.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-2197-4) contains supplementary material, which is available to authorized users.

Appropriateness of Using Tests for Blood Glucose and Diabetic Complications in Clinical Practice: Experiences in a Hospital in Thailand

BACKGROUND This study aimed to evaluate how the tests for blood glucose (BG) and diabetic complications have been utilized in a hospital in Thailand. MATERIAL AND METHODS Patient medical records having the results of BG, HbA1c, and/or urine microalbumin presented and the records of DM patients having the results of serum lipids, serum LDL-C, and/or serum creatinine presented were selected. The data of diagnosis, ordered tests, and testing results in these records were extracted for evaluation. RESULTS This study recruited 1066 patients diagnosed with DM and 3081 patients diagnosed with other diseases. Point-of-care testing (POCT) for BG was repeatedly used in 371 non-DM cases; most of its results were normal. The results of BG and HbA1c were often used together. There was a good relationship between them, and these test results indicated poor glycemic control in 58% of DM cases. In non-DM cases, the test results agreed, indicating normoglycemia in 17.32%, pre-diabetes in 20.47%, and diabetes in 21.78%. To prevent diabetic nephropathy, serum creatinine was frequently used, whereas urine microalbumin, the recommended test, was underutilized. The result of LDL-C from both direct measurement and calculation were used; however, based on the same guidelines, the results of measured LDL-C indicated risk of cardiovascular diseases in a higher percentage of DM cases than did the results of calculated LDL-C. CONCLUSIONS The use of POCT for BG in hospitalized patients may be inappropriate. The utilization of urine microalbumin should be promoted to effectively prevent diabetic nephropathy.