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Rugg C, Schmid S, Zipperle J, Kreutziger J. Stress hyperglycaemia following trauma - a survival benefit or an outcome detriment? Curr Opin Anaesthesiol 2024; 37:131-138. [PMID: 38390910 DOI: 10.1097/aco.0000000000001350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2024]
Abstract
PURPOSE OF REVIEW Stress hyperglycaemia occur often in critically injured patients. To gain new consideration about it, this review compile current as well as known immunological and biochemical findings about causes and emergence. RECENT FINDINGS Glucose is the preferred energy substrate for fending immune cells, reparative tissue and the cardiovascular system following trauma. To fulfil these energy needs, the liver is metabolically reprogrammed to rebuild glucose from lactate and glucogenic amino acids (hepatic insulin resistance) at the expenses of muscles mass and - to a less extent - fat tissue (proteolysis, lipolysis, peripheral insulin resistance). This inevitably leads to stress hyperglycaemia, which is evolutionary preserved and seems to be an essential and beneficial survival response. It is initiated by damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs), intensified by immune cells itself and mainly ruled by tumour necrosis factor (TNF)α and catecholamines with lactate and hypoxia inducible factor (HIF)-1α as intracellular signals and lactate as an energy shuttle. Important biochemical mechanisms involved in this response are the Warburg effect as an efficient metabolic shortcut and the extended Cori cycle. SUMMARY Stress hyperglycaemia is beneficial in an acute life-threatening situation, but further research is necessary, to prevent trauma patients from the detrimental effects of persisting hyperglycaemia.
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Affiliation(s)
- Christopher Rugg
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Stefan Schmid
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Johannes Zipperle
- Johannes Zipperle, Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Janett Kreutziger
- Department of Anaesthesia and Intensive Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
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Zhang L, Du WQ, Zong ZW, Zhong X, Jia YJ, Jiang RQ, Ye Z. Modified Glucose-insulin-potassium Therapy for Hemorrhage-induced Traumatic Cardiac Arrest in Rabbits. Curr Med Sci 2023; 43:1238-1246. [PMID: 37955782 DOI: 10.1007/s11596-023-2796-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 08/14/2023] [Indexed: 11/14/2023]
Abstract
OBJECTIVE Resuscitation with whole blood is known to be better than that with saline in attaining the return of spontaneous circulation (ROSC) and improving the short-term survival rate for hemorrhage-induced traumatic cardiac arrest (HiTCA). However, the resuscitation with whole blood alone fails to address the pathophysiological abnormalities, including hyperglycemia, hyperkalemia and coagulopathy, after HiTCA. The present study aimed to determine whether the modified glucose-insulin-potassium (GIK) therapy can ameliorate the above-mentioned pathophysiological abnormalities, enhance the ROSC, improve the function of key organs, and reduce the mortality after HiTCA. METHODS HiTCA was induced in rabbits (n=36) by controlled hemorrhage. Following arrest, the rabbits were randomly divided into three groups (n=12 each): group A (no resuscitation), group B (resuscitation with whole blood), and group C (resuscitation with whole blood plus GIK). The GIK therapy was administered based on the actual concentration of glucose and potassium. The ROSC rate and survival rate were obtained. Hemodynamical and biochemical changes were detected. Thromboelastography (TEG) was used to measure coagulation parameters, and enzyme-linked immunosorbent assay to detect parameters related to inflammation, coagulation and the function of brain. RESULTS All animals in groups B and C attained ROSC. Two rabbits died 24-48 h after HiTCA in group B, while no rabbits died in group C. The GIK therapy significantly reduced the levels of blood glucose, potassium, and biological markers for inflammatory reaction, and improved the heart, kidney, liver and brain function in group C when compared to group B. Furthermore, the R values of TEG were significantly lower in group C than in group B, and the maximum amplitude of TEG was slightly lower in group B than in group C, with no significant difference found. CONCLUSION Resuscitation with whole blood and modified GIK therapy combined can ameliorate the pathophysiological disorders, including hyperglycemia, hyperkalemia and coagulopathy, and may improve the function of key organs after HiTCA.
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Affiliation(s)
- Lin Zhang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Wen-Qiong Du
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Zhao-Wen Zong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China.
- Department of Orthopedics, Xinqiao Hospital, Army Medical University, Chongqing, 400037, China.
| | - Xin Zhong
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Yi-Jun Jia
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Ren-Qing Jiang
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
| | - Zhao Ye
- State Key Laboratory of Trauma, Burn and Combined Injury, Department for Combat Casualty Care Training, Training Base for Army Health Care, Army Medical University, Chongqing, 400038, China
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Shehadeh A, Feng J, Selde W, Billian J, Mastenbrook J. Higher Prehospital Blood Glucose Levels Associated With Return of Spontaneous Circulation in Out-of-Hospital Non-traumatic Cardiac Arrests. Air Med J 2023; 42:471-476. [PMID: 37996185 DOI: 10.1016/j.amj.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/30/2023] [Accepted: 09/02/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE Cardiac arrest leads to an array of metabolic disturbances. We aimed to investigate the association between prehospital blood glucose levels (BGLs) and rates of return of spontaneous circulation (ROSC) in non-traumatic out-of-hospital cardiac arrests (OHCAs). METHODS A retrospective analysis of adult non-traumatic OHCAs within Kalamazoo County, MI, from January 2018 to May 2020 using the Michigan Emergency Medical Services Information System database was performed. Demographic data, Utstein variables, and BGLs (hypoglycemia < 70 mg/dL, euglycemia 70-120 mg/dL, and hyperglycemia >120 mg/dL) were abstracted. Chi-square and Wilcoxon rank sum tests were used to evaluate the relationship between BGL and ROSC. RESULTS In total, 314 patients met the inclusion criteria. The mean age was 62.9 years. ROSC was achieved in 147 (46.8%) patients. Fifty (15.9%), 75 (23.9%), and 189 (60.2%) patients were hypoglycemic, euglycemic, and hyperglycemic, respectively. An association was found between the glycemic group and ROSC (P < .0001), with an estimated odds of ROSC being 77% lower (95% confidence interval, 46%-90%) for hypoglycemic than euglycemic or hyperglycemic patients. The point difference between median ROSC-yes BGL (median [interquartile range] = 160 mg/dL [110-225 mg/dL]) was 33 mg/dL (95% CI, 13-51 mg/dL) greater than the ROSC-no group (median [interquartile range] = 127 mg/dL [75-190 mg/dL], P = .001). CONCLUSION Non-traumatic OHCA patients achieving ROSC had a significantly higher prehospital BGL than the ROSC-no group. Further study is warranted to investigate the role intra-arrest BGL may have as a prognostic marker for ROSC.
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Affiliation(s)
- Ayman Shehadeh
- Department of Student Affairs, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Jeffrey Feng
- Department of Student Affairs, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - William Selde
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Joseph Billian
- Department of Biomedical Informatics, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI
| | - Joshua Mastenbrook
- Department of Emergency Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI.
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Wongtanasarasin W, Ungrungseesopon N, Phinyo P. Association between Intra-Arrest Blood Glucose Level and Outcomes of Resuscitation at the Emergency Department: A Retrospective Study. J Clin Med 2022; 11:jcm11113067. [PMID: 35683454 PMCID: PMC9181384 DOI: 10.3390/jcm11113067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 05/20/2022] [Accepted: 05/27/2022] [Indexed: 02/07/2023] Open
Abstract
Since current cardiac arrest guidelines do not address the benefit of blood glucose measurement, the ideal ranges and target of blood glucose (BG) levels during cardiac arrest to achieve a better result are warranted. We intended to investigate the associations between intra-arrest BG levels and outcomes of cardiac arrest resuscitation at the emergency department (ED). We conducted a retrospective observational study at a single university hospital. Cardiac arrest patients at the ED between 2017 and 2020 were included. Multivariable logistic regression analysis was performed to examine the associations between intra-arrest BG levels and clinical outcomes. We categorized intra-arrest BG into five groups: <70 mg/dL, 70−99 mg/dL, 100−180 mg/dL, 181−250 mg/dL, and >250 mg/dL. Eight hundred and nineteen patients experienced ED cardiac arrest during the study period. Of all, 385 intra-arrest BG measurements were included in the data analysis. The mean age was 60.4 years. The mean intra-arrest BG level was 171.1 mg/dL, with 64 (16.6%) patients who had intra-arrest BG level below 70 mg/dL and 73 (19.0%) patients who had intra-arrest BG level more than 250 mg/dL. Markedly low (<70 mg/dL) and low (70−99 mg/dL) intra-arrest BG levels were significantly associated with a lower chance of return of spontaneous circulation (ROSC, OR 0.36, 95% CI 0.14−0.99, p = 0.05 and OR 0.33, 95% CI 0.12−0.93, p = 0.04, respectively). For patients who experienced cardiac arrest at the ED, an intra-arrest BG level of less than 100 was inversely correlated with sustained ROSC. Although we could not draw a causal relationship between variables concerning this study design, normalizing intra-arrest BG was shown to result in good clinical outcomes.
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Affiliation(s)
- Wachira Wongtanasarasin
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA 95817, USA
- Correspondence: ; Tel.: +66-99-270-0493
| | - Nat Ungrungseesopon
- Department of Emergency Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
| | - Phichayut Phinyo
- Department of Family Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand;
- Center for Clinical Epidemiology and Clinical Statistics, Faculty of Medicine, Chiang Mai University, Chiang Mai 50200, Thailand
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Absence of Stress Hyperglycemia Indicates the Most Severe Form of Blunt Liver Trauma. Diagnostics (Basel) 2021; 11:diagnostics11091667. [PMID: 34574008 PMCID: PMC8470453 DOI: 10.3390/diagnostics11091667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 08/24/2021] [Accepted: 09/08/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Stress hyperglycemia is common in trauma patients. Increasing injury severity and hemorrhage trigger hepatic gluconeogenesis, glycogenolysis, peripheral and hepatic insulin resistance. Consequently, we expect glucose levels to rise with injury severity in liver, kidney and spleen injuries. In contrast, we hypothesized that in the most severe form of blunt liver injury, stress hyperglycemia may be absent despite critical injury and hemorrhage. Methods: All patients with documented liver, kidney or spleen injuries, treated at a university hospital between 2000 and 2020 were charted. Demographic, laboratory, radiological, surgical and other data were analyzed. Results: A total of 772 patients were included. In liver (n = 456), spleen (n = 375) and kidney (n = 152) trauma, an increase in injury severity past moderate to severe (according to the American Association for the Surgery of Trauma, AAST III-IV) was associated with a concomitant rise in blood glucose levels independent of the affected organ. While stress-induced hyperglycemia was even more pronounced in the most severe forms (AAST V) of spleen (median 10.7 mmol/L, p < 0.0001) and kidney injuries (median 10.6 mmol/L, p = 0.004), it was absent in AAST V liver injuries, where median blood glucose level even fell (5.6 mmol/L, p < 0.0001). Conclusions: Absence of stress hyperglycemia on hospital admission could be a sign of most severe liver injury (AAST V). Blood glucose should be considered an additional diagnostic criterion for grading liver injury.
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Blood Glucose Levels Combined with Triage Revised Trauma Score Improve the Outcome Prediction in Adults and in Elderly Patients with Trauma. Prehosp Disaster Med 2020; 36:175-182. [PMID: 33345764 DOI: 10.1017/s1049023x2000148x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Lazzeri C, Bonizzoli M, Cianchi G, Ciapetti M, Socci F, Peris A. The prognostic role of peak glycemia and glucose variability in trauma: a single-center investigation. Acta Diabetol 2020; 57:931-935. [PMID: 32125532 DOI: 10.1007/s00592-020-01493-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 01/28/2020] [Indexed: 12/22/2022]
Abstract
AIM Admission hyperglycemia and glucose variability were associated with mortality in critically ill patients, but data on trauma patients are to date scarce and heterogeneous. METHODS We assessed the prognostic role of ICU death of admission and peak glycemia and glucose variability (indicated by the standard deviation of mean glucose levels and the coefficient of variation of glucose) in 252 patients consecutively admitted for trauma in our ICU (January 1, 2016-December 31, 2018). RESULTS The in-ICU mortality rate was 17% (43/252). When compared to patients who died during ICU stay, survivors were younger (p = 0.001), more frequently males (p = 0.002), with a lower incidence of hypertension (p = 0.023). Higher values of SAPS II, SOFA and ISS were observed in nonsurvivors (p < 0.001, p < 0.001, p < 0.001, respectively). Survivors exhibited significantly lower values of admission glycemia (p = 0.001), peak glycemia (p = 0.002) and mean glucose values measured during the first 24 h since ICU admission (p = 0.001). Glucose variability was significantly higher in nonsurvivors, as indicated by higher values of SD and CV (p = 0.001 and p = 0.001, respectively). At multivariate regression analysis, admission glycemia (Model 1), peak glycemia (Model 2) and glucose variability (Model 3 and 4) were independent predictors for in-ICU mortality. CONCLUSIONS Our findings indicate that not only admission glycemia but also peak glycemia and glucose variability show a correlation with in-ICU mortality in trauma patients.
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Affiliation(s)
- Chiara Lazzeri
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 1, 50134, Florence, Italy.
| | - Manuela Bonizzoli
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 1, 50134, Florence, Italy
| | - Giovanni Cianchi
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 1, 50134, Florence, Italy
| | - Marco Ciapetti
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 1, 50134, Florence, Italy
| | - Filippo Socci
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 1, 50134, Florence, Italy
| | - Adriano Peris
- Intensive Care Unit and Regional ECMO Referral Centre, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla 1, 50134, Florence, Italy
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