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Almagthali A, Alsohimi S, Alkhalaf A, Al Sulaiman K, Aljuhani O. Assessing glycemic variability in critically ill patients: A prospective cohort study comparing insulin infusion therapy with insulin sliding scale. Sci Rep 2024; 14:10128. [PMID: 38698018 PMCID: PMC11066101 DOI: 10.1038/s41598-024-57403-5] [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: 06/26/2023] [Accepted: 03/18/2024] [Indexed: 05/05/2024] Open
Abstract
Glycemic variability (GV) has been associated with an increased mortality rate among critically ill patients. The clinical outcomes of having less GV even with slight hyperglycemia are better than those having tight glycemic control but higher GV. Insulin infusion remains the preferred method to control stress hyperglycemia in critically ill patients. However, its impacts on GV and clinical outcomes in critically ill patients still need further investigation. This study intended to evaluate the impact of insulin infusion therapy (IIT) compared to the insulin sliding scale (ISS) on the extent of GV and explore its impact on the clinical outcomes for critically ill patients. A prospective, single-center observational cohort study was conducted at a tertiary academic hospital in Saudi Arabia between March 2021 and November 2021. The study included adult patients admitted to ICUs who received insulin for stress hyperglycemia management. Patients were categorized into two groups based on the regimen of insulin therapy during ICU stay (IIT versus ISS). The primary outcome was the GV between the two groups. Secondary outcomes were ICU mortality, the incidence of hypoglycemia, and ICU length of stay (LOS). A total of 381 patients were screened; out of them, eighty patients met the eligibility criteria. The distribution of patients having diabetes and a history of insulin use was similar between the two groups. The GV was lower in the IIT group compared to the ISS group using CONGA (- 0.65, 95% CI [- 1.16, - 0.14], p-value = 0.01). Compared with ISS, patients who received IIT had a lower incidence of hypoglycemia that required correction (6.8% vs 2.77%; p-value = 0.38). In contrast, there were no significant differences in ICU LOS and ICU mortality between the two groups. Our study demonstrated that the IIT is associated with decreased GV significantly in critically ill patients without increasing the incidence of severe hypoglycemia. There is no survival benefit with the use of the IIT. Further studies with larger sample size are required to confirm our findings and elaborate on IIT's potential effect in reducing ICU complications in critically ill patients.
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Affiliation(s)
- Alaa Almagthali
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia.
| | - Samiah Alsohimi
- Pharmaceutical Care Department, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
- Pharmaceutical Care Department, King Fahad Armed Forces hospital, Jeddah, Saudi Arabia
| | - Arwa Alkhalaf
- Measurement and Psychometrics, Psychology Department, Faculty of Graduate Educational Studies, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Khalid Al Sulaiman
- Pharmaceutical Care Department, King Abdulaziz Medical City, Riyadh, Saudi Arabia
- College of Pharmacy, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center-King Saud Bin Abdulaziz University for Health Sciences, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia
- Saudi Critical Care Pharmacy Research (SCAPE) Platform, Riyadh, Saudi Arabia
- Saudi Society for Multidisciplinary Research Development and Education (SCAPE Society), Riyadh, Saudi Arabia
| | - Ohoud Aljuhani
- Department of Pharmacy Practice, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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Desgrouas M, Demiselle J, Stiel L, Brunot V, Marnai R, Sarfati S, Fiancette M, Lambiotte F, Thille AW, Leloup M, Clerc S, Beuret P, Bourion AA, Daum J, Malhomme R, Ravan R, Sauneuf B, Rigaud JP, Dequin PF, Boulain T. Insulin therapy and blood glucose management in critically ill patients: a 1-day cross-sectional observational study in 69 French intensive care units. Ann Intensive Care 2023; 13:53. [PMID: 37330419 DOI: 10.1186/s13613-023-01142-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 05/24/2023] [Indexed: 06/19/2023] Open
Abstract
BACKGROUND Hyperglycaemia is common in critically ill patients, but blood glucose and insulin management may differ widely among intensive care units (ICUs). We aimed to describe insulin use practices and the resulting glycaemic control in French ICUs. We conducted a multicentre 1-day observational study on November 23, 2021, in 69 French ICUs. Adult patients hospitalized for an acute organ failure, severe infection or post-operative care were included. Data were recorded from midnight to 11:59 p.m. the day of the study by 4-h periods. RESULTS Two ICUs declared to have no insulin protocol. There was a wide disparity in blood glucose targets between ICUs with 35 different target ranges recorded. In 893 included patients we collected 4823 blood glucose values whose distribution varied significantly across ICUs (P < 0.0001). We observed 1135 hyperglycaemias (> 1.8 g/L) in 402 (45.0%) patients, 35 hypoglycaemias (≤ 0.7 g/L) in 26 (2.9%) patients, and one instance of severe hypoglycaemia (≤ 0.4 g/L). Four hundred eight (45.7%) patients received either IV insulin (255 [62.5%]), subcutaneous (SC) insulin (126 [30.9%]), or both (27 [6.6%]). Among patients under protocolized intravenous (IV) insulin, 767/1681 (45.6%) of glycaemias were above the target range. Among patients receiving insulin, short- and long-acting SC insulin use were associated with higher counts of hyperglycaemias as assessed by multivariable negative binomial regression adjusted for the propensity to receive SC insulin: incidence rate ratio of 3.45 (95% confidence interval [CI] 2.97-4.00) (P < 0.0001) and 3.58 (95% CI 2.84-4.52) (P < 0.0001), respectively. CONCLUSIONS Practices regarding blood glucose management varied widely among French ICUs. Administration of short or long-acting SC insulin was not unusual and associated with more frequent hyperglycaemia. The protocolized insulin algorithms used failed to prevent hyperglycaemic events.
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Affiliation(s)
- Maxime Desgrouas
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 45100, Orléans, France.
| | - Julien Demiselle
- Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
- UMR 1260 Nanomedicine Regenerative, INSERM, Université de Strasbourg, Strasbourg, France
| | - Laure Stiel
- Réanimation Médicale, Groupe Hospitalier de la Région Mulhouse Sud Alsace, Mulhouse, France
- UMR 1231, Inserm, LNC, Dijon, France
- LipSTIC, LabEx, Dijon, France
| | - Vincent Brunot
- Médecine Intensive Réanimation, Hôpital Universitaire Lapeyronie, Université de Montpellier, Montpellier, France
| | - Rémy Marnai
- Service de Réanimation Médico-Chirurgicale, Centre Hospitalier Le Mans, 72000, Le Mans, France
| | - Sacha Sarfati
- Medical Intensive Care Unit, Normandie Univ, UNIROUEN, UR 3830, CHU Rouen, 76000, Rouen, France
| | - Maud Fiancette
- Service de Médecine Intensive Réanimation, CHD Vendée la Roche Sur Yon, La Roche Sur Yon, France
| | - Fabien Lambiotte
- Service de Réanimation Polyvalente, Centre Hospitalier de Valenciennes, Valenciennes, France
| | - Arnaud W Thille
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France
| | - Maxime Leloup
- Service de Réanimation, Groupe Hospitalier La Rochelle Ré Aunis, La Rochelle, France
| | - Sébastien Clerc
- Service de Médecine Intensive Et Réanimation (Département R3S), AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, 75013, Paris, France
| | - Pascal Beuret
- Réanimation Et Soins Continus, Centre Hospitalier de Roanne, Roanne, France
| | | | - Johan Daum
- Médecine Intensive Réanimation, Centre Hospitalier Intercommunal Ballanger, Aulnay Sous Bois, France
| | - Rémi Malhomme
- Service de Réanimation, Centre Hospitalier Antibes Juan-Les-Pins, Antibes, France
| | - Ramin Ravan
- Réanimation Polyvalente et Surveillance Continue, Centre Hospitalier de Vichy, Vichy, France
| | - Bertrand Sauneuf
- Médecine Intensive Réanimation, Centre Hospitalier Public du Cotentin, 50100, Cherbourg en Cotentin, France
| | - Jean-Philippe Rigaud
- Médecine Intensive Réanimation, Centre Hospitalier de Dieppe, Avenue Pasteur, 76200, Dieppe, France
| | - Pierre-François Dequin
- Médecine Intensive - Réanimation, Hôpital Bretonneau, Tours, France
- Centre d'Étude Des Pathologies Respiratoires, UMR 1100, INSERM, Université de Tours, Tours, France
- INSERM CIC 1415, Tours, France
- CRICS-TriGGERSep Network, Paris, France
| | - Thierry Boulain
- Médecine Intensive Réanimation, Centre Hospitalier Régional d'Orléans, 45100, Orléans, France
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Emidio AC, Faria R, Bispo B, Vaz-Pinto V, Messias A, Meneses-Oliveira C. GlucoSTRESS - A project to optimize glycemic control in a level C (III) Portuguese intensive care unit. Rev Bras Ter Intensiva 2021; 33:138-145. [PMID: 33886863 PMCID: PMC8075347 DOI: 10.5935/0103-507x.20210015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Accepted: 06/17/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To double the percentage of time within the 100 - 180mg/dL blood glucose range in the first three months following a phased implementation of a formal education program, and then, of an insulin therapy protocol, without entailing an increased incidence of hypoglycemia. Methods The pre-intervention glycemic control was assessed retrospectively. Next, were carried out the implementation of a formal education program, distribution of manual algorithms for intravenous insulin therapy - optimized by the users, based on the modified Yale protocol - and informal training of the nursing staff. The use of electronic blood glucose control systems was supported, and the results were recorded prospectively. Results The first phase of the program (formal education) lead to improvement of the time within the euglycemic interval (28% to 37%). In the second phase, euglycemia was achieved 66% of the time, and the incidence of hypoglycemia was decreased. The percentage of patients on intravenous insulin infusion at 48 hours from admission increased from 6% to 35%. Conclusion The phased implementation of a formal education program, fostering the use of electronic insulin therapy protocols and dynamic manuals, received good adherence and has shown to be safe and effective for blood glucose control in critically ill patients, with a concomitant decrease in hypoglycemia.
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Affiliation(s)
- Ana Catarina Emidio
- Serviço de Medicina Interna, Centro Hospitalar de Setúbal - Setúbal, Portugal
| | - Rita Faria
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
| | - Bruno Bispo
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
| | - Vítor Vaz-Pinto
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
| | - António Messias
- Serviço de Medicina Intensiva, Hospital Beatriz Ângelo - Loures, Lisboa, Portugal
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Bain SC, Czernichow S, Bøgelund M, Madsen ME, Yssing C, McMillan AC, Hvid C, Hettiarachchige N, Panton UH. Costs of COVID-19 pandemic associated with diabetes in Europe: a health care cost model. Curr Med Res Opin 2021; 37:27-36. [PMID: 33306421 DOI: 10.1080/03007995.2020.1862775] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Diabetes is associated with progression to severe COVID-19. The objective of this study was to estimate to what extent the increased risk among people with diabetes could impact the secondary care costs of COVID-19 throughout Europe during the first wave of the COVID-19 pandemic from January to June 2020. METHODS Applying a health care cost model based on inputs from data published in international peer-reviewed journals, identified via a rapid literature review this study aimed to estimate the total secondary sector costs of COVID-19. Estimates of unit costs were based on data from Denmark, France, Spain and the UK. We calculated average costs per patient without diabetes and according to four diabetes categories based on risk of hospitalization, admission to intensive care unit, ventilator support and length of hospital stay. RESULTS The estimated cost per hospital admission during the first wave of COVID-19 in Europe ranged between EUR 25,018 among people with type 2 diabetes in good glycaemic control to EUR 57,244 among people with type 1 diabetes in poor glycaemic control, reflecting higher risk of intensive care, ventilator support and longer hospital stay according to diabetes category, while the corresponding cost for people without diabetes was estimated at EUR 16,993. The total direct costs of secondary care of COVID-19 in Europe were estimated at EUR 13.9 billion. Thus, 23.5% of the total costs accounted for treating people with diabetes. CONCLUSIONS This study highlights the importance of a greater focus on prevention and adequate treatment of diabetes and the need for special attention to avoid infection with COVID-19 to the extent possible among those already diagnosed with diabetes.
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Affiliation(s)
- Stephen C Bain
- Diabetes Research Unit, Swansea University Medical School and Swansea Bay University Health Board, Swansea, UK
| | - Sebastien Czernichow
- Faculté de Santé, Université de Paris, Paris, France
- Assistance Publique-Hôpitaux de Paris (AP-HP), Service de Nutrition, Centre Spécialisé Obésité, Hôpital Européen Georges Pompidou, Paris, France
- INSERM, UMR1153, Epidemiology and Biostatistics Sorbonne Paris Cité Centre (CRESS), Paris, France
| | | | | | | | | | - Christian Hvid
- Novo Nordisk North West Europe Pharmaceuticals A/S, Copenhagen, Denmark
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Singh AK, Gupta R, Ghosh A, Misra A. Diabetes in COVID-19: Prevalence, pathophysiology, prognosis and practical considerations. Diabetes Metab Syndr 2020; 14:303-310. [PMID: 32298981 PMCID: PMC7195120 DOI: 10.1016/j.dsx.2020.04.004] [Citation(s) in RCA: 455] [Impact Index Per Article: 113.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 04/04/2020] [Accepted: 04/04/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS High prevalence of diabetes makes it an important comorbidity in patients with COVID-19. We sought to review and analyze the data regarding the association between diabetes and COVID-19, pathophysiology of the disease in diabetes and management of patients with diabetes who develop COVID-19 infection. METHODS PubMed database and Google Scholar were searched using the key terms 'COVID-19', 'SARS-CoV-2', 'diabetes', 'antidiabetic therapy' up to April 2, 2020. Full texts of the retrieved articles were accessed. RESULTS There is evidence of increased incidence and severity of COVID-19 in patients with diabetes. COVID-19 could have effect on the pathophysiology of diabetes. Blood glucose control is important not only for patients who are infected with COVID-19, but also for those without the disease. Innovations like telemedicine are useful to treat patients with diabetes in today's times.
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Affiliation(s)
| | - Ritesh Gupta
- Fortis CDOC Hospital, Chirag Enclave, New Delhi, India
| | - Amerta Ghosh
- Fortis CDOC Hospital, Chirag Enclave, New Delhi, India
| | - Anoop Misra
- Fortis CDOC Hospital, Chirag Enclave, New Delhi, India; National Diabetes, Obesity and Cholesterol Foundation, New Delhi, India; Diabetes Foundation, New Delhi, India
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Singh AK, Khunti K. Assessment of risk, severity, mortality, glycemic control and antidiabetic agents in patients with diabetes and COVID-19: A narrative review. Diabetes Res Clin Pract 2020; 165:108266. [PMID: 32533989 PMCID: PMC7286824 DOI: 10.1016/j.diabres.2020.108266] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 05/26/2020] [Accepted: 06/06/2020] [Indexed: 02/08/2023]
Abstract
AIMS Rising prevalence of non-communicable diseases world-wide has made diabetes an important comorbidity in patients with coronavirus disease-19 (COVID-19). We sought to review the risk, severity and mortality in COVID-19 and its relation to the glycemic control, and role of anti-diabetic agents in patients with diabetes. METHODS A Boolean search was made in PubMed, MedRxiv and Google Scholar database until May 10, 2020 and full articles with supplementary appendix were retrieved using the specific key words related to the topic. RESULTS There is a high prevalence of diabetes in patients with COVID-19. Patients with diabetes had a significantly more severe variety of COVID-19 and increased mortality, compared to the groups without diabetes. Moreover, poor glycemic control is associated with a significantly higher severe COVID-19 and increased mortality, compared to the well-controlled glycemic groups. No data currently available for or against any anti-diabetic agents in COVID-19. CONCLUSIONS Diabetes, in particular poorly-controlled group is associated with a significantly higher risk of severe COVID-19 and mortality. This calls for an optimal glycemic control and an increased emphasis on future preventative therapies including the vaccination programs for these groups in addition to the traditional risk prevention such as social distancing and self-isolation.
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Affiliation(s)
- Awadhesh Kumar Singh
- Department of Diabetes & Endocrinology, G.D Hospital & Diabetes Institute, Kolkata, India.
| | - Kamlesh Khunti
- Leicester Diabetes Research Centre, Leicester LE5 4PW, UK.
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Nader ND, Hamishehkar H, Naghizadeh A, Shadvar K, Iranpour A, Sanaie S, Chang F, Mahmoodpoor A. Effect of Adding Insulin Glargine on Glycemic Control in Critically Ill Patients Admitted to Intensive Care Units: A Prospective Randomized Controlled Study. Diabetes Metab Syndr Obes 2020; 13:671-678. [PMID: 32210600 PMCID: PMC7073596 DOI: 10.2147/dmso.s240645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Accepted: 02/20/2020] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE We aimed to examine the effects of adding a longer-acting insulin glargine to existing glucose control on reducing blood-glucose fluctuations in an intensive care unit (ICU). METHODS A total of 110 patients randomly received adjuvant insulin glargine 15 IU/day (glargine) or placebo (control), in addition to daily infusion of insulin to maintain glucose levels at a target of 140-180 mg/dL. End points were mean and variance of blood glucose and frequency of hypoglycemia, hyperglycemia, ICU stay, and mortality. Data were analyzed with repeated-measures ANOVA and Mann-Whitney U test. RESULTS Average daily glucose level was significantly less in the glargine group than controls (P<0.0001), while there was no difference in daily variance in blood glucose between the two groups. The duration of glucose concentrations being within the target range was identical between the glargine and control groups (16.6±4.9 vs 16.4±4.6 hours/day, P=0.844) during the 7 days of admission. The frequency of hypoglycemia was greater in the glargine group and total duration of hyperglycemia (>180 mg/dL) much longer among controls (P<0.001). Similar mortality rates were observed in both groups, while ICU length of stay was 2 days shorter in the glargine group. CONCLUSION Addition of insulin glargine to routine protocols more effectively reduces glucose levels and decreases incidence of hyperglycemic episodes and regular insulin usage. This adjustment may be associated with decreases in duration of ICU stay or increases in hypoglycemic events.
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Affiliation(s)
- Nader D Nader
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Hadi Hamishehkar
- Department of Clinical Pharmacy, Faculty of Pharmacy, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdolreza Naghizadeh
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
| | | | - Sarvin Sanaie
- Neurosiences Research Center, Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Francis Chang
- State University of New York at Buffalo, Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Ata Mahmoodpoor
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Correspondence: Ata Mahmoodpoor Anesthesiology, Tabriz University of Medical Sciences, School of Medicine, Tabriz, Iran Email
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