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Wang F, Guo Y, Tang Y, Zhao S, Xuan K, Mao Z, Lu R, Hou R, Zhu X. Combined assessment of stress hyperglycemia ratio and glycemic variability to predict all-cause mortality in critically ill patients with atherosclerotic cardiovascular diseases across different glucose metabolic states: an observational cohort study with machine learning. Cardiovasc Diabetol 2025; 24:199. [PMID: 40346649 PMCID: PMC12065353 DOI: 10.1186/s12933-025-02762-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2025] [Accepted: 04/28/2025] [Indexed: 05/11/2025] Open
Abstract
BACKGROUND Stress hyperglycemia ratio (SHR) and glycemic variability (GV) reflect acute glucose elevation and fluctuations, which correlate with adverse outcomes in patients with atherosclerotic cardiovascular disease (ASCVD). However, the prognostic significance of combined SHR-GV evaluation for ASCVD mortality remains unclear. This study examines associations of SHR, GV, and their synergistic effects with mortality in patients with ASCVD across different glucose metabolic states, incorporating machine learning (ML) to identify critical risk factors influencing mortality. METHODS Patients with ASCVD were screened in the Medical Information Mart for Intensive Care IV (MIMIC-IV) database and stratified into normal glucose regulation (NGR), pre-diabetes mellitus (Pre-DM), and diabetes mellitus (DM) groups based on glucose metabolic status. The primary endpoint was 28-day mortality, with 90-day mortality as the secondary outcome. SHR and GV levels were categorized into tertiles. Associations with mortality were analyzed using Kaplan-Meier(KM) curves, Cox proportional hazards models, restricted cubic splines (RCS), receiver operating characteristic (ROC) curves, landmark analyses, and subgroup analyses. Five ML algorithms were employed for mortality risk prediction, with SHapley Additive exPlanations (SHAP) applied to identify critical predictors. RESULTS A total of 2807 patients were included, with a median age of 71 years, and 58.78% were male. Overall, 483 (23.14%) and 608 (29.13%) patients died within 28 and 90 days of ICU admission, respectively. In NGR and Pre-DM subgroups, combined SHR-GV assessment demonstrated superior predictive performance for 28-day mortality versus SHR alone [NGR: AUC 0.688 (0.636-0.739) vs. 0.623 (0.568-0.679), P = 0.028; Pre-DM: 0.712 (0.659-0.764) vs. 0.639 (0.582-0.696), P = 0.102] and GV alone [NGR: 0.688 vs. 0.578 (0.524-0.633), P < 0.001; Pre-DM: 0.712 vs. 0.593 (0.524-0.652), P < 0.001]. Consistent findings were observed for 90-day mortality prediction. However, in the DM subgroup, combined assessment improved prediction only for 90-day mortality vs. SHR alone [AUC 0.578 (0.541-0.616) vs. 0.560 (0.520-0.599), P = 0.027], without significant advantages in other comparisons. CONCLUSIONS Combined SHR and GV assessment serves as a critical prognostic tool for ASCVD mortality, providing enhanced predictive accuracy compared to individual metrics, particularly in NGR and Pre-DM patients. This integrated approach could inform personalized glycemic management strategies, potentially improving clinical outcomes.
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Affiliation(s)
- Fuxu Wang
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yu Guo
- Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Yuru Tang
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Shuangmei Zhao
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Kaige Xuan
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Zhi Mao
- Department of Critical Care Medicine, The First Medical Center of PLA General Hospital, Beijing, China
| | - Ruogu Lu
- Medical Innovation Research Department, Chinese PLA General Hospital, Beijing, China.
| | - Rongyao Hou
- Department of Neurology, The Affiliated Hiser Hospital of Qingdao University, Qingdao, China.
| | - Xiaoyan Zhu
- Department of Critical Care Medicine, The Affiliated Hospital of Qingdao University, Qingdao, China.
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Buford A, Anderson T, Jandarov R, Schaffer J, Wells J, Bartlett M, Houston L, White C, Buford L, Sopirala M. Risk factor evaluation and performance improvement for surgical site infections in patients undergoing abdominal hysterectomy at a large academic safety net hospital. Infect Control Hosp Epidemiol 2025; 46:1-7. [PMID: 40190224 PMCID: PMC12034447 DOI: 10.1017/ice.2025.34] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2024] [Revised: 12/10/2024] [Accepted: 01/29/2025] [Indexed: 04/29/2025]
Abstract
OBJECTIVE To identify Surgical Site Infection (SSI) risk factors for abdominal hysterectomy patients and report the results of a performance improvement initiative. DESIGN Retrospective case-control. SETTING Parkland Hospital, an 882-bed academic, safety-net, tertiary referral center and a level 1 trauma center serving a diverse population of primarily uninsured patients in North Texas. PARTICIPANTS Patients over 18 who underwent abdominal hysterectomy and were diagnosed with SSIs within 30 days of surgery between 2019 and 2021. METHODS Cases were matched to controls from the same or closest calendar month in a 1:2 ratio. Chart review of electronic medical records (EMR) was performed comparing variables using Pearson's χ2 test for categorical variables and Student's t-test for continuous variables followed by logistic regression for multivariate analysis. Upon identifying vaginal preparation technique as an area of improvement while investigating SSI bundle compliance, we implemented an OR staff training intervention. RESULTS Diabetes was identified as a significant risk factor while Hispanic or Latino ethnicity was associated with significantly lower rates of infection. Most organisms identified were enteric pathogens. Following the intervention, Parkland's deep and organ-space Standardized Infection Ratio (SIR) decreased from 1.46 in 2021 to 0.519 for the rolling 12 months as of June 2024. CONCLUSIONS Our multidisciplinary intervention improving the quality and consistency of pre-operative vaginal preparation was associated with a reduction in abdominal hysterectomy SSI.
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Affiliation(s)
- Anna Buford
- University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Tyler Anderson
- University of Texas Southwestern School of Medicine, Dallas, TX, USA
| | - Roman Jandarov
- University of Cincinnati College of Medicine, Cincinnati, OHUSA
| | - Joseph Schaffer
- Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | | | | | - Madhuri Sopirala
- Parkland Health, Dallas, TXUSA
- Division of Infectious Diseases and Geographic Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Kano KI, Yamamoto R, Yoshida M, Sato T, Nishita Y, Ito J, Nagatomo K, Ohbe H, Takahashi K, Kaku M, Sakuramoto H, Nakanishi N, Inoue K, Hatakeyama J, Kasuya H, Hayashi M, Tsunemitsu T, Tatsumi H, Higashibeppu N, Nakamura K. Strategies to Maximize the Benefits of Evidence-Based Enteral Nutrition: A Narrative Review. Nutrients 2025; 17:845. [PMID: 40077715 PMCID: PMC11901663 DOI: 10.3390/nu17050845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2025] [Revised: 02/26/2025] [Accepted: 02/27/2025] [Indexed: 03/14/2025] Open
Abstract
Enteral nutrition (EN) has been reported to have some physiological importance for critically ill patients. However, the advantage of EN over parenteral nutrition remains controversial in recent paradigms. To maximize the benefits and efficiency of EN, implementing measures based on comprehensive evidence is essential. Here, we systematically reviewed EN-related studies and integrated them into the best and most up-to-date EN practices. We extracted studies from 13 systematic reviews during the development of Japanese Critical Care Nutrition Guidelines, summarizing findings on the assessment of enteral feeding intolerance (EFI), the timing of EN, formula composition and nutrients, and method of administration in critically ill adult patients. Multifaceted EFI assessment may be needed in patients for high-risk patients. Early EN may reduce infectious complications, and initiating EN even earlier may offer an additional advantage. High protein intake (≥1.2 g/kg/day) could maintain muscle mass and physical function without increasing gastrointestinal complications. Probiotics, prebiotics, and synbiotics may serve as beneficial options for preventing infection and gastrointestinal complications, although their efficacy depends on the strains, types, and combinations used. For patients with EFI, post-pyloric feeding could be an effective approach, while intermittent feeding may be a safer approach. Both methods should be utilized to achieve nutritional targets. Integrating these nutritional interventions into EN strategies may help maximize their effectiveness and minimize complications. However, careful consideration regarding timing, dosage, nutrient selection, administration methods, and patient selection is required.
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Affiliation(s)
- Ken-Ichi Kano
- Department of Pharmacoepidemiology, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan;
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo 106-8502, Japan;
| | - Minoru Yoshida
- Department of Health Data Science, Graduate School of Data Science, Yokohama City University, Yokohama 236-0004, Japan
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Kawasaki 216-8511, Japan
| | - Takeaki Sato
- Emergency Center, Tohoku University Hospital, Sendai 980-0872, Japan;
| | - Yoshihiro Nishita
- Department of Pharmacy, Kanazawa Medical University Hospital, Kanazawa 920-0293, Japan;
| | - Jiro Ito
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan; (J.I.); (N.H.)
| | - Kazuki Nagatomo
- Department of Emergency and Critical Care Medicine, University of Tsukuba Hospital, Ibaraki 305-8576, Japan;
| | - Hiroyuki Ohbe
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Sendai 980-8575, Japan;
| | - Kanako Takahashi
- Department of Nephrology, Sapporo Hokushin Hospital, Sapporo 004-8618, Japan;
| | - Masayuki Kaku
- Department of Nutrition, NHO Kumamoto Medical Center, Kumamoto 860-0008, Japan;
| | - Hideaki Sakuramoto
- Department of Acute Care Nursing, Japanese Red Cross Kyushu International College of Nursing, Munakata 811-4157, Japan;
| | - Nobuto Nakanishi
- Department of Disaster and Emergency Medicine, Graduate School of Medicine, Kobe University, Kobe 650-0017, Japan;
| | - Kazushige Inoue
- Department of Critical Care Medicine and Trauma, National Hospital Organization Disaster Medical Center, Tokyo 190-0014, Japan;
| | - Junji Hatakeyama
- Department of Emergency and Critical Care Medicine, Osaka Medical and Pharmaceutical University, Osaka 569-8686, Japan;
| | - Hidenori Kasuya
- Department of Nursing, Daido Hospital Kojunkai, Social Medical Corporation, Nagoya 457-8511, Japan;
| | - Minoru Hayashi
- Department of Emergency Medicine, Fukui Prefectural Hospital, Fukui 910-8526, Japan;
| | - Takefumi Tsunemitsu
- Department of Preventive Services, Graduate School of Medicine, Kyoto University, Kyoto 606-8501, Japan;
| | - Hiroomi Tatsumi
- Department of Intensive Care Medicine, School of Medicine, Sapporo Medical University, Sapporo 060-8543, Japan;
| | - Naoki Higashibeppu
- Department of Anesthesia and Critical Care, Kobe City Medical Center General Hospital, Kobe 650-0047, Japan; (J.I.); (N.H.)
| | - Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, Yokohama 236-0004, Japan;
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Du S, Yu Z, Li J, Jiang Y, Wang J, Hu J, Su N. Association of blood urea nitrogen to glucose ratio with 365-day mortality in critically ill patients with chronic kidney disease: a retrospective study. Sci Rep 2025; 15:6697. [PMID: 40000743 PMCID: PMC11862077 DOI: 10.1038/s41598-025-91012-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2024] [Accepted: 02/17/2025] [Indexed: 02/27/2025] Open
Abstract
Low blood glucose levels and high urea nitrogen levels affect patient prognosis, but few studies have investigated whether the blood urea nitrogen to glucose (BGR) ratio predicts the risk of death.This retrospective research examined the connection between the BGR and 365-day mortality in patients with chronic kidney disease (CKD) stages 1-4 admitted to an intensive care unit (ICU). The study utilized data from 6,380 patients in the Medical Information Mart for Intensive Care IV version 2.2 (MIMIC-IV v2.2), taking into account confounding factors such as demographics, vital signs, laboratory indicators, and comorbidities. The study employed both univariate and multivariate Cox regression analyses stratified by BGR quartiles. Additionally, restricted cubic spline regression and inflection point analysis were used to explore the linear relationship between BGR and 365-day mortality, while Kaplan-Meier curve analysis was used to observe mortality changes under different BGR stratifications. Subgroup and mediating effect analyses were performed to evaluate the robustness of BGR's effect on 365-day mortality. The study found a cumulative 365-day mortality rate of 34.2% among CKD stages 1-4 patients, with a 2.43-fold increase in the risk of death associated with BGR and at least a 44% increase in the risk of death for each unit increase in BGR (P = 0.022). A significant nonlinear relationship was identified, showing a stepwise change in the risk of death with a marked increase in the slope of the curve for BGR values below 0.52 and above 0.9 (P < 0.001). Subgroup analyses indicated interactions between BGR and factors such as age, sepsis, first-day antibiotic use, and cerebrovascular disease (P < 0.05). In conclusion, this study confirms that BGR is a significant and stable predictor of 1-year mortality risk in patients with CKD stages 1-4. Interventions aimed at timely adjustment, correction of metabolic imbalances, reduction of inflammation, and management of BGR levels are beneficial for reducing mortality in this patient population.
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Affiliation(s)
- Shenghua Du
- Department of Nephrology, Guangzhou Chest Hospital, Guangzhou Medical University, Guangzhou, China
| | - Zhaoxian Yu
- State Key Laboratory of Respiratory Disease, Guangzhou Key Laboratory of Tuberculosis, Department of Critical Care Medicine, Guangzhou Chest Hospital, Institute of Tuberculosis, Guangzhou Medical University, Guangzhou, China
| | - Junghong Li
- State Key Laboratory of Respiratory Disease, Guangzhou Key Laboratory of Tuberculosis, Department of Critical Care Medicine, Guangzhou Chest Hospital, Institute of Tuberculosis, Guangzhou Medical University, Guangzhou, China
| | - Yingyi Jiang
- State Key Laboratory of Respiratory Disease, Guangzhou Key Laboratory of Tuberculosis, Department of Critical Care Medicine, Guangzhou Chest Hospital, Institute of Tuberculosis, Guangzhou Medical University, Guangzhou, China
| | - Juan Wang
- State Key Laboratory of Respiratory Disease, Guangzhou Key Laboratory of Tuberculosis, Department of Critical Care Medicine, Guangzhou Chest Hospital, Institute of Tuberculosis, Guangzhou Medical University, Guangzhou, China
| | - Jinxing Hu
- State Key Laboratory of Respiratory Disease, Guangzhou Key Laboratory of Tuberculosis Research, Department of Tuberculosis, Guangzhou Chest Hospital, Institute of Tuberculosis, Guangzhou Medical University, Guangzhou, China.
| | - Ning Su
- State Key Laboratory of Respiratory Disease, Guangzhou Chest Hospital, Guangzhou Medical University, Guangzhou, China.
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Di Mario F, Sabatino A, Fiaccadori E. Clinical nutrition in patients with Acute Kidney Injury: Traditional approaches and emerging perspectives. Clin Nutr ESPEN 2025; 65:348-356. [PMID: 39681163 DOI: 10.1016/j.clnesp.2024.12.015] [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: 12/09/2024] [Accepted: 12/11/2024] [Indexed: 12/18/2024]
Abstract
Acute kidney injury (AKI) is a complex clinical syndrome characterized by a rapid decline in kidney function, often resulting in complex metabolic and hormonal derangements. A major concern in managing AKI patients is the development of protein energy wasting (PEW), a condition marked by loss of lean body mass and negative impact on overall health outcomes. Additionally, the need of Kidney Replacement Therapy (KRT) for the most severe forms of AKI may further increase the risk of PEW, with a substantial impact on fluid and metabolic balance. Adequate nutritional support is crucial in the management of AKI, as it plays a pivotal role in muscle mass preservation, morbidity reduction and recovery of renal function. This paper aims to evaluate the current evidence regarding nutritional strategies in AKI patients, focusing on energy and protein requirements, timing and route of nutritional intervention, and impact of individualized nutrition plans on PEW prevention and management.
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Affiliation(s)
- Francesca Di Mario
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy.
| | - Alice Sabatino
- Division of Renal Medicine and Baxter Novum, Department of Clinical Science, Technology and Intervention, Karolinska Institute, Stockholm, Sweden
| | - Enrico Fiaccadori
- UO Nefrologia, Azienda Ospedaliero-Universitaria Parma, Dipartimento di Medicina e Chirurgia, Università di Parma, Parma, Italy; Scuola di Specializzazione in Nefrologia, Università di Parma, Dipartimento di Medicina e Chirurgia, Parma, Italy
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Ohbe H, Yoshida M, Okada K, Inoue T, Yamada K, Nakamura K, Yamamoto R, Nozaki A, Higashibeppu N, Kotani J. Effects of high-fat, low-carbohydrate enteral nutrition in critically ill patients: A systematic review with meta-analysis. Clin Nutr 2024; 43:2399-2406. [PMID: 39288649 DOI: 10.1016/j.clnu.2024.09.023] [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: 06/19/2024] [Revised: 07/26/2024] [Accepted: 09/06/2024] [Indexed: 09/19/2024]
Abstract
BACKGROUND & AIMS High-fat, low-carbohydrate enteral nutrition has gained attention, with expectations of an improved respiratory condition, fewer complications, and lower mortality. The present study performed a systematic review and meta-analysis of randomized controlled trials to examine the effects of high-fat, low-carbohydrate enteral nutrition in critically ill adult patients. METHODS We searched MEDLINE via Pubmed, Cochrane Central Register of Controlled Trials (CENTRAL), and ICHUSHI for randomized controlled trials comparing high-fat, low-carbohydrate enteral nutrition to standard enteral nutrition in critically ill adult patients who received enteral nutrition. The primary outcome was mortality. Secondary outcomes included intensive care unit (ICU) mortality, length of ICU stay, length of mechanical ventilation, and adverse events of diarrhea and gastric residual volume. We examined the risk of bias using the Cochrane risk-of-bias tool for randomized trials version 2. We assessed the overall certainty of evidence based on the Grading of Recommendations Assessment, Development, and Evaluation methodology. Synthesis results were calculated with risk ratios and 95% confidence intervals using a Mantel-Haenszel random-effects model. RESULTS Eight trials with 607 patients were included. The effects of high-fat, low-carbohydrate enteral nutrition on mortality did not significantly differ from those of standard enteral nutrition (62/280 [22.1%] vs. 39/207 [18.8%], risk ratios = 1.14, 95% confidence intervals 0.80 to 1.62, P = 0.47). No significant differences were observed in ICU mortality, ICU length of stay, diarrhea, or gastric residual volume between the two groups. However, high-fat, low-carbohydrate enteral nutrition was associated with a significantly shorter duration of mechanical ventilation (mean difference -1.72 days, 95% confidence intervals -2.93 to -0.50, P = 0.005). CONCLUSION High-fat, low-carbohydrate enteral nutrition may not affect mortality, but may decrease the duration of mechanical ventilation in critically ill adult patients. Limitations include the small number of studies and potential for bias. Further research is needed to confirm these results and investigate effects on other outcomes and in a subgroup of patients requiring mechanical ventilation.
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Affiliation(s)
- Hiroyuki Ohbe
- Department of Emergency and Critical Care Medicine, Tohoku University Hospital, Japan; Department of Clinical Epidemiology and Health Economics, The University of Tokyo, Japan.
| | - Minoru Yoshida
- Department of Emergency and Critical Care Medicine, St. Marianna University School of Medicine, Japan.
| | - Kazuya Okada
- Critical Care Medicine, Tokyo Metropolitan Bokutoh Hospital, Japan.
| | - Takaaki Inoue
- Department of Nursing, Fukushima Medical University Hospital, Japan.
| | - Kohei Yamada
- Department of Traumatology and Critical Care Medicine, National Defense Medical College Hospital, Japan.
| | - Kensuke Nakamura
- Department of Critical Care Medicine, Yokohama City University Hospital, Japan.
| | - Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan.
| | - Ayumu Nozaki
- Department of Pharmacy, Kyoto-Katsura Hospital, Japan.
| | - Naoki Higashibeppu
- Department of Anesthesia and Intensive Care/Nutrition Support Team, Kobe City Medical Center General Hospital, Japan.
| | - Joji Kotani
- Division of Disaster and Emergency Medicine, Department of Surgery Related, Kobe University Graduate School of Medicine, Japan.
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Grigonyte-Daraskeviciene M, Møller MH, Kaas-Hansen BS, Bestle MH, Nielsen CG, Perner A. Glucose evaluation and management in the ICU (GEM-ICU): Protocol for a bi-centre cohort study. Acta Anaesthesiol Scand 2024; 68:1271-1274. [PMID: 38898601 DOI: 10.1111/aas.14468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Revised: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024]
Abstract
INTRODUCTION Hyperglycaemia is common in intensive care unit (ICU) patients. Glycaemic monitoring and effective glycaemic control with insulin are crucial in the ICU to improve patient outcomes. However, glycaemic control and insulin use vary between ICU patients and hypo- and hyperglycaemia occurs. Therefore, we aim to provide contemporary data on glycaemic control and management, and associated outcomes, in adult ICU patients. We hypothesise that the occurrence of hypoglycaemia in acutely admitted ICU patients is lower than that of hyperglycaemia. METHODS We will conduct a bi-centre cohort study of 300 acutely admitted adult ICU patients. Routine data will be collected retrospectively at baseline (ICU admission) and daily during ICU stay up to a maximum of 30 days. The primary outcome will be the number of patients with hypoglycaemia during their ICU stay. Secondary outcomes will be occurrence of severe hypoglycaemia, occurrence of hyperglycaemia, time below blood glucose target range, time above target range, all-cause mortality at Day 30, number of days alive without life support at Day 30 and number of days alive and out of hospital at Day 30. Process outcomes include the number of in-ICU days, glucose measurements (number of measurements and method) and use of insulin (including route of administration and dosage). All statistical analyses will be descriptive. CONCLUSIONS This cohort study will provide a contemporary overview of glucose evaluation and management practices in adult ICU patients and, thus, highlight potential areas for improvement through future clinical trials in this area.
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Affiliation(s)
- Milda Grigonyte-Daraskeviciene
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Morten Heiberg Bestle
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, University of Copenhagen, Copenhagen, Denmark
| | - Christian Gantzel Nielsen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Hallman TG, Golovko G, Song J, Palackic A, Wolf SE, El Ayadi A. Metformin is associated with reduced risk of mortality and morbidity in burn patients compared to insulin. Burns 2024; 50:1779-1789. [PMID: 38981799 DOI: 10.1016/j.burns.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/02/2024] [Accepted: 05/20/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE The standard of care for burned patients experiencing hyperglycemia associated with the hypermetabolic response is insulin therapy. Insulin treatment predisposes burn patients to hypoglycemia, which increases morbidity and mortality. Metformin has been suggested as an alternative to insulin therapy for glycemic control in burn patients given its safety profile, but further research is warranted. This study investigated whether metformin use in burn patients is associated with improved glycemic control and morbidity/mortality outcomes compared to insulin use alone. MATERIALS AND METHODS Using the TriNetX database, we conducted a retrospective study of burned patients who were administered insulin, metformin, or both within one week of injury. Demographic, comorbidity, and burn severity information were collected. Patients were categorized by treatment type, propensity score-matched, and compared for the following outcomes within 3 months: hyperglycemia, hypoglycemia, sepsis, lactic acidosis, and death. Statistical significance was set a priori at p ≤ 0.05. RESULTS The insulin cohort was at increased risk for all outcomes (all p < 0.0001) compared to the metformin cohort, and an increased risk for sepsis, lactic acidosis, and death (all p ≤ 0.0002) compared to the insulin/metformin combination cohort. When compared to the metformin cohort, the combination cohort was at increased risk for all outcomes (all p ≤ 0.0107) except death. CONCLUSIONS Treatment with metformin after burn is associated with a reduced risk of morbidity and mortality compared to insulin. The combination of insulin and metformin is no more effective in reducing the risk of hyperglycemia and hypoglycemia than insulin alone but is less effective than metformin alone.
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Affiliation(s)
- Taylor G Hallman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Georgiy Golovko
- Department of Pharmacology, University of Texas Medical Branch, Galveston, TX, USA
| | - Juquan Song
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Alen Palackic
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Department of Hand, Plastic and Reconstructive Surgery, Burn Trauma Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Germany
| | - Steven E Wolf
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Amina El Ayadi
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA.
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Li Y, Li W, Xu B. Between blood glucose and mortality in critically ill patients: Retrospective analysis of the MIMIC-IV database. J Diabetes Investig 2024; 15:931-938. [PMID: 38470005 PMCID: PMC11215680 DOI: 10.1111/jdi.14182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/13/2024] Open
Abstract
AIMS/INTRODUCTION Mean blood glucose (MBG) level is associated with mortality among critically ill patients. We undertook a cohort study to investigate the relationship between MBG and mortality in critically ill patients. MATERIALS AND METHODS Critically ill patients were enrolled from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. MBG was calculated to represent the overall glycemic status during intensive care unit (ICU) hospitalization, and a multivariate logistic regression determined the relationship between MBG and ICU mortality in different subgroups of critically ill patients. RESULTS A total of 8,973 patients were included in the study, 1,244 of whom died within 28 days, including 5,402 men and 3,571 women. Multivariate adjusted restricted cubic spline analyses suggested that the relationship between MBG and ICU mortality was a "J" shape. Logistic regression showed 28 day mortality in group 3 (glucose ≥10 mmol/L): the adjusted odds ratio was 2.06 (95% confidence interval 1.65-2.57). The results of subgroup analysis showed that hyperglycemia had a more significant impact on ICU mortality in patients without diabetes, hypoglycemia and liver disease, and the ICU mortality risk of non-diabetes patients was always higher than that of diabetes patients with the same hyperglycemia level. CONCLUSIONS Current evidence suggested a J-shaped relationship between MBG and mortality in critically ill patients.
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Affiliation(s)
- Yuanyuan Li
- Department of ICUJining No.1 People's HospitalJiningChina
| | - Wenqiang Li
- Department of ICUJining No.1 People's HospitalJiningChina
| | - Baocai Xu
- Department of urologyJining No.1 People's HospitalJiningChina
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Rondanelli M, Barrile GC, Cavioni A, Donati P, Genovese E, Mansueto F, Mazzola G, Patelli Z, Pirola M, Razza C, Russano S, Sivieri C, Tartara A, Valentini EM, Perna S. A Narrative Review on Strategies for the Reversion of Prediabetes to Normoglycemia: Food Pyramid, Physical Activity, and Self-Monitoring Innovative Glucose Devices. Nutrients 2023; 15:4943. [PMID: 38068801 PMCID: PMC10707766 DOI: 10.3390/nu15234943] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 11/16/2023] [Accepted: 11/21/2023] [Indexed: 12/18/2023] Open
Abstract
In 2019, "Nutrition Therapy for Adults with Diabetes or Prediabetes: A Consensus Report" was published. This consensus report, however, did not provide an easy way to illustrate to subjects with prediabetes (SwPs) how to follow a correct dietary approach. The purpose of this review is to evaluate current evidence on optimum dietary treatment of SwPs and to provide a food pyramid for this population. The pyramid built shows that everyday consumption should consist of: whole-grain bread or potatoes eaten with their skins (for fiber and magnesium) and low glycemic index carbohydrates (GI < 55%) (three portions); fruit and vegetables (5 portions), in particular, green leafy vegetables (for fiber, magnesium, and polyphenols); EVO oil (almost 8 g); nuts (30 g, in particular, pistachios and almonds); three portions of dairy products (milk/yogurt: 300-400 g/day); mineral water (almost 1, 5 L/day for calcium intake); one glass of wine (125 mL); and three cups of coffee. Weekly portions should include fish (four portions), white meat (two portions), protein plant-based food (four portions), eggs (egg portions), and red/processed meats (once/week). At the top of the pyramid, there are two pennants: a green one means that SwPs need some personalized supplementation (if daily requirements cannot be satisfied through diet, vitamin D, omega-3, and vitamin B supplements), and a red one means there are some foods and factors that are banned (simple sugar, refined carbohydrates, and a sedentary lifestyle). Three to four times a week of aerobic and resistance exercises must be performed for 30-40 min. Finally, self-monitoring innovative salivary glucose devices could contribute to the reversion of prediabetes to normoglycemia.
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Affiliation(s)
- Mariangela Rondanelli
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Gaetan Claude Barrile
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Alessandro Cavioni
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Paolo Donati
- AICUBE srl, 20090 Trezzano sul Naviglio, Italy; (P.D.); (S.R.)
| | - Elisa Genovese
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Francesca Mansueto
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Giuseppe Mazzola
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Zaira Patelli
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Martina Pirola
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Claudia Razza
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Stefano Russano
- AICUBE srl, 20090 Trezzano sul Naviglio, Italy; (P.D.); (S.R.)
| | - Claudia Sivieri
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Alice Tartara
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Eugenio Marzio Valentini
- Department of Public Health, Experimental and Forensic Medicine, University of Pavia, 27100 Pavia, Italy; (G.C.B.); (A.C.); (E.G.); (F.M.); (G.M.); (Z.P.); (M.P.); (C.R.); (C.S.); (A.T.); (E.M.V.)
| | - Simone Perna
- Department of Food, Environmental and Nutritional Sciences, Division of Human Nutrition, University of Milan, 20133 Milan, Italy;
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Kalamaras I, Dafoulas G, Bargiota A, Votis K. Real-world data analysis for the association of glucose control and mortality in critically ill patients. Health Informatics J 2023; 29:14604582231199554. [PMID: 37864314 DOI: 10.1177/14604582231199554] [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] [Indexed: 10/22/2023]
Abstract
Existing results regarding the usage of glycemic control in critically ill patients for reduced morbidity and mortality have been based on clinical studies but could not be reproduced in large prospective studies. Current guidelines for glycemic control suggest a target blood glucose of 140-180 mg/dL, with lower targets being appropriate for some patients. The current study aims to provide additional evidence to this area, through the usage of real-world retrospective data of everyday clinical practice. We have used the large, credentialed access database MIMIC-IV to assess the effect of glycemic control to patient mortality. Glycemic control has been characterized by the percentage of time that the glucose measurements fall within pre-specified glucose bands. Results from logistic regression and survival analysis are reported, along with visualizations based on methods from the machine learning literature, which all suggest that increased time in low and high glucose values is related to increased ICU mortality and decreased survival.
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Affiliation(s)
- Ilias Kalamaras
- Informatics and Telematics Institute, Centre for Research and Technology Hellas, Thermi Thessaloniki, Greece
| | - George Dafoulas
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Alexandra Bargiota
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, University of Thessaly, Larisa, Greece
| | - Konstantinos Votis
- Informatics and Telematics Institute, Centre for Research and Technology Hellas, Thermi Thessaloniki, Greece
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Zhou T, Boettger M, Knopp J, Lange M, Heep A, Chase JG. Model-based subcutaneous insulin for glycemic control of pre-term infants in the neonatal intensive care unit. Comput Biol Med 2023; 160:106808. [PMID: 37163965 DOI: 10.1016/j.compbiomed.2023.106808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 03/02/2023] [Accepted: 03/20/2023] [Indexed: 03/30/2023]
Abstract
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.
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Xiong X, Chen D, Cai S, Qiu L, Shi J. Association of intraoperative hyperglycemia with postoperative composite infection after cardiac surgery with cardiopulmonary bypass: A retrospective cohort study. Front Cardiovasc Med 2023; 9:1060283. [PMID: 36712254 PMCID: PMC9880037 DOI: 10.3389/fcvm.2022.1060283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/29/2022] [Indexed: 01/14/2023] Open
Abstract
Background The association between intraoperative hyperglycemia (IH) and postoperative infections in patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) is inadequately studied. Methods A total of 3,428 patients who underwent cardiac surgery with CPB at our institution between June 1, 2019 and July 30, 2021 were enrolled to evaluate the association of IH (blood glucose ≥ 180 mg/dL) with postoperative infection in patients. The new onset of any type of infection and the optimal cutoff values of intraoperative glucose to predict in-hospital infection were determined. Results The composite outcome occurred in 497 of 3,428 (14.50%) patients. IH was associated with an increased risk of postoperative composite infection [adjusted odds ratio: 1.39, (95% confidence interval), 1.06-1.82, P = 0.016]. Restricted cubic splines were applied to flexibly model and visualize the association of intraoperative peak glucose with infection, and a J-shaped association was revealed. Besides, it was demonstrated that the possibility of infection was relatively flat till 150 mg/dL glucose levels which started to rapidly increase afterward. Conclusion We summarize that IH is associated with an elevated risk of postoperative new-onset composite infections and perioperative blood glucose management should be more stringent, i.e., lesser than 150 mg/dL in patients undergoing cardiac surgery.
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Affiliation(s)
- Xinglong Xiong
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Dongxu Chen
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Shuang Cai
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Li Qiu
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Jing Shi
- Department of Anesthesiology, The Affiliated Hospital of Guizhou Medical University, Guiyang, China
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Muacevic A, Adler JR, Torres R, Maita K, Garcia J, Serrano L, Ho O, Forte AJ. Modulation of Burn Hypermetabolism in Preclinical Models. Cureus 2023; 15:e33518. [PMID: 36779088 PMCID: PMC9904913 DOI: 10.7759/cureus.33518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/11/2023] Open
Abstract
Severe burns elicit a state of physiological stress and increased metabolism to help the body compensate for the changes associated with the traumatic injury. However, this hypermetabolic state is associated with increased insulin resistance, cardiovascular dysfunction, skeletal muscle catabolism, impaired wound healing, and delayed recovery. Several interventions were attempted to modulate burn hypermetabolism, including nutritional support, early excision and grafting, and growth hormone application. However, burn hypermetabolism still imposes significant morbidity and mortality in burn patients. Due to the limitations of in vitro models, animal models are indispensable in burn research. Animal models provide researchers with invaluable tools to test the safety and efficacy of novel treatments or advance our knowledge of previously utilized agents. Several animal studies evaluated novel therapies to modulate burn hypermetabolism in the last few years, including recombinant human growth hormone, erythropoietin, acipimox, apelin, anti-interleukin-6 monoclonal antibody, and ghrelin therapies. Results from these studies are promising and may be effectively translated into human studies. In addition, other studies revisited drugs previously used in clinical practice, such as insulin and metformin, to further investigate their underlying mechanisms as modulators of burn hypermetabolism. This review aims to update burn experts with the novel therapies under investigation in burn hypermetabolism with a focus on applicability and translation. Furthermore, we aim to guide researchers in selecting the correct animal model for their experiments by providing a summary of the methodology and the rationale of the latest studies.
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15
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Effects of Intensive Blood Glucose Control on Surgical Site Infection for Liver Transplant Recipients: A Randomized Controlled Trial. Transplant Proc 2023; 55:170-177. [PMID: 36567173 DOI: 10.1016/j.transproceed.2022.10.062] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 09/07/2022] [Accepted: 10/18/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND The evidence supporting intensive blood glucose control to prevent surgical site infections (SSIs) among liver transplant recipients is insufficient. We aimed to assess the effects of postoperative intensive blood glucose control (IBGC) against standard blood glucose control (SBGC) on the incidence of SSIs among adult liver transplant recipients. METHODS We performed a randomized controlled trial (ClinicalTrials.gov identifier NCT03474666). The IBGC target was 80 to 130 mg/dL, and the SBGC target was below 180 mg/dL. Analyses were made on an intention-to-treat basis. RESULTS Of the 41 recipients enrolled onto the trial, 20 were randomly allocated to the IBGC group and 21 to the SBGC group. There were no significant differences in SSIs among recipients allocated to either group (relative risk [RR], 0.78; 95% confidence interval [CI], 0.21-2.88; P = .69). Mean (SD) blood glucose levels were significantly lower in the IBGC group in the 24-hour period after surgery (145.0 [20.7] mg/dL and 230.2 [51.6] mg/dL; P = .001). While there were fewer episodes of hypoglycemia in the IBGC group, this was not statistically significant. There were no episodes of severe hypoglycemia in either group. Hyperglycemia and severe hyperglycemia were significantly more frequent in the SBGC group (RR, 0.70; 95% CI, 0.52-0.93; P = .001 and RR, 0.07; 95% CI, 0.01-0.48; P = .001, respectively). Length of hospital stay was significantly shorter for recipients in the IBGC group (13.1 [5.5] days vs 19.3 [12.1] days; P = .04). CONCLUSIONS Although this small trial did not find intensive control reduced SSI, it was associated with lower blood glucose levels, fewer episodes of hyperglycemia and severe hyperglycemia, and shorter length of hospital stay.
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Risk Factors for Mortality in Sepsis Patients without Lactate Levels Increasing Early. Emerg Med Int 2023; 2023:6620157. [PMID: 36875806 PMCID: PMC9984259 DOI: 10.1155/2023/6620157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
Objectives Our purpose was to investigate the influencing factors for mortality in sepsis patients without lactate levels increasing in the early stage. Methods We conducted a retrospective observational study involving 830 adult sepsis patients admitted to ICU. We calculated time-weighted lactate (LacTW), a dynamic value that incorporates both the magnitude of change and the time interval of such change, to represent lactate levels in the first 24 hours. ROC curve was used to find the cutoff of LacTW for predicting mortality, and the influencing factors for lactate levels and mortality in the low lactate group were further studied. The primary outcome was hospital mortality. Results Among 830 patients, LacTW > 1.975 mmo/L was found to be the cutoff threshold for predicting mortality (AUC = 0.646, P < 0.001). The following indexes related to organ dysfunction influenced LacTW: acute physiology and chronic health evaluation II (APACHE II) score (P < 0.001), activated partial thromboplastin time (APTT) (P = 0.002), total bilirubin (P = 0.012), creatinine (P = 0.037), with hypotension (P < 0.001), chronic kidney disease (P = 0.013), and required continuous renal replacement therapy (CRRT) (P < 0.001). Of the 394 patients in the low lactate group, age (P = 0.002), malignancy (P < 0.001), lactate dehydrogenase (P = 0.006), required treatment such as mechanical ventilation (P < 0.001), CRRT (P < 0.001), vasoactive drugs (P < 0.001), and glucocorticoid (P < 0.001), and failure to reach the target fluid resuscitation of 30 ml/kg within 6 hours (P = 0.003) were independently associated with hospital mortality. Conclusions Due to the lower incidence of early organ dysfunction, lactate levels are not increased or delayed in some septic shock patients in the early stage, thus affecting the alertness of clinicians and the timeliness and adequacy of fluid resuscitation, and finally affects the prognosis.
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Addinsall AB, Cacciani N, Backéus A, Hedström Y, Shevchenko G, Bergquist J, Larsson L. Electrical stimulated GLUT4 signalling attenuates critical illness-associated muscle wasting. J Cachexia Sarcopenia Muscle 2022; 13:2162-2174. [PMID: 35502572 PMCID: PMC9397497 DOI: 10.1002/jcsm.12978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 02/12/2022] [Accepted: 02/21/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Critical illness myopathy (CIM) is a debilitating condition characterized by the preferential loss of the motor protein myosin. CIM is a by-product of critical care, attributed to impaired recovery, long-term complications, and mortality. CIM pathophysiology is complex, heterogeneous and remains incompletely understood; however, loss of mechanical stimuli contributes to critical illness-associated muscle atrophy and weakness. Passive mechanical loading and electrical stimulation (ES) therapies augment muscle mass and function. While having beneficial outcomes, the mechanistic underpinning of these therapies is less known. Therefore, here we aimed to assess the mechanism by which chronic supramaximal ES ameliorates CIM in a unique experimental rat model of critical care. METHODS Rats were subjected to 8 days of critical care conditions entailing deep sedation, controlled mechanical ventilation, and immobilization with and without direct soleus ES. Muscle size and function were assessed at the single cell level. RNAseq and western blotting were employed to understand the mechanisms driving ES muscle outcomes in CIM. RESULTS Following 8 days of controlled mechanical ventilation and immobilization, soleus muscle mass, myosin : actin ratio, and single muscle fibre maximum force normalized to cross-sectional area (CSA; specific force) were reduced by 40-50% (P < 0.0001). ES significantly reduced the loss of soleus muscle fibre CSA and myosin : actin ratio by approximately 30% (P < 0.05) yet failed to effect specific force. RNAseq pathway analysis revealed downregulation of insulin signalling in the soleus muscle following critical care, and GLUT4 trafficking was reduced by 55% leading to an 85% reduction of muscle glycogen content (P < 0.01). ES promoted phosphofructokinase and insulin signalling pathways to control levels (P < 0.05), consistent with the maintenance of GLUT4 translocation and glycogen levels. AMPK, but not AKT, signalling pathway was stimulated following ES, where the downstream target TBC1D4 increased 3 logFC (P = 0.029) and AMPK-specific P-TBC1D4 levels were increased approximately two-fold (P = 0.06). Reduction of muscle protein degradation rather than increased synthesis promoted soleus CSA, as ES reduced E3 ubiquitin proteins, Atrogin-1 (P = 0.006) and MuRF1 (P = 0.08) by approximately 50%, downstream of AMPK-FoxO3. CONCLUSIONS ES maintained GLUT4 translocation through increased AMPK-TBC1D4 signalling leading to improved muscle glucose homeostasis. Soleus CSA and myosin content was promoted through reduced protein degradation via AMPK-FoxO3 E3 ligases, Atrogin-1 and MuRF1. These results demonstrate chronic supramaximal ES reduces critical care associated muscle wasting, preserved glucose signalling, and reduced muscle protein degradation in CIM.
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Affiliation(s)
- Alex B. Addinsall
- Basic and Clinical Muscle Biology Group, Department of Physiology and PharmacologyKarolinska InstituteSolnaSweden
| | - Nicola Cacciani
- Basic and Clinical Muscle Biology Group, Department of Physiology and PharmacologyKarolinska InstituteSolnaSweden
- Department of Clinical NeuroscienceKarolinska InstituteSolnaSweden
| | - Anders Backéus
- Basic and Clinical Muscle Biology Group, Department of Physiology and PharmacologyKarolinska InstituteSolnaSweden
| | - Yvette Hedström
- Basic and Clinical Muscle Biology Group, Department of Physiology and PharmacologyKarolinska InstituteSolnaSweden
| | - Ganna Shevchenko
- Department of Chemistry – BMC, Analytical ChemistryUppsala UniversityUppsalaSweden
| | - Jonas Bergquist
- Department of Chemistry – BMC, Analytical ChemistryUppsala UniversityUppsalaSweden
| | - Lars Larsson
- Basic and Clinical Muscle Biology Group, Department of Physiology and PharmacologyKarolinska InstituteSolnaSweden
- Department of Clinical NeuroscienceKarolinska InstituteSolnaSweden
- Viron Molecular Medicine InstituteBostonUSA
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Huang CH, Ni SY, Lu HY, Huang APH, Kuo LT. Predictors of Prolonged Mechanical Ventilation Among Patients with Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping. Neurol Ther 2022; 11:697-709. [PMID: 35184263 PMCID: PMC9095775 DOI: 10.1007/s40120-022-00336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is a fatal event with high mortality and morbidity rates. Survivors may require prolonged intubation with mechanical ventilation (MV). However, the risk factors for prolonged intubation in these patients remain unclear. The aim of this study was to determine the predictors of prolonged MV in aSAH patients who underwent surgical clipping. METHODS In total, 108 adult patients with a primary diagnosis of aSAH who were on MV > 48 h and survived > 14 days after surgery were included. Clinicodemographic and radiological characteristics, laboratory tests on admission, and initial Glasgow Coma Scale (GCS) and its components were analyzed. RESULTS The average age of the patients included in the analysis was 59.1 ± 12.5 years. Overall, 32 patients (29.6%) had prolonged MV. The group with prolonged MV showed a higher prevalence of diabetes mellitus and hypertension, lower initial GCS and its components, higher World Federation of Neurosurgeons (WFNS) and Hunt and Hess grades, and higher initial white cell counts. The independent factors associated with prolonged MV were a history of diabetes mellitus (odds ratio [OR] 5.799, 95% confidence interval [CI] 1.109-30.334; P = 0.037) and Hunt and Hess grade 3-5 (OR 7.217, 95% CI 1.090-47.770; P = 0.040). CONCLUSION A history of diabetes mellitus and Hunt and Hess grade 3-5 independently predict prolonged MV after microsurgical clipping in patients with aSAH. Thus, knowledge of potential predictors for prolonged MV is essential to improve the early initiation of adequate treatment in the early stages of treatment and provide useful information for communication between caregivers and families.
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Affiliation(s)
- Ching-Hua Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
| | - Shih-Ying Ni
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, Taiwan
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
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Determinants of blood sugar level among type I diabetic patients in Debre Tabor General Hospital, Ethiopia: a longitudinal study. Sci Rep 2022; 12:9035. [PMID: 35641604 PMCID: PMC9156690 DOI: 10.1038/s41598-022-12891-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/18/2022] [Indexed: 11/08/2022] Open
Abstract
In 2019 among all populous countries in Africa, Ethiopia has the fourth-highest number of people with diabetes (1.7 million). This aggravated prevalence figure implies that diabetes mellitus is a major public health problem in Ethiopia. Due to urbanization, this problem is very critical in the Amhara region, Ethiopia. The study aimed to identify factors that affect the longitudinal fasting blood sugar among T1DM (Type I diabetes mellitus) patients in Debre Tabor General Hospital (DTGH); North-west Ethiopia. A retrospective study design was conducted from 210 randomly selected T1DM patients in the clinic (Outpatient Department) at Debre Tabor General Hospital under the follow-up period from September 2019 to August 2021. To fit these retrospective data records, we used Random intercept and slope models. In this study, the unstructured variance-covariance structure was the appropriate structure for the random intercept and slope model. At a 5% level of significance, family history of diabetes mellitus, age, comorbidity, hemoglobin, and visit time in months were significant factors. Also, all the random effect parameters were statistically significant. It implies that the variability within and between T1DM patients in FBS over time was statistically significant. The mean fasting blood sugar level at baseline was 5.4944 mg/dl and decreased to 5.0679 mg/dl at the final follow-up time. Major contributors for the increment of fasting blood sugar level were increasing age, decreasing haemoglobin, having comorbidity, and belonging from a family with diabetes history. The overall within and between variability in fasting blood sugar level among T1DM patients in DTGH were high. Intervention measures at DTGH level should be undertaken using health education and other measures by providing an emphasis on the prevention, early detection, and treatment of diabetes mellitus.
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Endocrine and Electrolyte Disorders. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00040-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Xiao F, Zhou Y, Zhang M, Chen D, Peng S, Tang H, Li L, Tang C, Liu J, Li B, Zhou H. Hyperglycemia and blood glucose deterioration are risk factors for severe COVID-19 with diabetes: a two-center cohort study. J Med Virol 2021; 94:1967-1975. [PMID: 34967028 PMCID: PMC9015512 DOI: 10.1002/jmv.27556] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/27/2021] [Indexed: 01/08/2023]
Abstract
We aimed to assess whether blood glucose control can be used as predictors for the severity of 2019 coronavirus disease (COVID‐19) and to improve the management of diabetic patients with COVID‐19. A two‐center cohort with a total of 241 confirmed cases of COVID‐19 with definite outcomes was studied. After the diagnosis of COVID‐19, the clinical data and laboratory results were collected, the fasting blood glucose levels were followed up at initial, middle stage of admission and discharge, the severity of the COVID‐19 was assessed at any time from admission to discharge. Hyperglycemia patients with COVID‐19 were divided into three groups: good blood glucose control, fair blood glucose control, and blood glucose deterioration. The relationship of blood glucose levels, blood glucose control status, and severe COVID‐19 were analyzed by univariate and multivariable regression analysis. In our cohort, 21.16% were severe cases and 78.84% were nonsevere cases. Admission hyperglycemia (adjusted odds ratio [aOR], 1.938; 95% confidence interval [95% CI], 1.387–2.707), mid‐term hyperglycemia (aOR, 1.758; 95% CI, 1.325–2.332), and blood glucose deterioration (aOR, 22.783; 95% CI, 2.661–195.071) were identified as the risk factors of severe COVID‐19. Receiver operating characteristic (ROC) curve analysis, reaching an area under ROC curve of 0.806, and a sensitivity and specificity of 80.40% and 68.40%, respectively, revealed that hyperglycemia on admission and blood glucose deterioration of diabetic patients are potential predictive factors for severe COVID‐19. Our results indicated that admission hyperglycemia and blood glucose deterioration were positively correlated with the risk factor for severe COVID‐19, and deterioration of blood glucose may be more likely to the occurrence of severe illness in COVID‐19.
High fasting blood glucose level, especially the initial level at admission was an important risk factor for severe cases. Deterioration of blood glucose may be more likely to the occurrence of severe 2019 coronavirus disease.
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Affiliation(s)
- Fen Xiao
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Yingchu Zhou
- The First Hospital of Changsha (The Hospital of Infectious Diseases of Changsha, the Public Health Treatment Center of Changsha), Changsha, Hunan, China
| | - Meibiao Zhang
- The First People's Hospital of Huaihua, Huaihua, Hunan, China
| | - Dong Chen
- The First Hospital of Changsha (The Hospital of Infectious Diseases of Changsha, the Public Health Treatment Center of Changsha), Changsha, Hunan, China
| | - Shaolin Peng
- The First People's Hospital of Huaihua, Huaihua, Hunan, China
| | - Haoneng Tang
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Long Li
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Chenyi Tang
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Jiyang Liu
- The First Hospital of Changsha (The Hospital of Infectious Diseases of Changsha, the Public Health Treatment Center of Changsha), Changsha, Hunan, China
| | - Bo Li
- The First Hospital of Changsha (The Hospital of Infectious Diseases of Changsha, the Public Health Treatment Center of Changsha), Changsha, Hunan, China
| | - Houde Zhou
- National Clinical Research Center for Metabolic Diseases, Hunan Provincial Key Laboratory for Metabolic Bone Diseases, and Department of Metabolism and Endocrinology, the Second Xiangya Hospital of Central South University, Changsha, Hunan, China
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22
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Russo MP, Fosser SNM, Elizondo CM, Giunta DH, Fuentes NA, Grande-Ratti MF. In-Hospital Mortality and Glycemic Control in Patients with Hospital Hyperglycemia. Rev Diabet Stud 2021; 17:50-56. [PMID: 34852895 PMCID: PMC9380085 DOI: 10.1900/rds.2021.17.50] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Stress-induced hyperglycemia is a phenomenon that occurs typically in patients hospitalized for acute disease and resolves spontaneously after regression of the acute illness. However, it can also occur in diabetes patients, a fact that is sometimes overlooked. It is thus important to make a proper diabetes diagnosis if hospitalized patients with episodes of hyperglycemia with and without diabetes are studied. AIMS To estimate the extent of the association between stress-induced hyperglycemia and in-hospital mortality in patients with hospital hyperglycemia (HH), and to explore potential differences between patients diagnosed with diabetes (HH-DBT) and those with stress-induced hyperglycemia (SH), but not diagnosed with diabetes. METHODS A cohort of adults with hospital hyperglycemia admitted to a tertiary, university hospital in Buenos Aires, Argentina, was analyzed retrospectively. RESULTS In the study, 2,955 patients were included and classified for analysis as 1,579 SH and 1,376 HH-DBT. Significant differences were observed in glycemic goal (35.53% SH versus 25.80% HH-DBT, p < 0.01), insulin use rate (26.66% SH versus 46.58% HH-DBT, p < 0.01), and severe hypoglycemia rate (1.32% SH versus 1.74% HH-DBT, p < 0.01). There were no differences in hypoglycemia rate (8.23% SH versus 10.53% HH-DBT) and hospital mortality. There was no increase in risk of mortality in the SH group adjusted for age, non-scheduled hospitalization, major surgical intervention, critical care, hypoglycemia, oncological disease, cardiovascular comorbidity, and prolonged hospitalization. CONCLUSIONS In this study, we observed better glycemic control in patients with SH than in those with HH-DBT, and there was no difference in hospital mortality.
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Affiliation(s)
- María Paula Russo
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Santiago Nicolas Marquez Fosser
- Clinical and Health Informatics Research Group, McGill University, Montr??al, Qu??bec, Canada; Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
| | | | - Diego Hernán Giunta
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - María Florencia Grande-Ratti
- Internal Medicine Research Unit, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina; Department of Health Informatics, Hospital Italiano de Buenos Aires, Ciudad de Buenos Aires, Argentina
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23
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Antonescu I, Haines KL, Agarwal S. Role of Nutrition in the Elderly Surgical Patient – Review of the Literature and Current Recommendations. CURRENT GERIATRICS REPORTS 2021. [DOI: 10.1007/s13670-021-00367-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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24
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See KC. Glycemic targets in critically ill adults: A mini-review. World J Diabetes 2021; 12:1719-1730. [PMID: 34754373 PMCID: PMC8554370 DOI: 10.4239/wjd.v12.i10.1719] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2021] [Revised: 06/06/2021] [Accepted: 09/03/2021] [Indexed: 02/06/2023] Open
Abstract
Illness-induced hyperglycemia impairs neutrophil function, increases pro-inflammatory cytokines, inhibits fibrinolysis, and promotes cellular damage. In turn, these mechanisms lead to pneumonia and surgical site infections, prolonged mechanical ventilation, prolonged hospitalization, and increased mortality. For optimal glucose control, blood glucose measurements need to be done accurately, frequently, and promptly. When choosing glycemic targets, one should keep the glycemic variability < 4 mmol/L and avoid targeting a lower limit of blood glucose < 4.4 mmol/L. The upper limit of blood glucose should be set according to casemix and the quality of glucose control. A lower glycemic target range (i.e., blood glucose 4.5-7.8 mmol/L) would be favored for patients without diabetes mellitus, with traumatic brain injury, or who are at risk of surgical site infection. To avoid harm from hypoglycemia, strict adherence to glycemic control protocols and timely glucose measurements are required. In contrast, a higher glycemic target range (i.e., blood glucose 7.8-10 mmol/L) would be favored as a default choice for medical-surgical patients and patients with diabetes mellitus. These targets may be modified if technical advances for blood glucose measurement and control can be achieved.
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Affiliation(s)
- Kay Choong See
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore 119228, Singapore
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25
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Veldscholte K, Cramer ABG, Joosten KFM, Verbruggen SCAT. Intermittent fasting in paediatric critical illness: The properties and potential beneficial effects of an overnight fast in the PICU. Clin Nutr 2021; 40:5122-5132. [PMID: 34461586 DOI: 10.1016/j.clnu.2021.07.030] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022]
Abstract
Although evidence for the superiority of continuous feeding over intermittent feeding is lacking, in most paediatric intensive care units (PICU) artificial feeding is administered continuously for 24 h per day. Until now, studies in PICU on intermittent feeding have primarily focused on surrogate endpoints such as nutritional intake and gastro-intestinal complaints and none have studied the effects of an extended fasting period. Intermittent fasting has been proven to have many health benefits in both animal and human studies. The observed beneficial effects are based on multiple metabolic and endocrine changes that are presumed crucial in critical illness as well. One key element is the transition to ketone body metabolism, which, among others, contributes to the stimulation of several cellular pathways involved in stress resistance (neuro)plasticity and mitochondrial biogenesis, and might help preserve brain function. Secondly, the fasting state stimulates the activation of autophagy, a process that is crucial for cellular function and integrity. Of the different intermittent fasting strategies investigated, time-restricted feeding with a daily extended fasting period appears most feasible in the PICU. Moreover, planning the fasting period overnight could help maintain the circadian rhythm. Although not investigated, such an overnight intermittent fasting strategy might improve the metabolic profile, feeding tolerance and perhaps even have beneficial effects on tissue repair, reperfusion injury, muscle weakness, and the immune response. Future studies should investigate practical implications in critically ill children and the optimal duration of the fasting periods, which might be affected by the severity of illness and by age.
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Affiliation(s)
- Karlien Veldscholte
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Arnout B G Cramer
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Koen F M Joosten
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands
| | - Sascha C A T Verbruggen
- Intensive Care Unit, Department of Paediatrics and Paediatric Surgery, Erasmus Medical Centre, Sophia Children's Hospital, Rotterdam, the Netherlands.
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26
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Sadhu AR, Patham B, Vadhariya A, Chikermane SG, Johnson ML. Outcomes of "Real-World" Insulin Strategies in the Management of Hospital Hyperglycemia. J Endocr Soc 2021; 5:bvab101. [PMID: 34235360 PMCID: PMC8252645 DOI: 10.1210/jendso/bvab101] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Indexed: 11/28/2022] Open
Abstract
CONTEXT Guidelines recommend scheduled long-acting basal and short-acting bolus insulin several times daily to manage inpatient hyperglycemia. In the "real world," insulin therapy is complicated, with limited data on the comparative effectiveness of different insulin strategies. OBJECTIVE This work aimed to evaluate the association of different insulin strategies with glucose control and hospital outcomes after adjustment for patient and physician factors that influence choice of therapy. METHODS This retrospective, observational study took place at an academic hospital. Participants included noncritically ill hospitalized medical/surgical patients (n = 4558) receiving subcutaneous insulin for 75% or longer during admission. Insulin therapy was grouped into 3 strategies within the first 48 hours: basal bolus (BB: scheduled long and short/rapid n = 2358), sliding scale (SS: short/rapid acting n = 1855), or basal only (BO: long only: n = 345). Main outcome measures included glucose control: hypoglycemic days, hyperglycemic days, euglycemic days, mean glucose; and hospitalization: in-hospital mortality, length of stay (LOS), and readmissions. RESULTS Initial therapy with BB was associated with more hypoglycemic (2.40; CI, 2.04 to 2.82) (P < .001) and fewer euglycemic days (0.90; CI, 0.85 to 0.97) (P = .003) than SS, whereas BO was associated with fewer hyperglycemic days (0.70; CI, 0.62 to 0.79) (P < .001), lower mean glucose (-18.03; CI, -22.46 to -12.61) (P < .001), and more euglycemic days (1.22; CI, 1.09 to 1.37) (P < .001) compared to SS. No difference in mortality, LOS, and readmissions was found. However, decreased LOS was observed in the BB subgroup with a medical diagnostic related group (0.93; CI, 0.89 to 0.97) (P < .001). CONCLUSION BO had a more favorable hyperglycemia profile than SS. BB, on the other hand, showed worse glycemic control as compared to SS. In the real-world hospital, BO may be a simpler and more effective insulin strategy.
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Affiliation(s)
| | | | - Aisha Vadhariya
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
| | | | - Michael L Johnson
- University of Houston, College of Pharmacy, Houston, Texas 77204, USA
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27
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Yun R, Javed AA, Jarrell AS, Crow J, Wright MJ, Burkhart RA, Rybny J, Wolfgang CL, Kruer RM. Impact of Postoperative Glycemic Control on Postoperative Morbidity in Patients Undergoing Open Pancreaticoduodenectomy. Pancreas 2021; 50:834-840. [PMID: 34347733 DOI: 10.1097/mpa.0000000000001856] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE To evaluate the impact of postoperative glycemic control on postoperative morbidity in patients undergoing a pancreaticoduodenectomy. METHODS A retrospective study was performed on patients at The Johns Hopkins Hospital between April 2015 and April 2016. Data were collected on postoperative insulin regimens, blood glucose, rates of hyperglycemia and hypoglycemia, and postoperative complications and were evaluated. RESULTS Out of 244 patients, 114 (46.7%) experienced at least 1 hyperglycemic (>180 mg/dL) episode and 16 (6.6%) experienced at least 1 hypoglycemic episode (<70 mg/dL) during the first postoperative 24 hours. Early postoperative hyperglycemia (>180 mg/dL) was associated with a significantly higher rate of surgical site infections (15.7% vs 7%; P = 0.031). Late postoperative hyperglycemia (>180 mg/dL) was associated with a significantly higher rate of fistulas (4.3% vs 14.6%; P = 0.021). CONCLUSIONS Early hyperglycemia (>180 mg/dL) is associated with a higher risk of surgical site infections while late hyperglycemia is associated with a higher risk of fistulas. Intensive glucose control (<150 mg/dL) was not demonstrated to decrease the risk of postoperative complications. Similar to other critically ill populations, targeting a glucose goal of <180 mg/dL may be an appropriate target to reduce morbidity without increasing the risk of hypoglycemia.
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Affiliation(s)
- Regina Yun
- From the Department of Pharmacy, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Ammar A Javed
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | - Andrew S Jarrell
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Jessica Crow
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | - Michael J Wright
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery
| | | | - Joseph Rybny
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
| | | | - Rachel M Kruer
- Department of Pharmacy, The Johns Hopkins Hospital, Baltimore, MD
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28
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Pasquel FJ, Urrutia MA, Cardona S, Coronado KWZ, Albury B, Perez-Guzman MC, Galindo RJ, Chaudhuri A, Iacobellis G, Palacios J, Farias JM, Gomez P, Anzola I, Vellanki P, Fayfman M, Davis GM, Migdal AL, Peng L, Umpierrez GE. Liraglutide hospital discharge trial: A randomized controlled trial comparing the safety and efficacy of liraglutide versus insulin glargine for the management of patients with type 2 diabetes after hospital discharge. Diabetes Obes Metab 2021; 23:1351-1360. [PMID: 33591621 PMCID: PMC8571803 DOI: 10.1111/dom.14347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/21/2021] [Accepted: 01/23/2021] [Indexed: 11/29/2022]
Abstract
AIM To compare a glucagon-like peptide-1 receptor agonist with basal insulin at hospital discharge in patients with uncontrolled type 2 diabetes in a randomized clinical trial. METHODS A total of 273 patients with glycated haemoglobin (HbA1c) 7%-10% (53-86 mol/mol) were randomized to liraglutide (n = 136) or insulin glargine (n = 137) at hospital discharge. The primary endpoint was difference in HbA1c at 12 and 26 weeks. Secondary endpoints included hypoglycaemia, changes in body weight, and achievement of HbA1c <7% (53 mmol/mol) without hypoglycaemia or weight gain. RESULTS The between-group difference in HbA1c at 12 weeks and 26 weeks was -0.28% (95% CI -0.64, 0.09), and at 26 weeks it was -0.55%, (95% CI -1.01, -0.09) in favour of liraglutide. Liraglutide treatment resulted in a lower frequency of hypoglycaemia <3.9 mmol/L (13% vs 23%; P = 0.04), but there was no difference in the rate of clinically significant hypoglycaemia <3.0 mmol/L. Compared to insulin glargine, liraglutide treatment was associated with greater weight loss at 26 weeks (-4.7 ± 7.7 kg vs -0.6 ± 11.5 kg; P < 0.001), and the proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia was 48% versus 33% (P = 0.05) at 12 weeks and 45% versus 33% (P = 0.14) at 26 weeks in liraglutide versus insulin glargine. The proportion of patients with HbA1c <7% (53 mmol/mol) without hypoglycaemia and no weight gain was higher with liraglutide at 12 (41% vs 24%, P = 0.005) and 26 weeks (39% vs 22%; P = 0.014). The incidence of gastrointestinal adverse events was higher with liraglutide than with insulin glargine (P < 0.001). CONCLUSION Compared to insulin glargine, treatment with liraglutide at hospital discharge resulted in better glycaemic control and greater weight loss, but increased gastrointestinal adverse events.
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Affiliation(s)
- Francisco J. Pasquel
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maria A. Urrutia
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Saumeth Cardona
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Karla W. Z. Coronado
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Bonnie Albury
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Mireya C. Perez-Guzman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Rodolfo J. Galindo
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Ajay Chaudhuri
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, Jacobs School of Medicine and Biomedical Sciences, State University of New York at Buffalo, Buffalo, New York
| | - Gianluca Iacobellis
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Juan Palacios
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University of Miami, Miami, Florida
| | - Javier M. Farias
- Division of Endocrinology Sanatorio Guemes, Ciudad Autonoma de Buenos Aires, Buenos Aires, Argentina
| | - Patricia Gomez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Isabel Anzola
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Priyathama Vellanki
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Maya Fayfman
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Georgia M. Davis
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Alexandra L. Migdal
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Limin Peng
- Deartment of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
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Sehgal IS, Agarwal R, Dhooria S, Prasad KT, Muthu V, Aggarwal AN. Etiology and Outcomes of ARDS in the Elderly Population in an Intensive Care Unit in North India. Indian J Crit Care Med 2021; 25:648-654. [PMID: 34316144 PMCID: PMC8286392 DOI: 10.5005/jp-journals-10071-23878] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Whether age would impact the outcomes in subjects with acute respiratory distress syndrome (ARDS) remains unclear. Herein, we study the effect of age as a predictor of mortality in ARDS. MATERIALS AND METHODS We categorized consecutive subjects with ARDS as either ARDSelderly (age >65 years) or ARDSnonelderly (age ≤65 years) admitted to the respiratory intensive care unit (ICU) of a tertiary care hospital in North India between January 2007 and December 2019. We compared the baseline clinical and demographic characteristics, lung mechanics, and mortality between the two groups. We also analyzed the factors predicting ICU survival using multivariate logistic regression analysis. RESULTS We included 625 patients (ARDSelderly, 140 [22.4%] and ARDSnonelderly, 485 [77.6%]) with a mean (standard deviation) age (56.3% males) of 40.6 (17.8) years. The ARDSelderly were more likely (p = 0.0001) to have the presence of any comorbid illness compared to ARDSnonelderly. The elderly subjects had significantly higher pulmonary ARDS than the younger group. The severity of ARDS was however, similarly distributed between the two study arms. There were 224 (35.8%) deaths, and the mortality was significantly higher (p = 0.012) in the ARDSelderly than the to ARDSnonelderly (ARDSelderly vs ARDSnonelderly, 45 vs 33.2%). On multivariate logistic regression analysis, the baseline sequential organ failure assessment scores, presence of pulmonary ARDS, and the development of new organ dysfunction were the independent predictors of mortality. CONCLUSION The outcomes in subjects with ARDS are dependent on the severity of illness at admission and the etiology of ARDS rather than the age alone. HOW TO CITE THIS ARTICLE Sehgal IS, Agarwal R, Dhooria S, Prasad KT, Muthu V, Aggarwal AN. Etiology and Outcomes of ARDS in the Elderly Population in an Intensive Care Unit in North India. Indian J Crit Care Med 2021;25(6):648-654.
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Affiliation(s)
- Inderpaul S Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Kuruswamy T Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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30
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Hirsch KR, Wolfe RR, Ferrando AA. Pre- and Post-Surgical Nutrition for Preservation of Muscle Mass, Strength, and Functionality Following Orthopedic Surgery. Nutrients 2021; 13:nu13051675. [PMID: 34063333 PMCID: PMC8156786 DOI: 10.3390/nu13051675] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 05/12/2021] [Accepted: 05/13/2021] [Indexed: 12/13/2022] Open
Abstract
Nutritional status is a strong predictor of postoperative outcomes and is recognized as an important component of surgical recovery programs. Adequate nutritional consumption is essential for addressing the surgical stress response and mitigating the loss of muscle mass, strength, and functionality. Especially in older patients, inadequate protein can lead to significant muscle atrophy, leading to a loss of independence and increased mortality risk. Current nutritional recommendations for surgery primarily focus on screening and prevention of malnutrition, pre-surgical fasting protocols, and combating post-surgical insulin resistance, while recommendations regarding macronutrient composition and timing around surgery are less established. The goal of this review is to highlight oral nutrition strategies that can be implemented leading up to and following major surgery to minimize atrophy and the resultant loss of functionality. The role of carbohydrate and especially protein/essential amino acids in combating the surgical stress cascade and supporting recovery are discussed. Practical considerations for nutrient timing to maximize oral nutritional intake, especially during the immediate pre- and post- surgical periods, are also be discussed.
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31
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Henrique LR, Crispim D, Vieceli T, Schaeffer AF, Bellaver P, Leitão CB, Rech TH. Copeptin and stress-induced hyperglycemia in critically ill patients: A prospective study. PLoS One 2021; 16:e0250035. [PMID: 33882083 PMCID: PMC8059855 DOI: 10.1371/journal.pone.0250035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 03/29/2021] [Indexed: 11/18/2022] Open
Abstract
Objectives Copeptin, an equimolar indicator of serum antidiuretic hormone levels, has been associated with higher mortality in critically ill patients and with the development of diabetes in the general population. The aim of the present study was to investigate the association of copeptin levels with glycemic parameters in critically ill patients and to compare the time-course of copeptin in survivors and non-survivors. Design Prospective cohort study. Patients From June to October 2019, critically ill patients were prospectively enrolled and followed for 90 days. Measurements Plasma copeptin levels were determined at intensive care unit (ICU) admission (copeptin T1), 24 h (copeptin T2), and 48 h (copeptin T3) after study entry. Blood glucose and glycated hemoglobin levels were measured. ICU, in-hospital, and 90-day mortality, and length of stay in the ICU and hospital were evaluated. Results 104 patients were included. No significant correlation was detected between copeptin levels and blood glucose (r = -0.17, p = 0.09), HbA1c (r = 0.01, p = 0.9), glycemic gap (r = -0.16, p = 0.11), and stress hyperglycemia ratio (r = -0.14, p = 0.16). Copeptin T3 levels were significantly higher in survivors than in non-survivors at hospital discharge (561 [370–856] vs 300 [231–693] pg/mL, p = 0.015) and at 90 days (571 [380–884] vs 300 [232–698] pg/mL, p = 0.03). Conclusions No significant correlations were found between copeptin levels and glycemic parameters, suggesting that copeptin is not a relevant factor in the induction of hyperglycemia during critical illness. Copeptin levels at ICU day 3 were higher in survivors than in non-survivors.
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Affiliation(s)
- Lilian Rodrigues Henrique
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Daisy Crispim
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tarsila Vieceli
- Internal Medicine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Ariell Freires Schaeffer
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Priscila Bellaver
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
| | - Cristiane Bauermann Leitão
- School of Medicine, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Endocrine Division, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
| | - Tatiana Helena Rech
- Post-Graduate Program in Medical Sciences: Endocrinology, Universidade Federal do Rio Grande do Sul, Porto Alegre, Rio Grande do Sul, Brazil
- Intensive Care Unit, Hospital de Clínicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil
- * E-mail:
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Chase JG, Shaw GM, Preiser JC, Knopp JL, Desaive T. Risk-Based Care: Let's Think Outside the Box. Front Med (Lausanne) 2021; 8:535244. [PMID: 33718394 PMCID: PMC7947294 DOI: 10.3389/fmed.2021.535244] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 01/22/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- James Geoffrey Chase
- Centre for Bioengineering, Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Geoffrey M Shaw
- Department of Intensive Care, Christchurch Hospital, University of Otago Christchurch School of Medicine, Christchurch, New Zealand
| | | | - Jennifer L Knopp
- Centre for Bioengineering, Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Thomas Desaive
- GIGA In Silico Medicine, University of Liege, Liege, Belgium
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Wang W, Chen W, Liu Y, Li L, Li S, Tan J, Sun X. Blood Glucose Levels and Mortality in Patients With Sepsis: Dose-Response Analysis of Observational Studies. J Intensive Care Med 2021; 36:182-190. [PMID: 31746263 DOI: 10.1177/0885066619889322] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND We undertook a systematic review and meta-analysis to investigate the relationship between blood glucose levels and mortality in patients with sepsis. METHODS Medline and EMBASE were searched from inception to April 8, 2018. Cohort studies or case-control studies reported the association between blood glucose and mortality in patients with sepsis were selected. Study characteristics, baseline characteristics, definition of hyperglycemia, and outcomes of interest were extracted. We performed a dose-response meta-analysis to assess the effect of blood glucose level on mortality. We also conducted meta-analysis for patients with or without diabetes separately. RESULTS Ten cohort studies involving 26 429 patients were included, of which 5 were prospective studies and 5 retrospective studies. Dose-response analysis showed that the effect of blood glucose on mortality may differ in patients with versus without diabetes. There was a U-shaped relationship for patients with diabetes and a J-shaped relationship for patients without diabetes, with blood glucose at 145 to 155 mg/dL corresponding to lowest mortality both in patients with and without diabetes. CONCLUSIONS Current evidence suggested U-shaped relationship between blood glucose and mortality in all patients irrespective of their diabetes status. Diabetic patients with blood glucose below 145 mg/dL may have poorer prognosis compared to patients without established diabetes.
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Affiliation(s)
- Wen Wang
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Wenwen Chen
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Yanmei Liu
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Ling Li
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Sheyu Li
- Department of Endocrinology and Metabolism, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Jing Tan
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
| | - Xin Sun
- Chinese Evidence-Based Medicine Centre and CREAT Group, West China Hospital, 12530Sichuan University, Chengdu, China
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Knopp JL, Chase JG, Shaw GM. Increased insulin resistance in intensive care: longitudinal retrospective analysis of glycaemic control patients in a New Zealand ICU. Ther Adv Endocrinol Metab 2021; 12:20420188211012144. [PMID: 34123348 PMCID: PMC8173630 DOI: 10.1177/20420188211012144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 04/02/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Critical care populations experience demographic shifts in response to trends in population and healthcare, with increasing severity and/or complexity of illness a common observation worldwide. Inflammation in critical illness impacts glucose-insulin metabolism, and hyperglycaemia is associated with mortality and morbidity. This study examines longitudinal trends in insulin sensitivity across almost a decade of glycaemic control in a single unit. METHODS A clinically validated model of glucose-insulin dynamics is used to assess hour-hour insulin sensitivity over the first 72 h of insulin therapy. Insulin sensitivity and its hour-hour percent variability are examined over 8 calendar years alongside severity scores and diagnostics. RESULTS Insulin sensitivity was found to decrease by 50-55% from 2011 to 2015, and remain low from 2015 to 2018, with no concomitant trends in age, severity scores or risk of death, or diagnostic category. Insulin sensitivity variability was found to remain largely unchanged year to year and was clinically equivalent (95% confidence interval) at the median and interquartile range. Insulin resistance was associated with greater incidence of high insulin doses in the effect saturation range (6-8 U/h), with the 75th percentile of hourly insulin doses rising from 4-4.5 U/h in 2011-2014 to 6 U/h in 2015-2018. CONCLUSIONS Increasing insulin resistance was observed alongside no change in insulin sensitivity variability, implying greater insulin needs but equivalent (variability) challenge to glycaemic control. Increasing insulin resistance may imply greater inflammation and severity of illness not captured by existing severity scores. Insulin resistance reduces glucose tolerance, and can cause greater incidence of insulin saturation and resultant hyperglycaemia. Overall, these results have significant clinical implications for glycaemic control and nutrition management.
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Affiliation(s)
| | - J. Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Geoffrey M. Shaw
- Department of Intensive Care, Christchurch Hospital, Christchurch, New Zealand
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Scheen M, Giraud R, Bendjelid K. Stress hyperglycemia, cardiac glucotoxicity, and critically ill patient outcomes current clinical and pathophysiological evidence. Physiol Rep 2021; 9:e14713. [PMID: 33463901 PMCID: PMC7814494 DOI: 10.14814/phy2.14713] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 01/07/2023] Open
Abstract
Stress hyperglycemia is a transient increase in blood glucose during acute physiological stress in the absence of glucose homeostasis dysfunction. Its's presence has been described in critically ill patients who are subject to many physiological insults. In this regard, hyperglycemia and impaired glucose tolerance are also frequent in patients who are admitted to the intensive care unit for heart failure and cardiogenic shock. The hyperglycemia observed at the beginning of these cardiac disorders appears to be related to a variety of stress mechanisms. The release of major stress and steroid hormones, catecholamine overload, and glucagon all participate in generating a state of insulin resistance with increased hepatic glucose output and glycogen breakdown. In fact, the observed pathophysiological response, which appears to regulate a stress situation, is harmful because it induces mitochondrial impairment, oxidative stress-related injury to cells, endothelial damage, and dysfunction of several cellular channels. Paradigms are now being challenged by growing evidence of a phenomenon called glucotoxicity, providing an explanation for the benefits of lowering glucose levels with insulin therapy in these patients. In the present review, the authors present the data published on cardiac glucotoxicity and discuss the benefits of lowering plasma glucose to improve heart function and to positively affect the course of critical illness.
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Affiliation(s)
- Marc Scheen
- Intensive Care DivisionUniversity HospitalsGenevaSwitzerland
- Geneva Hemodynamic Research GroupGenevaSwitzerland
- Faculty of MedicineGenevaSwitzerland
| | - Raphael Giraud
- Intensive Care DivisionUniversity HospitalsGenevaSwitzerland
- Geneva Hemodynamic Research GroupGenevaSwitzerland
- Faculty of MedicineGenevaSwitzerland
| | - Karim Bendjelid
- Intensive Care DivisionUniversity HospitalsGenevaSwitzerland
- Geneva Hemodynamic Research GroupGenevaSwitzerland
- Faculty of MedicineGenevaSwitzerland
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Qian J, Kuang L, Che L, Chen F, Liu X. Maximum blood glucose levels during hospitalisation to predict mortality in patients with acute coronary syndrome: a retrospective cohort study. BMJ Open 2020; 10:e042316. [PMID: 33310809 PMCID: PMC7735113 DOI: 10.1136/bmjopen-2020-042316] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
OBJECTIVE The aim in this study was to stratify maximum blood glucose levels to identify the the best cut-off value of glucose levels to predict mortality in acute coronary syndrome (ACS) patients, regardless of whether they had diabetes. DESIGN A retrospective cohort study. SETTING All clinical data were obtained from the 'Medical Information Mart for Intensive Care III' database. PARTICIPANTS A total of 3078 patients with ACS were included in the study. We divided the patients into four levels based on their maximum blood glucose levels (glucosemax), then analysed the relationship between each group with mortality. RESULTS Among enrolled patients, 2780 and 298 were survivors and non-survivors, respectively. Blood glucose levels and mortality showed a 'tick' type relationship, with levels 3 and 4 found to be closely associated with increased hospital mortality (p<0.05), relative to level 1 (<6.1 mmol/L), used as the reference group. No significant association was observed in mortality between level 2 and level 1 (p=0.095). In addition, we found a gradual increase in OR for level 2 (OR: 2.42, 95% CI 0.86 to 6.80, p=0.095), level 3 (OR: 4.33, 95% CI 1.55 to 12.13, p=0.005) and level 4 (OR: 7.27, 95% CI 2.56 to 20.62, p<0.001), relative to level 1. Based on receiver operating characteristic curves, the optimal cut-off value for predicting mortality were 11.5 (area under curve (AUC)=0.724), 11.2 (AUC=0.729), 13.4 (AUC=0.638), 15.8 (AUC=0.717) and 11.3 mmol/L (AUC=0.764) in all ACS, acute myocardial infarction, unstable angina, diabetes and non-diabetes patients, respectively. The results of subgroup analysis suggested that in patients with significantly elevated blood glucose, the mortality of non-diabetes was higher than patients with diabetes (OR: 0.42, 95% CI 0.31 to 0.57, p<0.001). CONCLUSION Overall, glucosemax ≥11.5 mmol/L had a significant association with increased mortality in patients with ACS. Non-diabetes ACS patients need a more robust blood glucose management strategy compared with diabetes counterparts.
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Affiliation(s)
- Jun Qian
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lijun Kuang
- Department of Ultrasound, Luwan Branch, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lin Che
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Fei Chen
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xuebo Liu
- Department of Cardiology, Shanghai Tongji Hospital, Tongji University School of Medicine, Shanghai, China
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Idrovo JP, Shults JA, Curtis BJ, Chen MM, Kovacs EJ. Alcohol Intoxication and the Postburn Gastrointestinal Hormonal Response. J Burn Care Res 2020; 40:785-791. [PMID: 31102437 DOI: 10.1093/jbcr/irz083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Gastrointestinal hormones are essential in postburn metabolism. Since near 50% of burn victims test positive for blood alcohol levels at hospital admission and have inferior outcomes compared to nonintoxicated burn patients; we hypothesized that the gastrointestinal hormone secretion is compromised in intoxicated burn victims. To test our theory, we quantified gastrointestinal hormones serum levels in a combine ethanol intoxication and burn injury mouse model. Thus, mice received a daily dose of ethanol for 3 days, rested 4 days, and were given ethanol 3 additional days. Mice underwent 15% TBSA scald burn 30 minutes after their last ethanol dose. Serum samples were collected 24 hours after burn injury. Nonintoxicated burned mice exhibited an increase in glucose, insulin, ghrelin, plasminogen activator inhibitor-1, leptin, and resistin by 1.4-, 3-, 13.5-, 6.2-, 9.4-, and 2.4-fold, respectively, compared to sham vehicle mice (P < .05). Burn injury also reduced serum gastric inhibitory polypeptide (GIP) by 32% compared to sham-injured, vehicle-treated mice. Leptin, resistin, glucagon-like peptide-1, as well as insulin, were not different from sham groups when intoxication preceded burn injury. Nevertheless, in burned mice treated with ethanol, gastric inhibitory polypeptide and glucagon serum levels exhibited a significant fold increase of 3.5 and 4.7, respectively. With these results, we conclude that 24 hours after burn injury, mice developed significant changes in gastrointestinal hormones, along with hyperglycemia. Moreover, the combined insult of burn and ethanol intoxication led to additional hormonal changes that may be attributed to a potential pancreatic dysfunction. Further multiday studies are required to investigate the etiology, behavior, and clinical significance of these hormonal changes.
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Affiliation(s)
- Juan-Pablo Idrovo
- Division of GI, Trauma and Endocrine Surgery, Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado, Denver, Aurora, Colorado
| | - Jill A Shults
- Department of Surgery, Alcohol Research Program, Loyola University Chicago, Maywood, Illinois
| | - Brenda J Curtis
- Division of GI, Trauma and Endocrine Surgery, Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado, Denver, Aurora, Colorado
| | - Michael M Chen
- Department of Surgery, Loyola University Chicago, Maywood, Illinois
| | - Elizabeth J Kovacs
- Division of GI, Trauma and Endocrine Surgery, Department of Surgery, Burn Research and Alcohol Research Programs, University of Colorado, Denver, Aurora, Colorado
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Comparison of the Effect of Enteral Feeding through the Bolus and Continuous Methods on Serum Phosphorus and Glucose Levels in Patients with Mechanical Ventilation: A Randomized Clinical Trial. J Nutr Metab 2020; 2020:6428418. [PMID: 33005454 PMCID: PMC7508222 DOI: 10.1155/2020/6428418] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 08/01/2020] [Accepted: 08/28/2020] [Indexed: 01/20/2023] Open
Abstract
Introduction Patients who are under mechanical ventilation in intensive care units need to have nutritional support. Also, feeding methods affect serum phosphorus and glucose levels, which are very important in weaning patients off the ventilator. Thus, this study is to compare the effects of both bolus and continuous enteral feeding methods on serum phosphorus and glucose levels in patients with mechanical ventilation. Methods In this clinical trial study, 34 patients in the intensive care unit of Imam Khomeini Hospital affiliated to the Tehran University of Medical Sciences satisfied inclusion criteria and were randomly divided into control and intervention groups. Sampling was done between October and February 2018. The intervention group received continuous enteral feeding for one week, and the control group received nutrition by the bolus method. The blood glucose level was measured every six hours, and the serum phosphorus level was recorded at the beginning and the end of the intervention, based on the data entry form with respect to all ethical considerations. Data analysis was done by SPSS-20 software. Results The serum phosphorus level was significantly increased in the intervention group (P=0.004) and in the control group (P < 0.001) and was compared with the previous intervention. No significant difference was found between the intervention and control groups before and after the intervention (P=0.22) and also one week after the intervention (P=0.14). There was also no significant difference between the glucose levels from day 1 to day 7 in the control group (P=0.33) and the intervention group (P=0.086). Discussion. Nutritional support in both bolus and continuous methods increased the serum phosphorus level. It indicates the importance of the nutritional method in controlling the phosphorus level in critically ill patients. However, there was no difference between the effects of dietary methods on blood glucose control.
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Papadokostaki E, Tentolouris N, Liberopoulos E. COVID-19 and diabetes: What does the clinician need to know? Prim Care Diabetes 2020; 14:558-563. [PMID: 32654982 PMCID: PMC7332931 DOI: 10.1016/j.pcd.2020.06.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/29/2020] [Indexed: 01/08/2023]
Abstract
COVID-19 and diabetes are currently two global pandemics. Epidemiological studies indicate that diabetes is the second most common comorbidity in COVID-19. This review aims to summarize currently available data about prevalence, possible pathophysiological mechanisms and management of patients with diabetes and COVID-19.
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Affiliation(s)
- Eleni Papadokostaki
- Department of Medicine, General Hospital of Heraklion Venizeleio-Pananeio, Heraklion, 71409, Greece
| | - Nikolaos Tentolouris
- Diabetes Center, First Department of Propaedeutic Internal Medicine, Medical School, National and Kapodistrian University of Athens, Laiko General Hospital, Athens, Greece
| | - Evangelos Liberopoulos
- Department of Medicine, Faculty of Medicine, University of Ioannina, Ioannina, 45110, Greece.
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Rabizadeh S, Tavakoli Ardakani MA, Mouodi M, Bitaraf M, Shab-Bidar S, Esteghamati A, Nakhjavani M. DPP4 Inhibitors in the Management of Hospitalized Patients With Type 2 Diabetes: A Systematic Review and Meta-Analysis of Randomized Clinical Trials. Adv Ther 2020; 37:3660-3675. [PMID: 32671686 DOI: 10.1007/s12325-020-01434-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Indexed: 12/12/2022]
Abstract
INTRODUCTION We studied the effects of dipeptidyl peptidase 4 (DPP4) inhibitors on glycemic control in non-critically ill patients admitted to hospital. METHODS We searched MEDLINE and EMBASE for published studies in English up to July 2019. We included randomized clinical trials (RCTs) that compared DPP4 inhibitors plus insulin supplementation versus basal-bolus insulin regimen in the management of hyperglycemia non-critically ill patients with type 2 diabetes admitted to hospital. Mean difference (MD), relative risk (RR), and 95% confidence intervals (CI) were generated to interpret the data. RESULTS Of 401 papers, four RCTs including 648 participants met inclusion criteria. There was no significant difference in mean daily blood glucose level between the two groups (MD 4.63; 95% CI = - 1.57, 10.83; p = 0.14) (I2 = 14%, p = 0.32). Total insulin dose per day was lower in patients receiving DPP4 inhibitors (MD - 14.27; CI = - 22.47, - 6.07; p = 0.001) (I2 = 92%, p = 0.001). Also, the number of insulin injection was significantly lower in patients receiving DPP4 inhibitors (MD - 0.79; CI = - 1.01, - 0.57; p = 0.001) (I2 = 0%, p = 0.68). The rate of hypoglycemia was not significantly different between the two groups (RR 0.60, CI = 0.34, 1.074; p = 0.08) (I2 = 37.3%, p = 0.18). Treatment failure was not significantly different between the two groups (RR 0.87, CI = 0.64, 4.8; p = 0.38) (I2 = 49%, p = 0.11). CONCLUSION The results indicate that using DPP4 inhibitors plus basal or supplemental insulin in hospitalized patients is non-inferior to a standard basal-bolus insulin regimen and leads to a lower amount of insulin use and a lower rate of insulin injection. Limitations of this study were heterogeneity of baseline characteristics of included patients, small sample size, short duration, and non-uniformly defined outcome assessment parameters in the included studies.
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Lorenzo-González C, Atienza-Sánchez E, Reyes-Umpierrez D, Vellanki P, Davis GM, Pasquel FJ, Cardona S, Fayfman M, Peng L, Umpierrez GE. Safety And Efficacy Of Dpp-4 Inhibitors For The Management Of Hospitalized General Medicine And Surgery Patients with Type 2 Diabetes. Endocr Pract 2020; 26:722-728. [PMID: 33471640 PMCID: PMC11305855 DOI: 10.4158/ep-2019-0481] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 02/09/2020] [Indexed: 01/12/2023]
Abstract
OBJECTIVE DPP-4 inhibitors (DPP-4i) have been shown to be effective for the management of inpatient diabetes. We report pooled data from 3 prospective studies using DPP-4i in general medicine and surgery patients with type 2 diabetes (T2D). METHODS We combined data from 3 randomized studies comparing DPP-4i alone or in combination with basal insulin or a basal-bolus insulin regimen. Medicine (n = 266) and surgery (n = 319) patients admitted with a blood glucose (BG) between 140 and 400 mg/dL, treated with diet, oral agents, or low-dose insulin therapy were included. Patients received DPP-4i alone (n = 144), DPP-4i plus basal insulin (n = 158) or basal-bolus regimen (n = 283). All groups received correctional doses with rapid-acting insulin for BG >140 mg/dL. The primary endpoint was differences in mean daily BG between groups. Secondary endpoints included differences in hypoglycemia and hospital complications. RESULTS There were no differences in mean hospital daily BG among patients treated with DPP-4i alone (170 ± 37 mg/dL), DPP-4i plus basal (172 ± 42 mg/dL), or basalbolus (172 ± 43 mg/dL), P = .94; or in the percentage of BG readings within target of 70 to 180 mg/dL (63 ± 32%, 60 ± 31%, and 64 ± 28%, respectively; P = .42). There were no differences in length of stay or complications, but hypoglycemia was less common with DPP-4i alone (2%) compared to DPP-4i plus basal (9%) and basal-bolus (10%); P = .004. CONCLUSION Treatment with DPP-4i alone or in combination with basal insulin is effective and results in a lower incidence of hypoglycemia compared to a basal-bolus insulin regimen in general medicine and surgery patients with T2D. ABBREVIATIONS BG = blood glucose; BMI = body mass index; CI = confidence interval; DPP-4i = dipeptidyl peptidase-4 inhibitors; HbA1c = hemoglobin A1c; OR = odds ratio; T2D = type 2 diabetes.
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Affiliation(s)
- Cristina Lorenzo-González
- Department of Endocrinology and Nutrition, Hospital Universitario Nuestra Señora de La Candelaria, Tenerife, Spain
| | - Elena Atienza-Sánchez
- Department of Endocrinology and Nutrition, Hospital Universitario Príncipe de Asturias, Madrid, Spain
| | | | | | | | | | | | - Maya Fayfman
- Department of Medicine, Emory University School of Medicine
| | - Limin Peng
- School of Public Health, Emory University, Atlanta, Georgia
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Pasquel FJ, Lansang MC, Khowaja A, Urrutia MA, Cardona S, Albury B, Galindo RJ, Fayfman M, Davis G, Migdal A, Vellanki P, Peng L, Umpierrez GE. A Randomized Controlled Trial Comparing Glargine U300 and Glargine U100 for the Inpatient Management of Medicine and Surgery Patients With Type 2 Diabetes: Glargine U300 Hospital Trial. Diabetes Care 2020; 43:1242-1248. [PMID: 32273271 PMCID: PMC7411278 DOI: 10.2337/dc19-1940] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/20/2020] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The role of U300 glargine insulin for the inpatient management of type 2 diabetes (T2D) has not been determined. We compared the safety and efficacy of glargine U300 versus glargine U100 in noncritically ill patients with T2D. RESEARCH DESIGN AND METHODS This prospective, open-label, randomized clinical trial included 176 patients with poorly controlled T2D (admission blood glucose [BG] 228 ± 82 mg/dL and HbA1c 9.5 ± 2.2%), treated with oral agents or insulin before admission. Patients were treated with a basal-bolus regimen with glargine U300 (n = 92) or glargine U100 (n = 84) and glulisine before meals. We adjusted insulin daily to a target BG of 70-180 mg/dL. The primary end point was noninferiority in the mean difference in daily BG between groups. The major safety outcome was the occurrence of hypoglycemia. RESULTS There were no differences between glargine U300 and U100 in mean daily BG (186 ± 40 vs. 184 ± 46 mg/dL, P = 0.62), percentage of readings within target BG of 70-180 mg/dL (50 ± 27% vs. 55 ± 29%, P = 0.3), length of stay (median [IQR] 6.0 [4.0, 8.0] vs. 4.0 [3.0, 7.0] days, P = 0.06), hospital complications (6.5% vs. 11%, P = 0.42), or insulin total daily dose (0.43 ± 0.21 vs. 0.42 ± 0.20 units/kg/day, P = 0.74). There were no differences in the proportion of patients with BG <70 mg/dL (8.7% vs. 9.5%, P > 0.99), but glargine U300 resulted in significantly lower rates of clinically significant hypoglycemia (<54 mg/dL) compared with glargine U100 (0% vs. 6.0%, P = 0.023). CONCLUSIONS Hospital treatment with glargine U300 resulted in similar glycemic control compared with glargine U100 and may be associated with a lower incidence of clinically significant hypoglycemia.
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Affiliation(s)
| | | | - Ameer Khowaja
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | | | | | | | | | - Maya Fayfman
- Emory University School of Medicine, Atlanta, GA
| | | | | | | | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, GA
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Davidson SM, Uyttendaele V, Pretty CG, Knopp JL, Desaive T, Chase JG. Virtual patient trials of a multi-input stochastic model for tight glycaemic control using insulin sensitivity and blood glucose data. Biomed Signal Process Control 2020. [DOI: 10.1016/j.bspc.2020.101896] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Abstract
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.
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Seuradge C, Chen D, Hariharan S. Glycaemic Control in Critically Ill Adult Patients: Is intensive insulin therapy beneficial? CARIBBEAN MEDICAL JOURNAL 2020. [DOI: 10.48107/cmj.2020.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES
Glycaemic control with intensive insulin therapy and its impact on patient outcomes have always been contentious in an intensive care setting. This study aims to assess the patterns of glycaemic control in critically ill patients at a tertiary care institution in Trinidad and its relationship to outcomes.
METHODS
All adult patients admitted to a multidisciplinary intensive care unit (ICU) for a period of two years were enrolled for a retrospective chart review. Data collected included demographics, admission blood glucose, mean morning blood glucose (MBG), the trend of glucose control, number of hypoglycaemic episodes, admission Simplified Acute Physiology Score (SAPS) II, ICU and hospital length of stay, duration of mechanical ventilation, anaemia, renal replacement therapy and hospital outcome.
RESULTS
A total of 104 patients were studied. Four different patterns of insulin therapy were practised at the ICU. The median age of patients was 55.5 years, the mean SAPS II was 49.3, the mean predicted mortality was 45.5% and the overall observed mortality was 38.5%. The majority of admissions had cardiovascular illnesses (25%), followed by sepsis (20.2%). Patients with multiple hypoglycaemic episodes had an increased mortality (p<0.01). Patients had a better outcome with a higher MBG (>100 mg/dL) (p<0.05). There was a significant difference in mortality among the four patterns of glycaemic control (p<0.001). Admission blood glucose, length of time of mechanical ventilation, ICU length of stay and renal replacement therapy were not found to be associated with adverse outcomes.
CONCLUSION
Intensive insulin therapy (IIT) may not benefit ICU patients but can be probably associated with higher mortality. Avoidance of hypoglycaemia as well as persistent hyperglycaemia may lead to a better outcome in critically ill patients.
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Affiliation(s)
- Crystal Seuradge
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St Augustine Campus, Eric Williams Medical Sciences Complex, Trinidad and Tobago
| | - Deryk Chen
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St Augustine Campus, Eric Williams Medical Sciences Complex, Trinidad and Tobago
| | - Seetharaman Hariharan
- Anaesthesia and Intensive Care Unit, The University of the West Indies, St Augustine Campus, Eric Williams Medical Sciences Complex, Trinidad and Tobago
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Canbolat O, Kapucu S, Kilickaya O. Comparison of Routine and Computer-Guided Glucose Management for Glycemic Control in Critically Ill Patients. Crit Care Nurse 2020; 39:20-27. [PMID: 31371364 DOI: 10.4037/ccn2019431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Glycemic control is crucial for reducing morbidity and mortality in critically ill patients. A standardized approach to glycemic control using a computer-guided protocol may help maintain blood glucose level within a target range and prevent human-induced medical errors. OBJECTIVE To determine the effectiveness of a computer-guided glucose management protocol for glycemic control in intensive care patients. METHODS This controlled, open-label implementation study involved 66 intensive care patients: 33 in the intervention group and 33 in the control group. The blood glucose level target range was established as 120 to 180 mg/dL. The control group received the clinic's routine glycemic monitoring approach, and the intervention group received monitoring using newly developed glycemic control software. At the end of the study, nurse perceptions and satisfaction were determined using a questionnaire. RESULTS The rates of hyperglycemia and hypoglycemia were lower and the blood glucose level was more successfully maintained in the target range in the intervention group than in the control group (P < .001). The time to achieve the target range was shorter and less insulin was used in the intervention group than in the control group (P < .05). Nurses reported higher levels of satisfaction with the computerized protocol, which they found to be more effective and reliable than routine clinical practice. CONCLUSIONS The computerized protocol was more effective than routine clinical practice in achieving glycemic control. It was also associated with higher nurse satisfaction levels.
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Affiliation(s)
- Ozlem Canbolat
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey.
| | - Sevgisun Kapucu
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey
| | - Oguz Kilickaya
- Ozlem Canbolat is an assistant professor, Faculty of Nursing, Necmettin Erbakan University, Selçuklu, Konya, Turkey. Sevgisun Kapucu is a professor, Faculty of Nursing, Hacettepe University, Ankara, Turkey. Oguz Kilickaya is an associate professor, Bahcelievler Medical Park Hospital, Istanbul, Turkey
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Yusuff OT, Kolawole BA, Ikem RT, Soyoye DO, Amjo OO. Cardiovascular Risk Indices and Their Impact on Outcome in Patients with Hyperglycaemic Emergencies in a Nigerian Hospital. J Natl Med Assoc 2020; 112:28-35. [PMID: 31973880 DOI: 10.1016/j.jnma.2019.12.004] [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: 09/18/2019] [Revised: 12/14/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND High sensitivity C-reactive protein (hsCRP) and Plasminogen Activator Inhibitor-1 (PAI-1) are recognised independent novel risk factors for cardiovascular disease. Few studies have assessed cardiovascular risk factors in patients with hyperglycaemic emergencies (HE), despite it being a major cause of death in diabetics. OBJECTIVE The objective of this study was to determine cardiovascular risk indices in patients with hyperglycaemic emergencies and related these with outcome. METHODS This cross sectional study involved 45 patients that presented with HE and 45 age and sex matched diabetics without HE who served as controls. Historical features, physical findings and laboratory parameters including hsCRP and PAI-1 were compared between subjects and controls. RESULTS The mean values of serum hsCRP and PAI-1 were significantly higher in patients with HE compared to diabetic control. (49.52 ± 13.6 vs. 2.4 ± 1.35, 51.2 ± 28.7 vs. 33.2 ± 10.7 respectively). Traditional cardiovascular risk factors such as HbA1c, Atherogenic Index and microalbuminuria were also significantly higher in them. Mortality was associated with increasing age, higher values of waist circumference, pulse rate, respiratory rate, hsCRP, Atherogenic index and lower blood pressure and HDL values. CONCLUSION Cardiovascular risk indices are higher in patients with HE.
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Affiliation(s)
- Olaoluwatomi T Yusuff
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria.
| | - Babatope A Kolawole
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Rosemary T Ikem
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - David O Soyoye
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
| | - Oluwadamilola O Amjo
- Department of Medicine, Obafemi Awolowo University Teaching Hospital, Ile Ife, Nigeria
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Davidson S, Pretty C, Uyttendaele V, Knopp J, Desaive T, Chase JG. Multi-input stochastic prediction of insulin sensitivity for tight glycaemic control using insulin sensitivity and blood glucose data. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2019; 182:105043. [PMID: 31470221 DOI: 10.1016/j.cmpb.2019.105043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 07/28/2019] [Accepted: 08/20/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Glycaemic control in the intensive care unit is dependent on effective prediction of patient insulin sensitivity (SI). The stochastic targeted (STAR) controller uses a 2D stochastic model for prediction, with current SI as an input and future SI as an output. METHODS This paper develops an extension of the STAR 2D stochastic model into 3D by adding blood glucose (G) as an input. The performance of the 2D and 3D stochastic models is compared over a retrospective cohort of 65,269 data points across 1525 patients. RESULTS Under five-fold cross-validation, the 3D model was found to better match the expected potion of data points within, above and below various credible intervals, suggesting it provided a better representation of the underlying probability field. The 3D model was also found to provide an 18.1% narrower 90% credible interval on average, and a narrower 90% credible interval in 96.4% of cases, suggesting it provided more accurate predictions of future SI. Additionally, the 3D stochastic model was found to avoid the undesirable tendency of the 2D model to overestimate SI for patients with high G, and underestimate SI for patients with low G. CONCLUSIONS Overall, the 3D stochastic model is shown to provide clear potential benefits over the 2D model for minimal clinical cost or effort, though further exploration into whether these improvements in SI prediction translate into improved clinical outcomes is required.
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Affiliation(s)
- Shaun Davidson
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand.
| | - Chris Pretty
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand
| | | | - Jennifer Knopp
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand
| | - Thomas Desaive
- GIGA-Cardiovascular Sciences, University of Liège, Liège, Belgium
| | - J Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, 20 Kirkwood Ave, Upper Riccarton, Christchurch 8041, New Zealand
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Mustafa OG, Whyte MB. The use of GLP-1 receptor agonists in hospitalised patients: An untapped potential. Diabetes Metab Res Rev 2019; 35:e3191. [PMID: 31141838 PMCID: PMC6899667 DOI: 10.1002/dmrr.3191] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Revised: 04/25/2019] [Accepted: 04/30/2019] [Indexed: 12/15/2022]
Abstract
In the outpatient setting, glucagon-like peptide-1 (GLP-1) receptor agonists have proved to be highly efficacious drugs that provide glycaemic control with a low risk of hypoglycaemia. These characteristics make GLP-1 receptor agonists attractive agents to treat dysglycaemia in perioperative or high-dependency hospital settings, where glycaemic variability and hyperglycaemia are associated with poor prognosis. GLP-1 also has a direct action on the myocardium and vasculature-which may be advantageous in the immediate aftermath of a vascular insult. This is a narrative review of the work in this area. The aim was to determine the populations of hospitalised patients being evaluated and the clinical and mechanistic end-points tested, with the institution of GLP-1 therapy in hospital. We searched the PubMed, Embase, and Google scholar databases, combining the term "glucagon-like peptide 1" OR "GLP-1" OR "incretin" OR "liraglutide" OR "exenatide" OR "lixisenatide" OR "dulaglutide" OR "albiglutide" AND "inpatient" OR "hospital" OR "perioperative" OR "postoperative" OR "surgery" OR "myocardial infarction" OR "stroke" OR "cerebrovascular disease" OR "transient ischaemic attack" OR "ICU" OR "critical care" OR "critical illness" OR "CCU" OR "coronary care unit." Pilot studies were reported in the fields of acute stroke, cardiac resuscitation, coronary care, and perioperative care that showed advantages for GLP-1 therapy, with normalisation of glucose, lower glucose variability, and lower risk of hypoglycaemia. Animal and human studies have reported improvements in myocardial performance when given acutely after vascular insult or surgery, but these have yet to be translated into randomised clinical trials.
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Affiliation(s)
- Omar G. Mustafa
- Department of DiabetesKing's College Hospital NHS Foundation TrustLondonUK
| | - Martin B. Whyte
- Department of DiabetesKing's College Hospital NHS Foundation TrustLondonUK
- Department of Clinical and Experimental MedicineUniversity of SurreyGuildfordUK
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50
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Yu G, Kim YJ, Lee SH, Ryoo SM, Kim WY. Optimal Hemodynamic Parameter to Predict the Neurological Outcome in Out-of-Hospital Cardiac Arrest Survivors Treated with Target Temperature Management. Ther Hypothermia Temp Manag 2019; 10:211-219. [PMID: 31633449 DOI: 10.1089/ther.2019.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Current guidelines suggest the maintenance of systolic blood pressure (SBP) at >90 mmHg and mean arterial pressure (MAP) at >65 mmHg in postcardiac arrest patients. There remains a lack of clarity regarding optimal values and timing of blood pressure parameters associated with the improvement of neurologic outcome. We investigated the association of time-weighted average (TWA) blood pressure parameters with favorable neurological outcome (FO) in postcardiac arrest patients. This was a registry-based observational study with consecutive adult out-of-hospital cardiac arrest (OHCA) survivors who were treated using targeted temperature management (TTM). During 72 hours of TTM period, we abstracted hemodynamic parameters such as SBP, diastolic blood pressure, pulse rate (PR), and MAP. Shock index (SI; PR/SBP) and modified shock index (MSI; PR/MAP) were calculated from each measured hemodynamics. Logistic regression was performed to assess the associations between TWA blood pressure parameters and FO, defined as cerebral performance category 1 or 2 at hospital discharge. Among the 173 patients (median age: 58 years; 64% male), 51 (29.3%) had FO in this study. MAP, SI, and MSI at 6 hours after return of spontaneous circulation (ROSC) showed considerable differences in patients with FO (MAP: 89.1 ± 14.7 vs. 83.6 ± 15.8 mmHg, p = 0.033, SI: 0.7 ± 0.2 vs. 0.9 ± 0.9, p = 0.002, MSI: 1.0 ± 0.3 vs. 1.2 ± 0.3, p ≤ 0.001). Among them, MSI, especially at 6 hours, had the highest area under the curve for prediction of FO (0.685; 95% confidence interval: 0.597-0.772, p < 0.001). Also, MSI <1.0 had a sensitivity of 64.7%, a specificity of 64.2% to predict FO. In comatose survivors of OHCA with TTM, MSI at 6 hours after ROSC had the highest prognostic value for neurologic outcome among blood pressure parameters.
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Affiliation(s)
- Gina Yu
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Hun Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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