Time in blood glucose range 70 to 140 mg/dl >80% is strongly associated with increased survival in non-diabetic critically ill adults

Introduction: Hyperglycemia, hypoglycemia and increased glucose variability are independently associated with increased risk of death in critically ill adults. The relationship between time in targeted blood glucose range (TIR) and mortality is not well described and may be a factor that has confounded the results of the major interventional trials of intensive insulin therapy. Methods: We conducted a retrospective analysis of prospectively collected data involving 3,297 patients with intensive care unit (ICU) lengths of stay (LOS) of ≥1.0 day who were admitted between 1 January 2009 and 31 December 2013 to a single mixed medical-surgical ICU. We investigated the relationship between TIR 70 to 140 mg/dl with mortality and compared outcomes of non-diabetics (NON) and individuals with diabetes mellitus (DM), including stratifying by TIR above (TIR-hi) and below (TIR-lo) the median value for the NON and DM groups. Results: There were 85,799 blood glucose (BG) values for the NON group and 32,651 for the DM group, and we found that 75.5% and 54.8%, respectively, were between 70 and 140 (P 80% is strongly associated with survival in critically ill patients without diabetes. These findings have implications for the design of clinical protocols for glycemic control in critically ill patients as well for the design of future interventional trials of intensive insulin therapy.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Safety and efficacy of personalized glycemic control in critically ill patients: A 2-year before and after interventional trial

Objective: To determine the safety and efficacy of a change in blood glucose (BG) control protocol from a single target to 2 targets based on diabetes mellitus (DM) status and glycated hemoglobin A1C (A1C) in a cohort of critically ill patients. Methods: This investigation includes 1,979 patients admitted to a single intensive care unit (ICU) between September 16, 2013 and September 15, 2015. The BG target was 90 to 120 mg/dL in the PRE era and 80 to 140 mg/dL for patients without diabetes (NON) and with DM with A1C <7% and 110 to 160 mg/dL for DM with A1C ≥7% (TIGHT and LOOSE protocols) in the POST era. The primary efficacy outcome was the observed:expected (O:E) mortality ratio. Results: Among NON, the mean BG was slightly lower in the POST era: 118 (106-132) versus 115 (101-120) mg/dL (P =.0003). Among DM, the mean BG was 139 (123-160) mg/dL in the PRE era versus 136 (119-149) and 159 (138-171) mg/dL for TIGHT and LOOSE in the POST era (P =.0668 and.0001, respectively). Overall, 11.0% and 11.8% of patients had at least 1 BG level <70 mg/dL in the 2 eras (P =.68). The O:E mortality ratios for NON and DM for the PRE and POST eras were 0.75 versus 0.74 (P =.51) and 0.69 versus 0.52 (P<.001) respectively, and among DM with A1C ≥7% were 0.74 versus 0.52 (P =.004). Conclusion: This hypothesis-generating investigation suggests the need for additional prospective interventional studies assessing the outcomes of patients randomized to personalized glucose targets.SCOPUS: ar.jinfo:eu-repo/semantics/publishe

Case-control Investigation of Previously Undiagnosed Diabetes in the Critically Ill

Context: The outcome of patients requiring intensive care can be influenced by the presence of previously undiagnosed diabetes (undiagDM). Objective: This work aimed to define the clinical characteristics, glucose control metrics, and outcomes of patients admitted to the intensive care unit (ICU) with undiagDM, and compare these to patients with known DM (DM). Methods: This case-control investigation compared undiagDM (glycated hemoglobin A1c [HbA1c] ≥ 6.5%, no history of diabetes) to patients with DM. Glycemic ratio (GR) was calculated as the quotient of mean ICU blood glucose (BG) and estimated preadmission glycemia, based on HbA1c ([28.7 × HbA1c]-46.7mg/dL). GR was analyzed by bands: less than 0.7, 0.7 to less than or equal to 0.9, 0.9 to less than 1.1, and greater than or equal to 1.1. Risk-adjusted mortality was represented by the Observed:Expected mortality ratio (OEMR), calculated as the quotient of observed mortality and mortality predicted by the severity of illness (APACHE IV prediction of mortality). Results: Of 5567 patients 294 (5.3%) were undiagDM. UndiagDM had lower ICU mean BG (P <. 0001) and coefficient of variation (P <. 0001) but similar rates of hypoglycemia (P =. 08). Mortality and risk-adjusted mortality were similar in patients with GR less than 1.1 comparing undiagDM and DM. However, for patients with GR greater than or equal to 1.1, mortality (38.5% vs 10.3% [P =. 0072]) and risk-adjusted mortality (OEMR 1.18 vs 0.52 [P <. 0001]) were higher in undiagDM than in DM. Conclusion: These data suggest that DM patients may develop tolerance to hyperglycemia that occurs during critical illness, a protective mechanism not observed in undiagDM, for whom hyperglycemia remains strongly associated with higher risk of mortality. These results may shed light on the natural history of diabetes.SCOPUS: ar.jinfo:eu-repo/semantics/publishe