Blood Glucose Variability is Associated with Mortality in the Surgical Intensive Care Unit

Dossett, Lesly A.; Cao, Hanqing; Mowery, Nathan T.; Dortch, Marcus J.; Morris, John; May, Addison K.

doi:10.1177/000313480807400802

Cited by 177 publications

(66 citation statements)

References 21 publications

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“…presence of previous diabetes, of a neurological impairment), to the treatment (amount and route of calories provided) and to the time from injury are not well defined. A number of observational studies confirmed a strong association between severe hyperglycemia (>180 mg/dl, 10 mmol/l) [341], marked glycemic variability (coefficient of variation > 20%) [342,343], mild hypoglycemia (<70 mg/dl, 3.9 mmol/l) [344] and increased mortality. However the prospective trials remain inconclusive, owing to differences in practices and to the difficulties in achieving safe and effective glycemic control.…”

Section: Commentary To Recommendations 53 and 54mentioning

confidence: 99%

ESPEN guideline on clinical nutrition in the intensive care unit

et al. 2019

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s u m m a r yFollowing the new ESPEN Standard Operating Procedures, the previous guidelines to provide best medical nutritional therapy to critically ill patients have been updated. These guidelines define who are the patients at risk, how to assess nutritional status of an ICU patient, how to define the amount of energy to provide, the route to choose and how to adapt according to various clinical conditions. When to start and how to progress in the administration of adequate provision of nutrients is also described. The best determination of amount and nature of carbohydrates, fat and protein are suggested. Special attention is given to glutamine and omega-3 fatty acids. Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy. Monitoring of this nutritional therapy is discussed in a separate document.

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Section: Commentary To Recommendations 53 and 54mentioning

confidence: 99%

ESPEN guideline on clinical nutrition in the intensive care unit

et al. 2019

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“…Increased BG variability was associated with an increased risk of death. 123 This finding was confirmed in a 2012 study where the risk of mortality increased with increased BG variability (adjusted relative risk: 1.61; 95% CI: 1.47-1.78). 125 This demonstrates the importance of minimizing BG variability while on IIT.…”

Section: Risks Of Hypoglycemiamentioning

confidence: 72%

“…Several studies have indicated that BG variability is a significant risk factor for mortality and the development of hypoglycemia in the critically ill population. 70,82,[123][124][125] When looking at surgical ICU patients, Kauffman et al 70 found a patient's BG variability increased in the 24 hours that preceded his or her hypoglycemic event. In another study examining critically ill surgical patients receiving IIT, ICU survivors and nonsurvivors had similar mean BG values over time, but the nonsurvivors had significantly more BG variability (P,0.001).…”

Section: Risks Of Hypoglycemiamentioning

confidence: 99%

Glycemic control in critically ill surgical patients: risks and benefits

Mukherjee¹,

Albaugh²,

Richards³

et al. 2015

OAS

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Glucose metabolism in humans is exceedingly complex. At baseline, it is controlled by elaborate signaling mechanisms, and these mechanisms are profoundly altered by the surge of catecholamines and cytokines associated with acute postsurgical and post-traumatic stress. These alterations in signaling mechanisms result in hyperglycemia; although this hyperglycemia can start very rapidly after the traumatic or surgical insult, it can persist during the entire period of critical illness and even afterward. Numerous randomized clinical trials have been conducted to determine if hyperglycemia is associated with increased mortality in surgical patients. These studies have had different conclusions that are difficult to interpret in light of differences in study methodology, but there is certainly ample evidence that inadequately controlled hyperglycemia causes harm due to increased infectious morbidity, and possibly increased mortality. As we have become more proficient in controlling hyperglycemia, the concept of insulin resistance, determined as the amount of insulin required to achieve hyperglycemia, has come to the fore. Insulin resistance is not a static concept, and may change before significant events such as infection. Patients with elevated and persistent insulin resistance have been demonstrated to suffer increased infectious morbidity and mortality, albeit in nonrandomized studies. Along with insulin resistance, the concept of glycemic variability, the amount of variation in serum blood glucose over time, has also become relevant; increased variability has been associated with hypoglycemia and mortality. Both of these risks can result from aggressive insulin therapy, and glycemic control protocols must be appropriately planned and implemented to avoid hypoglycemia and excessive externally induced variability. Computer-assisted protocols may be of significant benefit in optimizing glycemic control. The most recent recommendations available are to keep serum blood glucose levels below 150 mg/dL and to avoid hypoglycemia.

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“…Poor microand macrovascular status has the potential to adversely affect the prognosis of acute stroke. On the other hand, in at least three retrospective studies, the positive association between GV and increased mortality in ICU patients were shown to be more prominent in non-diabetic patients [15,[37][38][39]. In addition, a similar association was also observed in cases with traumatic brain injury [40].…”

Section: Discussionmentioning

confidence: 89%

Blood glucose variability during the first 24 hours and prognosis in acute stroke patients treated with IV thrombolysis

Pektezel¹,

Yılmaz²,

Arsava³

et al. 2019

TÃ¼rk Beyin Damar Hast Derg

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INTRODUCTION: Hyperglycemia in acute ischemic stroke decreases the effectiveness of intravenous tissue plasminogen activator (IV tPA) and increases its hemorrhagic complications. Therefore, optimization of blood glucose (BG) is suggested. But, no consensus is achieved on which of the BG parameters to be used such as admission BG, post-treatment BG, first day maximum and average BG (maxBG and aveBG), or BG variability indices such as the standard deviation of mean BG (SDBG), coefficient of variation of BG (CVBG) and J-index. METHODS: Admission and 24h BG were measured in 145 acute stroke patients (55% female, age: 70±13 yr; NIHSS: 14 ± 6, symptom-to-needle time: 160 ± 58 minutes) treated with IV tPA. BG variability indices were evaluated in 107 patients with serial BG measurement available. RESULTS: AveBG was significantly higher in patients with 3rd month mRS>2 (46.2%), but admission BG, SDBG, CVBG and J-index were not significantly different. An exploratory regression analysis indicated that the connection of aveBG to worse prognosis (β=-0.155, p=0.045) persisted after adjustment for admission NIHSS, age and DM history. No BG parameter predicted symptomatic tPA-associated type-II intracerebral hemorrhage (6.7%), albeit these patients had marginally higher average BG levels (p=0.045). Presence of diabetes, HbA1c, admission BG, average first day BG and variability indices had not modified the beneficial (52%) and dramatic response (28%) to IV tPA. DISCUSSION and CONCLUSION: Sustained hyperglycemia, not glucose variability, during the first 24 hour predicts poor prognosis in acute stroke patients treated with IV thrombolysis.

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Blood Glucose Variability is Associated with Mortality in the Surgical Intensive Care Unit

Cited by 177 publications

References 21 publications

ESPEN guideline on clinical nutrition in the intensive care unit

ESPEN guideline on clinical nutrition in the intensive care unit

Glycemic control in critically ill surgical patients: risks and benefits

Blood glucose variability during the first 24 hours and prognosis in acute stroke patients treated with IV thrombolysis

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