Higher glycemic variability within the first day of ICU admission is associated with increased 30-day mortality in ICU patients with sepsis

Abstract

Background: High glycemic variability (GV) is common in critically ill patients; however, the prevalence and mortality association with early GV in patients with sepsis remains unclear.Methods: This retrospective cohort study was conducted in a medical intensive care unit (ICU) in central Taiwan. Patients in the ICU with sepsis between January 2014 and December 2015 were included for analysis. All of these patients received protocol-based management, including blood sugar monitoring every 2 h for the first 24 h of ICU admission. Mean amplitude of glycemic excursions (MAGE) and coefficient of variation (CoV) were used to assess GV. Results:A total of 452 patients (mean age 71.4 ± 14.7 years; 76.7% men) were enrolled for analysis. They were divided into high GV (43.4%, 196/452) and low GV (56.6%, 256/512) groups using MAGE 65 mg/dL as the cut-off point. Patients with high GV tended to have higher HbA1c (6.7 ± 1.8% vs. 5.9 ± 0.9%, p < 0.01) and were more likely to have diabetes mellitus (DM) (50.0% vs. 23.4%, p < 0.01) compared with those in the low GV group. Kaplan-Meier analysis showed that a high GV was associated with increased 30-day mortality (log-rank test, p = 0.018). The association remained strong in the non-DM (log-rank test, p = 0.035), but not in the DM (log-rank test, p = 0.254) group. Multivariate Cox proportional hazard regression analysis identified that high APACHE II score (adjusted hazard ratio (aHR) 1.045, 95% confidence interval (CI) 1.013-1.078), high serum lactate level at 0 h (aHR 1.009, 95% CI 1.003-1.014), having chronic airway disease (aHR 0.478, 95% CI 0.302-0.756), high mean day 1 glucose (aHR 1.008, 95% CI 1.000-1.016), and high MAGE (aHR 1.607, 95% CI 1.008-2.563) were independently associated with increased 30-day mortality. The association with 30-day mortality remained consistent when using CoV to assess GV. Conclusions:We found that approximately 40% of the septic patients had a high early GV, defined as MAGE > 65 mg/dL. Higher GV within 24 h of ICU admission was independently associated with increased 30-day mortality. These findings highlight the need to monitor GV in septic patients early during an ICU admission.

Issues of Cardiovascular Risk Management in People With Diabetes in the COVID-19 Era

“…Glucose variability during the hospitalization may amplify these phenomena (53), worsening the prognosis. Also deserving attention is the fact that high glycemic variability is predictive per se of high ICU mortality (54). Therefore, it has already been suggested that the management of glucose variability has to be part of the more comprehensive approach to the management of hyperglycemia today: it seems that this must be urgently applied in ICUs (53).…”

Clinical Management of Diabetes Mellitus in the Era of COVID-19: Practical Issues, Peculiarities and Concerns

“…The main goals of in-hospital glucose monitoring are to limit abnormal glycemic variability (time in range >70%) and minimize hypoglycemic episodes (time in hypoglycemia <4%) [ 103 ]. Increased glycemic variability, defined as fluctuations between abnormally high and low glucose levels [ 104 ], has been recognized as an important adverse prognostic factor for critically ill patients, especially in the ICU setting [ 105 ]. Hypoglycemia can be also detrimental for severely infected patients, since it stimulates the release of stress hormones, such as cortisol and catecholamines, leading to elevated levels of circulating inflammatory mediators and the augmentation of pre-existing inflammation [ 106 ], and may also exert arrhythmogenic effects by prolonging the QT interval, thus increasing cardiovascular mortality [ 94 ].…”

Issues for the management of people with diabetes and COVID-19 in ICU

“…Finally, there are plenty of reports in the literature that glucose variability is producing a worsening of the prognosis in ICU [ 16 , 19 – 22 ] even when glucose is kept in normal range [ 22 ]. So it seems advisable that glucose variability should be avoided.…”

“…In the pandemic "Corona Virus Disease 2019" (COVID- 19) people with diabetes have a high risk to require ICU admission. The management of diabetes in Intensive Care Unit is always challenging, however, when diabetes is present in COVID-19 the situation seems even more complicated.…”