Hospital‐acquired complications in intensive care unit patients with diabetes: A before‐and‐after study of a conventional versus liberal glucose control protocol

Abstract

BackgroundCritically ill patients with diabetes mellitus (DM) are at increased risk of in-hospital complications and the optimal glycemic target for such patients remains unclear. A more liberal approach to glucose control has recently been suggested for patients with DM, but uncertainty remains regarding its impact on complications. MethodsWe aimed to test the hypothesis that complications would be more common with a liberal glycemic target in ICU patients with DM. Thus, we compared hospital-acquired complications in the first 400 critically ill patients with DM included in a sequential before-and-after trial of liberal (glucose target: 10-14 mmol/l) versus conventional (glucose target: 6-10 mmol/l) glucose control. ResultsOf the 400 patients studied, 165 (82.5%) patients in the liberal and 177 (88.5%) in the conventionalcontrol group were coded for at least one hospital-acquired complication (p=0.09). When comparing clinically relevant complications diagnosed between ICU admission and hospital discharge, we found no difference in the odds for infectious (adjusted odds ratio [aOR] for liberal-control: 1.15 [95% CI: 0.68-1.96], p=0.60), cardiovascular (aOR 1.40 [95% CI: 0.63-3.12], p=0.41) or neurological complications (aOR: 1.07 [95% CI: 0.61-1.86], p=0.81), acute kidney injury (aOR 0.83 [95% CI: 0.43-1.58], p=0.56) or hospital mortality (aOR: 1.09 [95% CI: 0.59-2.02], p=0.77) between the liberal and the conventional-control group. ConclusionIn this prospective before-and-after study, liberal glucose control was not associated with an increased risk of hospital-acquired infectious, cardiovascular, renal or neurological complications in critically ill patients with diabetes.

Association between Achievement of Estimated Average Glucose Level and 6-Month Neurologic Outcome in Comatose Cardiac Arrest Survivors: A Propensity Score-Matched Analysis

“…However, diabetic subgroup with the HbA1c ≥ 6.5% was not associated with hypoglycemia, unlike the non-diabetic and pre-diabetic subgroups in the present study. Previous studies demonstrated that liberal glucose control reduced hypoglycemia in critically ill patients with HbA1c ≥ 7% [22,23]. Thus, even if the association between hypoglycemia and unfavorable neurologic outcome is unclear in the present study, it might be acceptable to recommend the EAG based glucose control in cardiac arrest survivors with chronic hyperglycemic status to avoid potential harm owing to hypoglycemia.…”

“…Although the multivariate models and propensity-score matched cohort failed to show any significant association between the glucose group and neurologic outcome, the final model adjusted for the interaction of HbA1c and mean glucose showed that the association between hyperglycemia and the neurologic outcome might differ according to the premorbid glycemic status. Previous studies demonstrated that liberal (180–252 mg/dL) glucose control was not associated with increased mortality or adverse events, whereas liberal glucose control was associated with reduced hypoglycemia and glucose variability than conventional (108–180 mg/dL) glucose control in critically ill patients with diabetes or patients with chronic hyperglycemia (HbA1c ≥ 7%) [21,22,23]. That previous research supports that HbA1c based glucose control might be better to avoid potential risk of adverse events in cardiac arrest survivors with chronic hyperglycemia or poorly controlled diabetes.…”

Is it time to personalise glucose targets during critical illness?

“…In patients with insufficiently controlled diabetes (HbA1c ≥7%) the incidence of hypoglycaemia was reduced with the liberal regimen without adversely affecting the duration of mechanical ventilation or mortality [21]. In subsequent analyses, liberal glucose control was not associated with an increased risk of hospital-acquired infections, cardiovascular, renal or neurological complications [22 ▪ ]. There are substantial limitations to both studies including that the intervention was not blinded, patients were not randomised and the before-and-after and historical comparator designs increase the risk of seasonal and secular changes introducing bias but these studies suggest that hypoglycaemia, a biomarker of harm, may be reduced with such an approach.…”

Update on glucose control during and after critical illness

“…The prospective studies evaluating a more liberal approach to glucose targets in patients with diabetes are limited to single-center studies that each have substantial methodological weaknesses [29 ▪ ,30,31]. Nonetheless, the signal from these studies is that allowing modest hyperglycemia before commencing insulin and targeting blood glucose concentrations between 180 and 250 mg/dL (10 and 14 mmol/L) appears well-tolerated with a tendency to reduce episodes of hypoglycemia [29 ▪ ,30,31,32].…”