Multidisciplinary strategies to treat severe hypoglycemia in hospitalized patients with diabetes mellitus reduce inpatient mortality rate: Experience from an academic community hospital

Kadayakkara, Deepak K.; Balasubramanian, Priyadarshini; Araque, Katherine A; Davis, Karri; Javed, Fawad; Niaki, Pontea; Majumdar, Sachin; Buller, Gregory K.

doi:10.1371/journal.pone.0220956

Cited by 16 publications

(13 citation statements)

References 14 publications

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“…We cannot prove causality for these associations, and it may be that hypoglycemia itself is a clinical sign of worsening or severe illness. However, one recent study found that reducing the frequency of inpatient hypoglycemia concomitantly reduced inpatient and 30-day mortality rates ( 53 ). Further trials are needed to determine if direct reduction of ICU hypoglycemia improves clinical outcomes.…”

Section: Discussionmentioning

confidence: 99%

Pathophysiologic Signature of Impending ICU Hypoglycemia in Bedside Monitoring and Electronic Health Record Data: Model Development and External Validation

Horton

Barros

Andris

et al. 2021

Critical Care Medicine

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We tested the hypothesis that routine monitoring data could describe a detailed and distinct pathophysiologic phenotype of impending hypoglycemia in adult ICU patients. DESIGN:Retrospective analysis leading to model development and validation. SETTING:All ICU admissions wherein patients received insulin therapy during a 4-year period at the University of Virginia Medical Center. Each ICU was equipped with continuous physiologic monitoring systems whose signals were archived in an electronic data warehouse along with the entire medical record. PATIENTS:Eleven thousand eight hundred forty-seven ICU patient admissions. INTERVENTIONS:The primary outcome was hypoglycemia, defined as any episode of blood glucose less than 70 mg/dL where 50% dextrose injection was administered within 1 hour. We used 61 physiologic markers (including vital signs, laboratory values, demographics, and continuous cardiorespiratory monitoring variables) to inform the model. MEASUREMENTS AND MAIN RESULTS:Our dataset consisted of 11,847 ICU patient admissions, 721 (6.1%) of which had one or more hypoglycemic episodes. Multivariable logistic regression analysis revealed a pathophysiologic signature of 41 independent variables that best characterized ICU hypoglycemia. The final model had a cross-validated area under the receiver operating characteristic curve of 0.83 (95% CI, 0.78-0.87) for prediction of impending ICU hypoglycemia. We externally validated the model in the Medical Information Mart for Intensive Care III critical care dataset, where it also demonstrated good performance with an area under the receiver operating characteristic curve of 0.79 (95% CI, 0.77-0.81). CONCLUSIONS:We used data from a large number of critically ill inpatients to develop and externally validate a predictive model of impending ICU hypoglycemia. Future steps include incorporating this model into a clinical decision support system and testing its effects in a multicenter randomized controlled clinical trial.

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Section: Discussionmentioning

confidence: 99%

Pathophysiologic Signature of Impending ICU Hypoglycemia in Bedside Monitoring and Electronic Health Record Data: Model Development and External Validation

Horton

Barros

Andris

et al. 2021

Critical Care Medicine

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“…7 On the other hand, inpatient hypoglycaemia continues to be an important issue associated with poor outcomes. 8 A limited number of studies have investigated the use of glucose-lowering agents other than insulin, such as glucagon-like peptide (GLP-1) receptor agonists, for acute illness, perioperative and critical care areas. 9 In this context, little is known about the efficacy and safety profiles of SGLT2i in hospitalized patients.…”

Section: What Is K Nown and Objec Tive Smentioning

confidence: 99%

The use of sodium‐glucose co‐transporter 2 inhibitors in the inpatient setting: Is the risk worth taking?

et al. 2020

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What is known and objective In the outpatient setting, sodium‐glucose co‐transporter 2 inhibitors (SGLT2i) are recognized as effective agents to optimize glycaemia and also developing robust evidence for cardiovascular (CV) and renal protection in people with type 2 diabetes, particularly those at higher risk. However, data on the safety and efficacy of these drugs in hospitalized patients remain limited. The purpose of this review is to discuss the balance between risks and benefits of SGLT2i use in the inpatient setting. Methods PubMed, Embase and Google Scholar databases were searched to identify relevant published work. Available evidence on the mechanisms of action and the safety profile of SGLT2i in the context of their use in hospitalized individuals are summarized and discussed in this narrative review. Results and discussion The rationale behind the use of these agents in the inpatient setting is based on the low risk of hypoglycaemia, the practical dosing scheme and the potential to decrease subsequent heart failure admission rates. In addition, data from animal studies indicate the ability of SGLT2i to ameliorate oxidative stress, suppress sympathetic activity, enhance autophagy and promote cardiac remodelling, when administered in the acute phase of CV episodes. On the other hand, these drugs have been linked to specific adverse events related to their mechanism of action, including an increased risk of euglycaemic diabetic ketoacidosis and volume depletion, which raises concerns over their usefulness in inpatients, particularly individuals with multimorbidities. What is new and conclusion Potential benefits deriving from the use of SGLT2i in the inpatient setting cannot mitigate possible risks, at least until robust evidence on their efficacy in hospitalized individuals become available. The concept of administering these agents in the acute phase of CV episodes, in people with or without diabetes, requires further evaluation in appropriately designed clinical studies.

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“…18 Standardized reporting, order sets, and hypoglycemia protocols are highly effective to reduce inpatient hypoglycemia. 18,22,23 The widespread use of electronic medical records (EMR), continuous subcutaneous insulin infusion (CSII) pumps, and continuous glucose monitoring (CGM) technology has led to renewed efforts to prevent hypoglycemia by developing automated tools, predictive scores, and remote surveillance. Eight strategies are reviewed below.…”

Section: Prevention Of Hypoglycemiamentioning

confidence: 99%

Inpatient Hypoglycemia: The Challenge Remains

Cruz

2020

J Diabetes Sci Technol

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Hypoglycemia in inpatients with diabetes remains the most common complication of diabetes therapies. Hypoglycemia is independently associated with increased morbidity and mortality, increased length of stay, increased readmission rate, and increased cost. This review describes the importance of reporting and addressing inpatient hypoglycemia; it further summarizes eight strategies that aid clinicians in the prevention of inpatient hypoglycemia: auditing the electronic medical record, formulary restrictions and dose-limiting strategies, hyperkalemia order sets, electronic glucose management systems, prediction tools, diabetes self-management, remote surveillance, and noninsulin medications.

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Multidisciplinary strategies to treat severe hypoglycemia in hospitalized patients with diabetes mellitus reduce inpatient mortality rate: Experience from an academic community hospital

Cited by 16 publications

References 14 publications

Pathophysiologic Signature of Impending ICU Hypoglycemia in Bedside Monitoring and Electronic Health Record Data: Model Development and External Validation

Pathophysiologic Signature of Impending ICU Hypoglycemia in Bedside Monitoring and Electronic Health Record Data: Model Development and External Validation

The use of sodium‐glucose co‐transporter 2 inhibitors in the inpatient setting: Is the risk worth taking?

Inpatient Hypoglycemia: The Challenge Remains

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