Association of Glycemic Control Parameters with Clinical Outcomes in Chronic Critical Illness.
ABSTRACT Objective: Chronic Critical Illness (CCI) designates patients requiring prolonged mechanical ventilation and tracheostomy, with associated poor outcomes. Our study assessed the impact of glycemic parameters on outcomes in a CCI population.Methods: A retrospective case series was performed on 148 patients in The Mount Sinai Hospital Respiratory Care Unit (2009-2010). Utilizing a semi-parametric mixture model, trajectories for the daily mean blood glucose, range and hypoglycemia rate over time identified low- (n=87) and high-risk (n=61) hyperglycemia groups, and low- (n=90) and high-risk (n=58) hypoglycemia groups. The cohort was also classified as diabetes (n=48), stress hyperglycemia (n=85), or normal glucose (n=15).Results: Hospital- (28% vs. 13%, p=0.0199) and one-year mortality (66% vs. 46%, p=0.0185) were significantly greater in the high- vs. low-risk hyperglycemia groups, respectively. The hypoglycemia rate (< 70 mg/dL) was lower among ventilator-liberated patients compared to those who failed to liberate (0.092 vs. 0.130; p<0.0001). In the stress hyperglycemia group, both hospital mortality (high-risk hyperglycemia 48%, low-risk hyperglycemia 15%; p=0.0013) and 1-year mortality (high-risk 74%, low-risk 50%; p=0.0482) remained significantly different, while in the diabetes group no significant difference was seen. There were lower hypoglycemia rates with stress hyperglycemia compared to diabetes (<70 mg/dl: 0.086 vs. 0.182, p<0.0001; <40 mg/dl: 0.012 vs. 0.022, p=0.0118, respectively).Conclusion: Tighter glycemic control was associated with improved outcomes in CCI patients with stress hyperglycemia, but not in CCI patients with diabetes. Confirmation of these findings may lead to stratified glycemic control protocols in CCI patients based on the presence or absence of diabetes.
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ABSTRACT: To describe a new aspect of critical care termed intensive metabolic support. We performed a MEDLINE search of the English-language literature published between 1995 and 2008 for studies regarding the metabolic stages of critical illness, intensive insulin treatment, and intensive metabolic support in the intensive care unit, and we summarize the clinical data. Intensive metabolic support is a 3-component model involving metabolic control and intensive insulin therapy, early nutrition support, and nutritional pharmacology aimed at preventing allostatic overload and the development of chronic critical illness. To improve clinical outcome and prevent mortality, intensive metabolic support should start on arrival to the intensive care unit and should end only when patients are in the recovery phase of their illness. Intensive metabolic support should be an essential part of the daily treatment strategy in critical care medicine. This will involve a newfound and extensive collaboration between the endocrinologist and the intensivist. We call for well-designed future studies involving implementation of this protocol to decrease the burden of chronic critical illness.Endocrine Practice 12/2008; 14(8):1047-54. · 2.49 Impact Factor
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ABSTRACT: Objective: Hyperglycemia is associated with increased mortality in critically ill patients treated with total parenteral nutrition (TPN). The role of glucose variability (GV) in predicting outcomes in these patients is not known.Methods: This retrospective study included medical and surgical patients receiving TPN in a community teaching hospital. GV was calculated by standard deviation (SD) of blood glucose (BG) values and by mean BG daily delta change (daily max - daily minimum).Results: 276 medical and surgical patients (mean age: 51±18 yr), 19% with history of diabetes (DM), and 74% with ICU admission were treated with TPN. During TPN mean daily BG was 142.9±33 mg/dl, frequency of hypoglycemia <70 mg/dl and <40 mg/dl was 41% and 3%, respectively, and hospital mortality was 27.2%. The mean GV by SD: 38±21 mg/dl and by mean delta change: 58±34 mg/dl. GV was significantly higher in deceased patients (SD: 48±25 vs. 34±18 mg/dL and Δ change: 75±39 vs. 51±29 mg/dl, both p<0.01) than non-deceased patients. Multivariate analysis adjusted for age, DM status, gender, APACHE score, mean daily glucose and hypoglycemia revealed that GV was an independent predictor of hospital mortality (p<0.05). The association between GV and mortality was limited to patients without a history of DM and was not present in patients with DM.Conclusion: High GV is associated with increased hospital mortality independent of the presence and severity of hyperglycemia or hypoglycemia during TPN therapy. Prospective randomized trials are needed to determine if reduction in GV with intensive glycemic control improves clinical outcomes in patients treated with TPN.Endocrine Practice 09/2013; · 2.49 Impact Factor
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ABSTRACT: INTRODUCTION: Optimal glucose management in the ICU remains unclear. In 2009, many clinicians at Intermountain Healthcare selected a moderate glucose control (90-140mg/dL) instead of tight glucose control (80-110mg/dL). We hypothesized that moderate glucose control would affect patients with and without pre-existing diabetes differently. METHODS: We performed a retrospective cohort analysis of all patients treated with eProtocol-insulin from November 2006 to March 2011, stratifying for diabetes. We performed multivariate logistic regression for 30-day mortality with covariates of age, modified APACHE II score, Charlson Comorbidity score, and target glucose. RESULTS: We studied 3529 patients in 12 different ICUs in 8 different hospitals. Diabetic patients had higher mean glucose (132 vs. 124mg/dL) and greater glycemic variability (sd = 41 vs. 29 mg/dL) than did non-diabetics (p <0.01 for both comparisons). Tight glucose control was associated with increased frequency of moderate and severe hypoglycemia (30.3% and 3.6%) compared to moderate glucose control (14.3% and 2.0%; p <0.01 for both). Multivariate analysis demonstrated that the moderate glucose target was independently associated with increased risk of mortality in non-diabetics (OR 1.36, 95% CI 1.01-1.84, p = 0.05), but decreased risk of mortality in diabetics (OR 0.65, 0.45-0.93, p = 0.01). CONCLUSIONS: Moderate glucose control (90-140mg/dL) may confer greater mortality in non-diabetic, critically ill patients compared to tight glucose control (80-110mg/dL). A single glucose target does not appear optimal for all critically ill patients. These data have important implications for the design of future interventional trials as well as for the glycemic management of critically ill patients.Chest 11/2012; · 7.13 Impact Factor