Hypoglycemia and Risk of Death in Critically Ill Patients

Finfer, Simon; Liu, Bette; Chittock, Dean R.; Norton, Robyn; Myburgh, John; McArthur, Colin; Mitchell, Imogen; Foster, Denise; Dhingra, Vinay; Henderson, William R.; Ronco, Juan J.; Bellomo, Rinaldo; Cook, Deborah J.; McDonald, Ellen; Dodek, Peter; Hébert, Paul C.; Heyland, Daren K.; Robinson, Bruce G.

doi:10.1056/nejmoa1204942

Cited by 811 publications

(273 citation statements)

References 32 publications

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“…Hypoglycaemia has been associated with cardiac arrhythmias and increased risk of death in critically ill, hospitalized patients 9, 10. Recently, there has been increased awareness about the importance of clinically significant hypoglycaemia (identified by the International Hypoglycaemia Study Group as BG <3.0 mmol/L [54 mg/dL]) with its associated risk of potential harm 11.…”

Section: Discussionmentioning

confidence: 99%

Prospective study evaluating the use of nasal glucagon for the treatment of moderate to severe hypoglycaemia in adults with type 1 diabetes in a real‐world setting

Seaquist

Dulude²,

Zhang

et al. 2018

Diabetes Obesity Metabolism

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In the present multicentre, open‐label, prospective, phase III study, we evaluated the real‐world effectiveness and ease of use of nasal glucagon (NG) in the treatment of moderate/severe hypoglycaemic events (HEs) in adults with type 1 diabetes (T1D). Patients and caregivers were taught how to use NG (3 mg) to treat moderate/severe HEs, record the time taken to awaken or return to normal status, and measure blood glucose (BG) levels over time. Questionnaires were used to collect information about adverse events and ease of use of NG. In the efficacy analysis population, 69 patients experienced 157 HEs. In 95.7% patients, HEs resolved within 30 minutes of NG administration. In all the 12 severe HEs, patients awakened or returned to normal status within 15 minutes of NG administration without additional external medical help. Most caregivers reported that NG was easy to use. Most adverse events were local and of low to moderate severity. In this study, a single, 3‐mg dose of NG demonstrated real‐life effectiveness in treating moderate and severe HEs in adults with T1D. NG was well tolerated and easy to use.

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Section: Discussionmentioning

confidence: 99%

Prospective study evaluating the use of nasal glucagon for the treatment of moderate to severe hypoglycaemia in adults with type 1 diabetes in a real‐world setting

Seaquist

Dulude²,

Zhang

et al. 2018

Diabetes Obesity Metabolism

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“…However, several subsequent studies including an RCT conducted in the medical ICU have failed to demonstrate reduced mortality in a group under very strict control 25, 26, 27. The NICE‐SUGAR trial19 comparing a very strict protocol and a conventional protocol with moderate BG control (<180 mg/dL) demonstrated a substantially increased mortality rate in the study group. In recent years, several meta‐analyses have confirmed detrimental effects for very strict control when using mortality as an endpoint, and have shown the risk of hypoglycemia affecting the mortality (Table 2.…”

Section: Indication For Intensive Protocol In Critically Ill Patientsmentioning

confidence: 99%

“…The NICE‐SUGAR trial,19 which included a relatively small number of patients with elective surgery (12.5%), was carried out in critically ill patients at high risk of death (Acute Physiology and Chronic Health Evaluation [APACHE] II score, 21.1; death at day 28, 21.5%), and 21.6% of the patients already had sepsis at the time of randomization. A post‐hoc analysis of the NICE‐SUGAR study database20 showed that very strict control leads to moderate and severe hypoglycemia, both of which are associated with an increased risk of death, whereas high incidence of hypoglycemia possibly leads to increased mortality in patients assigned to a group under very strict control.…”

Section: Indication For Intensive Protocol In Critically Ill Patientsmentioning

confidence: 99%

“…This recommendation has been challenged by recent studies suggesting that an even lower target BG is required to prevent SSI 12, 13, 14, 15, 16, 17, 18. The intensive insulin administration protocol (intensive protocol), however, leads to an increased risk of hypoglycemia, which, in turn, is associated with increased morbidity and mortality 19, 20. It seems that very strict glycemic control has modest benefits, with adverse effects often outweighing these advantages in critically ill patients.…”

Section: Introductionmentioning

confidence: 99%

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Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Takesue

Tsuchida

2017

Annals of Gastroent Surgery

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Perioperative hyperglycemia is a risk factor for surgical site infections (SSI). Although the recommended target blood glucose level (BG) is 140–180 mg/dL for critically ill patients, recent studies conducted in patients undergoing surgery showed a significant benefit of intensive insulin therapy for the management of perioperative hyperglycemia. The aim of the present review is to evaluate the benefits of strict glycemic control for reducing SSI in gastroenterological surgery. We carried out a post‐hoc analysis of the previously published data from research on the risk factors for SSI. The highest BG within 24 hours after surgery was evaluated. A total of 1555 patients were enrolled in the study. In multivariate analysis, a dose–response relationship between the level of hyperglycemia and the odds of SSI was demonstrated when compared with the reference group (≤150 mg/dL) (odds ratio [OR] = 1.68, 95% confidence interval [CI] 1.14–2.49 for 150–200 mg/dL; and OR = 2.15, 95% CI 1.40–3.29 for >200 mg/dL). Unexpectedly, hyperglycemia was not a significant risk factor for SSI among diabetes patients. By contrast, non‐diabetes patients with a BG of >150 mg/dL were found to have increased odds of SSI. In conclusion, a target BG of ≤150 mg/dL is recommended in patients without diabetes who undergo gastroenterological surgery. Additional study is required to determine an optimal target BG in diabetes patients. Because of the risk of hypoglycemia, a conventional protocol is indicated for patients admitted to the general ward where frequent glucose measurement is not assured.

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“…8 Aggressive control of blood glucose levels has been shown to be of benefit to both diabetic and non-diabetic patients admitted to an intensive care unit, with significant reductions in death rates from multiple organ dysfunction. 9 However, since this study was published in 2001, these results have been difficult to reproduce and the NICE-SUGAR study 10 and a metaanalysis 11 have informed consensus opinion that "aggressive" blood glucose control is potentially harmful. The main issue is that an "aggressive" approach to glycaemic control increases Departments of Digestive Diseases and Diabetes, University Hospitals of Leicester NHS Trust, Leicester, UK LEARNING FROM PRACTICE the likelihood of hypoglycaemic episodes.…”

Section: Historic Backgroundmentioning

confidence: 99%

Can pre-operative carbohydrate loading be used in diabetic patients undergoing colorectal surgery?

Farrukh

Gregory

2014

Br J Diabetes

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The introduction of enhanced recovery after surgery (ERAS) has been associated with shortening post-operative recovery. It achieves such outcomes by minimizing the physical and physiological trauma of surgery. Benefits include superior pain control, reduced duration of ileus, improved pulmonary function and a reduction in thromboembolic and cardiac events. Within the ERAS approach the role of oral carbohydrate supplements is based on dealing with insulin resistance which characterizes periods of stress. Aggressive control of blood glucose levels has been shown to benefit both diabetic and non-diabetic patients admitted to intensive care units, however original studies in this area have not been consistently reproducible. The development of low osmolality carbohydrate drinks during the mid 1990s opened up the possibility of extending these benefits to surgical patients by providing them with a carbohydrate load two to three hours prior to anaesthesia. The benefits of the ERAS approach to colorectal surgery has been confirmed in several reports. However, its role in diabetic patients has, as yet, received limited attention. This review examines this limited number of publications and considers the potential benefit of preoperative carbohydrate loading in all diabetic patients. Br J Diabetes Vasc Dis 2014;14:102-104

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Hypoglycemia and Risk of Death in Critically Ill Patients

Cited by 811 publications

References 32 publications

Prospective study evaluating the use of nasal glucagon for the treatment of moderate to severe hypoglycaemia in adults with type 1 diabetes in a real‐world setting

Prospective study evaluating the use of nasal glucagon for the treatment of moderate to severe hypoglycaemia in adults with type 1 diabetes in a real‐world setting

Strict glycemic control to prevent surgical site infections in gastroenterological surgery

Can pre-operative carbohydrate loading be used in diabetic patients undergoing colorectal surgery?

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