Mean glucose during ICU admission is related to mortality by a U-shaped curve in surgical and medical patients: a retrospective cohort study

Abstract

IntroductionLowering of hyperglycemia in the intensive care unit (ICU) is widely practiced. We investigated in which way glucose regulation, defined as mean glucose concentration during admission, is associated with ICU mortality in a medical and a surgical cohort.MethodsRetrospective database cohort study including patients admitted between January 2004 and December 2007 in a 20-bed medical/surgical ICU in a teaching hospital. Hyperglycemia was treated using a computerized algorithm targeting for glucose levels of 4.0-7.0 mmol/l. Five thousand eight hundred twenty-eight patients were eligible for analyses, of whom 1,339 patients had a medical and 4,489 had a surgical admission diagnosis.ResultsThe cohorts were subdivided in quintiles of increasing mean glucose. We examined the relation between these mean glucose strata and mortality. In both cohorts we observed the highest mortality in the lowest and highest strata. Logistic regression analysis adjusted for age, sex, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, admission duration and occurrence of severe hypoglycemia showed that in the medical cohort mean glucose levels <6.7 mmol/l and >8.4 mmol/l and in the surgical cohort mean glucose levels < 7.0 mmol/l and >9.4 mmol/l were associated with significantly increased ICU mortality (OR 2.4-3.0 and 4.9-6.2, respectively). Limitations of the study were its retrospective design and possible incomplete correction for severity of disease.ConclusionsMean overall glucose during ICU admission is related to mortality by a U-shaped curve in medical and surgical patients. In this cohort of patients a 'safe range' of mean glucose regulation might be defined approximately between 7.0 and 9.0 mmol/l.

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016

“…Stricter ranges, such as 110-140 mg/dL, may be appropriate for selected patients if this can be achieved without significant hypoglycemia [463,465]. Treatment should avoid hyperglycemia (>180 mg/dL), hypoglycemia, and wide swings in glucose levels that have been associated with higher mortality [466][467][468][469][470][471]. The continuation of insulin infusions, especially with the cessation of nutrition, has been identified as a risk factor for hypoglycemia [454].…”

Admission hyperglycemia and outcome in ICU patients with sepsis

“…Stress hyperglycemia is a very common feature in the intensive care (ICU) setting and it is related to multiple causes that include inflammatory and neuro-endocrine derangements in critically ill patients, which lead to insulin resistance and high hepatic glucose output (1). The target for glucose management in this population and its relationship with the patients' outcome is not clear, and results from literature are contrasting.…”

“…A recent retrospective study examined the relation between mean glucose strata values and mortality (1). For each patient, the mean overall glucose values measured during admission and the mean morning glucose from the first value available between 5 and 7 a.m. per patient per day was calculated.…”

A.S.P.E.N. Clinical Guidelines

“…25,38,39,[40][41][42][43][44][45][46][47][48][49][50][51][52][53][54] Hypoglycemia could be partly responsible for the adverse effects noted with intensive insulin therapy, including mortality. 25 A large retrospective analysis of hypoglycemia in ICUs showed a stepwise and significant increase in mortality with increasingly severe hypoglycemia.…”