Risk Factors for Hypoglycemia During Treatment of Hyperglycemic Crises

Abstract

Objective Diabetic ketoacidosis and hyperosmolar hyperglycemic state are life-threatening hyperglycemic crises often requiring intensive care unit (ICU) management. Treatment includes intravenous (IV) insulin with a transition to subcutaneous (SC) insulin upon resolution. Hypoglycemia is a common complication associated with treatment of hyperglycemic crises, but risk factors have not been well established. This study aimed to assess risk factors associated with hypoglycemia during treatment for hyperglycemic crises. Methods This case-control study included ICU patients admitted with hyperglycemic crises at a single Veterans Affairs health system from 1 January 2013 to 31 March 2020. Patients who developed hypoglycemia during insulin treatment were compared with a control group. Odds of hypoglycemia were assessed based on risk factors, including BMI, comorbidities, and type of SC insulin used. Results Of 216 cases of hyperglycemic crises included, hypoglycemia occurred in 61 cases (44 on SC insulin, 11 on IV insulin, and 6 on both). Odds for hypoglycemia were significantly higher for underweight patients (odds ratio [OR] 4.52 [95% CI 1.05–19.55]), type 1 diabetes (OR 4.02 [95% CI 2.09–7.73]), chronic kidney disease (OR 1.94 [95% CI 1.05–3.57]), those resumed on the exact chronic SC insulin regimen following resolution (OR 2.91 [95% CI 1.06–7.95]), and patients who received NPH versus glargine insulin (OR 5.13 [95% CI 1.54–17.06]). No significant differences were seen in the other evaluated variables. Conclusion This study found several factors associated with hypoglycemia during hyperglycemic crises treatment, many of which are not addressed in consensus statement recommendations. These findings may help ICU clinicians prevent complications related to hyperglycemic crisis management and generate hypotheses for future studies.

Hypoglycemia during hyperosmolar hyperglycemic crises is associated with long-term mortality

“…The frequency of hypoglycemia during the IIITP (mean duration, 67 h) in our sample (present in about a quarter of patients) was proportionally similar to that observed in the first 48 h in previous studies (12–16%) [ 8 ]. Consistent with previous studies in patients hospitalized for hyperglycemic crises, hypoglycemia was more frequent in patients with low BMI [ 18 ], in patients with probable concomitant infection [ 21 ], and in those receiving higher doses of insulin [ 17 ]. Additional risk factors found in our study for hypoglycemia during HHC were older age, the presence of a greater number of comorbidities (higher CCI), and outpatient treatment with insulin prior to admission; these had not been reported in patients admitted for hyperosmolar crises, but had been documented in patients with diabetes who were admitted for other reasons [ 24 ].…”

“…Several studies have shown that the incidence of hypoglycemia during hyperglycemic crises depends on the dosage and amount of insulin received [ 13 – 20 ]. In addition, 2 studies performed in patients admitted for DKA demonstrated a higher incidence of hypoglycemia in patients with low body weight [ 18 ], fever [ 21 ], hepatic disease [ 21 ], and impaired renal function [ 18 , 21 ]. Thus, few studies have analyzed risk factors other than insulin therapy for the occurrence of hypoglycemia during the treatment of hyperglycemic crises.…”