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Hyperglycemia and Short-term Outcome in Patients with Spontaneous Intracerebral Hemorrhage

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Abstract

Background

Hyperglycemia has a detrimental effect in several acute neurological critical illnesses. No consensus exists on the optimal management of hyperglycemia in spontaneous intracerebral hemorrhage (sICH). Our aim was to determine whether blood glucose (BG) would predict 30-day mortality in sICH.

Methods

All patients with a well-defined diagnosis of sICH admitted into 24 h in three primary referred centers were included in this prospective observational follow-up study. Patients had extensive monitoring of BG values and those with BG values >8.29 mmol/l (150 mg/dl) received a variable intravenous insulin dose to maintain BG concentrations during the first 72 h after sICH between 3.32 and 8.29 mmol/l (60–150 mg/dl) using pre-specified insulin dosing schedule protocol.

Results

Between January 1, 2002, and December 31, 2003, 295 consecutive patients (mean ± SD age 66 ± 12 years) were prospectively included. A 1.0 mmol/l (18 mg/dl) increase in the BG concentration at admission was associated with a 33% mortality increase (OR: 1.33; 95%CI: 1.22–1.46; P < 0.0001). Adjusting for demographics, risk factors, stroke severity, and surgery there was no change in the increased risk. During the first 12 h after sICH, the insulin treatment protocol was enabling to reduce mortality (OR: 1.36, 95%CI: 1.14–1.61; P = 0.0005, per 1 IU increase) while thereafter this association was greatly attenuated and not more significant.

Conclusions

Hyperglycemia is a common condition after sICH and may worsen prognosis. Very early insulin therapy apparently does not improve prognosis. These results raise concern about routine clinical practice implementation of this intervention without any evidence from randomized trials.

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Authors and Affiliations

  1. Neurointensive Care Unit, Sanatorio Pasteur, Chacabuco 645, San Fernando del Valle de Catamarca, Provincia de Catamarca, K4700, Argentina

    Daniel A. Godoy

  2. Intensive Care Unit, Hospital Municipal de Agudos Dr. Leonidas Lucero, Bahia Blanca, Provincia de Buenos Aires, Argentina

    Gustavo R. Piñero

  3. Intensive Care Unit, Hospital Provincial Castro Rendón, Neuquen, Provincia de Neuquen, Argentina

    Silvana Svampa

  4. Neurological Section, SMDN-Center for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Via Trento, 41, Sulmona (L’Aquila), 67039, Italy

    Francesca Papa & Mario Di Napoli

  5. Neurological Service, San Camillo de, Lellis General Hospital, Rieti, Italy

    Mario Di Napoli

Authors
  1. Daniel A. Godoy
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  2. Gustavo R. Piñero
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  3. Silvana Svampa
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  4. Francesca Papa
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  5. Mario Di Napoli
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Corresponding authors

Correspondence to Daniel A. Godoy or Mario Di Napoli.

Appendix

Appendix

Neurointensive Care Unit protocol for glycemic management

Goal

The goal of this protocol was maintaining BG concentrations between 3.32 and 8.29 mmol/l (60–150 mg/dl).

Monitoring

BG concentrations were evaluated by routine laboratory determinations or finger-stick testing using the following schedule:

  1. 1.

    Routine laboratory determinations were made at admission and then Q 8 h until stabilization. After this target Q 12 h.

  2. 2.

    Bedside monitoring with trips (Medisense, Precision Plus, Abbott Laboratories, United Kingdom) Q 2 h until the patient was within the target on more than 3 consecutive readings.

  3. 3.

    Once obtained target, monitoring Q 4 h.

  4. 4.

    If BG concentrations were unstable or out of ranges: resuming monitoring Q 2 h.

Treatment of Hyperglycemia

  1. 1.

    In diabetic patients, stop long-acting insulin and/or antidiabetic oral medications.

  2. 2.

    Insulin was not given with the first two determinations. Corrections beginning with the third value.

  3. 3.

    Schedule regimen for corrections with intravenous (i.v.) short-acting insulin (Table 1A).

  4. 4.

    If BG concentrations >19.34 mmol/l (>350 mg/dl) in 2 consecutive measurements or diabetic patients with ketoacidosis, hyperosmolar coma, patients with mechanical ventilation or sepsis: insulin infusion protocol was started with hourly BG monitoring (Table 1A).

Hypoglycemia Management

  1. 1.

    Give 50% dextrose in water (D50W) using the following formula: (100 − Glucose level) × 0.3 = ml D50W i.v. bolus.

  2. 2.

    Check BG every 30 min.

  3. 3.

    If BG < 3.32 mmol/l (<60 mg/dl), repeat previous steps and call attending physician.

Table 1A Insulin protocols
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Godoy, D.A., Piñero, G.R., Svampa, S. et al. Hyperglycemia and Short-term Outcome in Patients with Spontaneous Intracerebral Hemorrhage. Neurocrit Care 9, 217–229 (2008). https://doi.org/10.1007/s12028-008-9063-1

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