Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality
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Hyperglycaemia is common in the critically ill. The objectives of this study were to determine the prevalence of critical illness-associated hyperglycaemia (CIAH) and recognised and unrecognised diabetes in the critically ill as well as to evaluate the impact of premorbid glycaemia on the association between acute hyperglycaemia and mortality.
In 1,000 consecutively admitted patients we prospectively measured glycated haemoglobin (HbA1c) on admission, and blood glucose concentrations during the 48 h after admission, to the intensive care unit. Patients with blood glucose ≥7.0 mmol/l when fasting or ≥11.1 mmol/l during feeding were deemed hyperglycaemic. Patients with acute hyperglycaemia and HbA1c <6.5 % (48 mmol/mol) were categorised as ‘CIAH’, those with known diabetes as ‘recognised diabetes’, and those with HbA1c ≥6.5 % but no previous diagnosis of diabetes as ‘unrecognised diabetes’. The remainder were classified as ‘normoglycaemic’. Hospital mortality, HbA1c and acute peak glycaemia were assessed using a logistic regression model.
Of 1,000 patients, 498 (49.8 %) had CIAH, 220 (22 %) had recognised diabetes, 55 (5.5 %) had unrecognised diabetes and 227 (22.7 %) were normoglycaemic. The risk of death increased by approximately 20 % for each increase in acute glycaemia of 1 mmol/l in patients with CIAH and those with diabetes and HbA1c levels <7 % (53 mmol/mol), but not in patients with diabetes and HbA1c ≥7 %. This association was lost when adjusted for severity of illness.
Critical illness-associated hyperglycaemia is the most frequent cause of hyperglycaemia in the critically ill. Peak glucose concentrations during critical illness are associated with increased mortality in patients with adequate premorbid glycaemic control, but not in patients with premorbid hyperglycaemia. Optimal glucose thresholds in the critically ill may, therefore, be affected by premorbid glycaemia.
KeywordsHyperglycemia Blood glucose Diabetes mellitus Critical illness Hemoglobin A
American Diabetes Association
Analysis of variance
Acute physiology and chronic health evaluation
Body mass index
Critical illness-associated hyperglycaemia
European Association for the Study of Diabetes
Intensive care unit
Oral glucose tolerance test
The authors acknowledge the assistance of biostatiscians Ms Kylie Lange and Ms Suzanne Edwards (University of Adelaide). Dr. Mark Plummer is supported by a Dawes Scholarship (co-funded University of Adelaide and Royal Adelaide Hospital) and Dr. Adam Deane is supported by a National Health and Medical Research Council of Australia (NHMRC) Early Career Fellowship. Data collection was supported by a project grant from the Diabetes Australia Research Trust. These data were presented in abstract form at the European Society of Intensive Care Medicine 26th Annual Congress (Paris).
Conflicts of interest
M.H. has participated in advisory boards and/or symposia for Novo/Nordisk, Sanofl-Aventis, Novartis, Eli-Lilly, Boehringer Ingelheim, AstraZeneca, Satlogen and Meyer Nutraceuticals. M.P.P., R.B., C.E.C., C.E.A., K.S., B.J.R., J.P.R., M.J.C and A.M.D have no duality of interests to declare.
- 10.Krinsley JS, Egi M, Kiss A, Devendra AN, Schuetz P, Maurer PM, Schultz MJ, van Hooijdonk RT, Kiyoshi M, Mackenzie IM, Annane D, Stow P, Nasraway SA, Holewinski S, Holzinger U, Preiser JC, Vincent JL, Bellomo R (2013) Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study. Crit Care 17:R37PubMedCentralPubMedCrossRefGoogle Scholar
- 11.Krinsley JS (2006) Glycemic control, diabetic status, and mortality in a heterogeneous population of critically ill patients before and during the era of intensive glycemic management: six and one-half years experience at a university-affiliated community hospital. Semin Thorac Cardiovasc Surg 18:317–325PubMedCrossRefGoogle Scholar
- 12.Inzucchi SE, Bergenstal RM, Buse JB, Diamant M, Ferrannini E, Nauck M, Peters AL, Tsapas A, Wender R, Matthews DR, American Diabetes Association & European Association for the Study of Diabetes (2012) Management of hyperglycemia in type 2 diabetes: a patient-centered approach: position statement of the American Diabetes Association (ADA) and the European Association for the Study of diabetes (EASD). Diabetes Care 35:1364–1379PubMedCentralPubMedCrossRefGoogle Scholar
- 16.NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hebert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297PubMedCrossRefGoogle Scholar
- 19.Preiser JC, Devos P, Ruiz-Santana S, Melot C, Annane D, Groeneveld J, Iapichino G, Leverve X, Nitenberg G, Singer P, Wernerman J, Joannidis M, Stecher A, Chiolero R (2009) A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med 35:1738–1748PubMedCrossRefGoogle Scholar
- 21.American Diabetes Association (2013) Diagnosis and classification of diabetes mellitus. Diabetes Care 36(Suppl 1):S67–S74Google Scholar
- 24.Dunstan DW, Zimmet PZ, Welborn TA, De Courten MP, Cameron AJ, Sicree RA, Dwyer T, Colagiuri S, Jolley D, Knuiman M, Atkins R, Shaw JE (2002) The rising prevalence of diabetes and impaired glucose tolerance: the Australian diabetes, obesity and lifestyle study. Diabetes Care 25:829–834PubMedCrossRefGoogle Scholar
- 33.Antonelli M, Bonten M, Chastre J, Citerio G, Conti G, Curtis JR, De Backer D, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Rocco P, Timsit JF, Wernerman J, Zhang H (2012) Year in review in intensive care medicine 2011: I. nephrology, epidemiology, nutrition and therapeutics, neurology, ethical and legal issues, experimentals. Intensive Care Med 38:192–209PubMedCentralPubMedCrossRefGoogle Scholar