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Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality

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Abstract

Purpose

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.

Methods

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.

Results

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.

Conclusions

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.

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Abbreviations

ADA:

American Diabetes Association

ANOVA:

Analysis of variance

APACHE:

Acute physiology and chronic health evaluation

BMI:

Body mass index

CIAH:

Critical illness-associated hyperglycaemia

EASD:

European Association for the Study of Diabetes

HbA1c :

Glycated haemoglobin

ICU:

Intensive care unit

OGTT:

Oral glucose tolerance test

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Acknowledgments

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.

Author information

Authors and Affiliations

  1. Department of Critical Care Services, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia

    Mark P. Plummer, Caroline E. Cousins, Christopher E. Annink, Krishnaswamy Sundararajan, Benjamin A. J. Reddi, John P. Raj, Marianne J. Chapman & Adam M. Deane

  2. Discipline of Acute Care Medicine, University of Adelaide, Level 5, Eleanor Harrald Building, Frome St, Adelaide, SA, 5000, Australia

    Mark P. Plummer, Krishnaswamy Sundararajan, Benjamin A. J. Reddi, Marianne J. Chapman & Adam M. Deane

  3. Department of Intensive Care, Austin Hospital, Studley Rd, Heidelberg, Victoria, 3084, Australia

    Rinaldo Bellomo

  4. Faculty of Medicine, University of Melbourne, Melbourne, Australia

    Rinaldo Bellomo

  5. Discipline of Medicine, University of Adelaide, Level 6, Eleanor Harrald Building, Frome St, Adelaide, SA, 5000, Australia

    Michael Horowitz

  6. Department of Endocrinology, Royal Adelaide Hospital, North Terrace, Adelaide, SA, 5000, Australia

    Michael Horowitz

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  1. Mark P. Plummer
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Correspondence to Adam M. Deane.

Additional information

Take-home message: 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 as determined by HbA1c. Optimal glucose thresholds in the critically ill may, therefore, be affected by premorbid glycaemia so that clinicians should consider the admission HbA1c when targeting glycaemic control.

Electronic supplementary material

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134_2014_3287_MOESM1_ESM.png

Fig. 1. Hospital mortality vs acute glycaemia when categorised according to premorbid glycaemia (HbA1c) adjusted for age, BMI, APACHE II and admission type (medical/surgical). After adjustment the interaction term peak BGL*HbA1c interaction was no longer significant (P = 0.13). The model was an adequate fit (Hosmer and Lemeshow goodness of fit test). Slope estimates for each category were HbA1c < 6 % (42 mmol/mol), odds ratio = 1.05 (95 % CI 0.97, 1.13), P = 0.22; 6 % ≤ HbA1c < 7 % (53 mmol/mol), odds ratio = 1.13 (95 % CI 1.02, 1.25), P = 0.016; and HbA1c ≥ 7 %, odds ratio = 0.97 (95 % CI 0.86, 1.09), P = 0.575.(PNG 731 kb)

Fig. 2 Insulin and blood glucose protocol during study period (DOC 125 kb)

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Plummer, M.P., Bellomo, R., Cousins, C.E. et al. Dysglycaemia in the critically ill and the interaction of chronic and acute glycaemia with mortality. Intensive Care Med 40, 973–980 (2014). https://doi.org/10.1007/s00134-014-3287-7

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  • DOI: https://doi.org/10.1007/s00134-014-3287-7

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