Severe hypoglycemia in critically ill patients: Risk factors and outcomes*

Objective:To determine the risk factors for development of severe hypoglycemia (defined as glucose <40 mg/dL) in critically ill patients and define the outcomes of this complication. Design:Retrospective database review, including a case-control analysis that matched each patient with severe hypoglycemia with three controls. Setting:Adult intensive care unit of a university-affiliated community hospital. Patients:A total of 102 patients with at least one episode of severe hypoglycemia extracted from a series of 5,365 medical, surgical, and cardiac patients admitted consecutively between October 1, 1999, and June 15, 2006. Interventions:A program of intensive glycemic monitoring and management, or tight glycemic control, was implemented on February 1, 2003; 2,666 patients were treated before and 2,699 after this date. Measurements and Main Results:Multivariable logistic regression analysis identified diabetes, septic shock, renal insufficiency, mechanical ventilation, severity of illness, reflected by Acute Physiology and Chronic Health Evaluation II score with the age component deleted, and treatment in the tight glycemic control period as independent risk factors for the development of severe hypoglycemia. Mortality was 55.9% among the 102 patients with severe hypoglycemia and 39.5% among the 306 controls (p = .0057). Multivariable logistic regression analysis identified severe hypoglycemia as an independent predictor of mortality for the entire cohort (odds ratio, 2.28; 95% confidence interval, 1.41–3.70; p = .0008). Among patients with severe hypoglycemia, only modified Acute Physiology and Chronic Health Evaluation II score and mechanical ventilation were identified as independent predictors of mortality. A sensitivity analysis was constructed that suggested that quadrupling the rate of severe hypoglycemia and doubling the mortality attributable to severe hypoglycemia would negate the survival benefit of tight glycemic control in this series. Conclusions:Case-control methodology and multivariable logistic regression analysis concurred that even a single episode of severe hypoglycemia was independently associated with increased risk of mortality. Safe implementation of tight glycemic control requires appropriate monitoring to reduce the risk of this complication.

[1]  Anthony N Thomas,et al.  Evaluation of short-term consequences of hypoglycemia in an intensive care unit. , 2007, Critical care medicine.

[2]  J. Krinsley,et al.  Icu Validation Of The Optiscanner, A Continuous Glucose Monitoring Device.: 255 , 2006 .

[3]  J. Krinsley.  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. , 2006, Seminars in thoracic and cardiovascular surgery.

[4]  G. Van den Berghe,et al.  Intensive insulin therapy in the medical ICU. , 2006, The New England journal of medicine.

[5]  S. Nasraway.  Hyperglycemia during critical illness. , 2006, JPEN. Journal of parenteral and enteral nutrition.

[6]  Marcus J Schultz,et al.  Predisposing factors for hypoglycemia in the intensive care unit* , 2006, Critical care medicine.

[7]  Brian Hutton,et al.  Reliability of point-of-care testing for glucose measurement in critically ill adults* , 2005, Critical care medicine.

[8]  Edward Abraham,et al.  Intensive insulin therapy in critical illness. , 2005, American journal of respiratory and critical care medicine.

[9]  James Stephen Krinsley,et al.  Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. , 2004, Mayo Clinic proceedings.

[10]  Irl B Hirsch,et al.  Management of diabetes and hyperglycemia in hospitals. , 2004, Diabetes care.

[11]  James Stephen Krinsley,et al.  Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. , 2003, Mayo Clinic proceedings.

[12]  J. Cooper,et al.  A single serum glucose measurement predicts adverse outcomes across the whole range of acute coronary syndromes , 2003, Heart.

[13]  G. Grunkemeier,et al.  Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. , 2003, The Journal of thoracic and cardiovascular surgery.

[14]  W. Ricart,et al.  Short-term mortality of myocardial infarction patients with diabetes or hyperglycaemia during admission , 2002, Journal of epidemiology and community health.

[15]  J. Rotich,et al.  Effects of admission hyperglycemia on mortality and costs in acute ischemic stroke , 2002, Neurology.

[16]  B. Bistrian,et al.  Intensive insulin therapy in critically ill patients. , 2002, The New England journal of medicine.

[17]  Jeffrey B. Boord,et al.  Practical management of diabetes in critically ill patients. , 2001, American journal of respiratory and critical care medicine.

[18]  H. Gerstein,et al.  Stress Hyperglycemia and Prognosis of Stroke in Nondiabetic and Diabetic Patients: A Systematic Overview , 2001, Stroke.

[19]  H. Knobler,et al.  The role of hyperglycemia in acute stroke. , 2001, Archives of neurology.

[20]  H. Gerstein,et al.  Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview , 2000, The Lancet.

[21]  G. Grunkemeier,et al.  Continuous intravenous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. , 1999, The Annals of thoracic surgery.

[22]  W. Lanier,et al.  Glucose modulation of ischemic brain injury: review and clinical recommendations. , 1996, Mayo Clinic proceedings.

[23]  W. Knaus,et al.  The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. , 1991, Chest.

[24]  J. Gerich,et al.  Hypoglycemia unawareness. , 1991, Endocrine reviews.

[25]  E. Draper,et al.  APACHE II: A severity of disease classification system , 1985, Critical care medicine.