Hyperglycemia in sepsis is a risk factor for development of type II diabetes

Background

Hyperglycemia is frequent in sepsis, even in patients without diabetes or impaired glucose metabolism. It is a consequence of inflammatory response and stress, so its occurrence is related to severity of illness. However, not all severely ill develop hyperglycemia and some do even in mild disease. We hypothesized the existence of latent disturbance of glucose metabolism that contributes to development of hyperglycemia and that those patients might have increased risk for diabetes.

Methods

Patients admitted with sepsis and no history of impaired glucose metabolism were included and divided in the hyperglycemia group (glucose ≥7.8 mmol/L) and normoglycemia group. Severity of sepsis was assessed. Surviving patients without diabetes at discharge were followed-up for 5 years to investigate risk for development of diabetes.

Results

Hyperglycemia was related to severity of sepsis. Follow-up was finished for 55 patients with hyperglycemia, of which 8 (15.7%) developed diabetes, and 118 patients with normoglycemia, of which 5 (4.2%) developed diabetes (P = .002). Relative risk for developing type 2 diabetes was 4.29 (95% CI, 1.35-13.64).

Conclusion

Patients with hyperglycemia in sepsis who are not diagnosed with diabetes before or during the hospitalization should be considered a population at increased risk for developing diabetes.     

Hyperglycemia,hypoglycemia, and glycemic complexity are associated with worse outcomes after surgery

Purpose

The purpose of this study was to determine if glycemic complexity, along with hypoglycemia and hyperglycemia, was associated with worse outcomes after cardiac surgery.

Materials and methods

We conducted a retrospective analysis of 970 patients who had insulin infusions designed to keep blood glucose levels between 80 and 110 mg/dL. Glycemic complexity was calculated using jackknifed approximate entropy. Logistic regression was used to adjust for confounders.

Results

A total of 495 patients (51%) developed complications, and 32 patients (3.3%) died. Along with older age, comorbidities, and complicated surgeries, any hypoglycemia (glucose <71 mg/dL) and the number of glucose values greater than 140 mg/dL were independent predictors of complications. Increased risk of mortality, after adjusting for other risk factors, was associated with older age, longer perfusion time, receiving intraoperative transfusions, and greater jackknifed approximate entropy of the glucose time series.

Conclusion

We found that hypoglycemia (glucose <71 mg/dL) and hyperglycemia (glucose >140 mg/dL) were associated with increased risk of complications, whereas greater complexity of the glucose time series was associated with mortality.     

Safer glycemic control using isomaltulose-based enteral formula: A pilot randomized crossover trial

Purpose

Preventing harmful hyperglycemia is important in critical illness. However, insulin therapy increases the risk of hypoglycemia. In patients with diabetes, isomaltulose-based enteral formula (IF) feeding has been shown to reduce glycemia. This randomized controlled crossover study was conducted to determine whether IF feeding improves glycemia in postoperative critically ill patients.

Material and Methods

Eight patients who developed hyperglycemia (>150 mg/dL) after esophagectomy were included. Patients were randomized to either the IF or the standard feeding formula (SF) arm. After 16 hours of administration of randomized formula and 8 hours of washout, patients crossed over to the other formula for the next 16 hours. Continuous glucose measurement using STG-22 (Nikkiso, Tokyo, Japan) was performed during the trial.

Results

Maximum blood glucose concentration was 181 mg/dL with IF, significantly lower than the 206 mg/dL with SF (P = .001). Mean glycemia during feeding periods was 162 mg/dL with IF, significantly lower than the 176 mg/dL with SF (P = .0001). Seven (87.5%) patients taking SF exceeded 180 mg/dL compared with 3 (37.5%) patients taking IF (P = .005). This effect was seen without any risk of hypoglycemia and complication.

Conclusions

Isomaltulose-based enteral formula might be useful for safer glycemic control in postoperative critically ill patients. Further study to determine clinical benefit of IF feeding is justified.     

The prevalence of undiagnosed diabetes mellitus and the association of baseline glycemic control on mortality in the intensive care unit: A prospective observational study

Purpose

Hyperglycemia is common during critical illness and can adversely affect clinical outcomes. We sought to determine the prevalence of undiagnosed diabetes among medical intensive care unit (MICU) patients with stress hyperglycemia and the association between baseline glycemic control and mortality.

Materials and methods

A prospective, observational cohort study was performed at a tertiary care MICU. Hemoglobin A1c (HbA1c) levels were obtained from any patient who developed hyperglycemia and all known diabetic patients. We assessed the prevalence of undiagnosed diabetes (defined by HbA1c) among patients with stress hyperglycemia, and the association between baseline glycemic control and mortality.

Results

We enrolled 299 patients. One hundred two (34.1%) had no history and 197 (65.9%) had a history of diabetes. Of the nondiabetic patients, 14 (13.7%) had an HbA1c of at least 6.5%. There was a significant difference in mortality between patients with HbA1c less than 6.5% and those with HbA1c of at least 6.5% (19.3% vs 11.7%, P = .038), despite similar Acute Physiology and Chronic Health Evaluation II scores. There was no significant difference in demographic characteristics between these groups. Multivariable logistic regression revealed lower HbA1c levels to be significantly associated with increased hospital mortality (odds ratio, 1.92; 95% confidence interval, 1.30-2.85; P = .001).

Conclusion

A significant number of MICU patients with stress hyperglycemia have undiagnosed diabetes. Hyperglycemia with lower baseline HbA1c was associated with increased mortality.     

Differing prevalence estimates of elevated blood pressure in ED patients using 4 methods of categorization

Objective

This study examined the variability of blood pressure measurements and prevalence estimates of elevated blood pressure in emergency department (ED) patients using 4 different methods of categorization.

Methods

A prospective, observational study was conducted on adult ED patients with elevated triage blood pressures (systolic ≥140 or diastolic ≥90 mm Hg). Three blood pressure measurements were obtained on all subjects and categorized as follows: (1) triage measurement only, (2) the mean of the triage and second measurement, (3) the mean of the 3 measurements, and (4) the mean of the second and third measurements.

Results

Of 2192 screened patients, 326 were included in the final analysis with mean triage systolic and diastolic blood pressures of 160 and 90 mm Hg, respectively. Prevalence estimates of elevated blood pressure in this sample ranged from 100% (reference standard: mean triage blood pressure) to the most conservative estimate of 67% (fourth method).

Conclusion

Determination of elevated blood pressure in ED patients is largely dependent on the method of blood pressure categorization.     

A randomized controlled trial comparing a computer-assisted insulin infusion protocol with a strict and a conventional protocol for glucose control in critically ill patients

Purpose

The objective of this study is to evaluate blood glucose (BG) control efficacy and safety of 3 insulin protocols in medical intensive care unit (MICU) patients.

Methods

This was a multicenter randomized controlled trial involving 167 MICU patients with at least one BG measurement ≥150 mg/dL and one or more of the following: mechanical ventilation, systemic inflammatory response syndrome, trauma, or burns. The interventions were computer-assisted insulin protocol (CAIP), with insulin infusion maintaining BG between 100 and 130 mg/dL; Leuven protocol, with insulin maintaining BG between 80 and 110 mg/dL; or conventional treatment—subcutaneous insulin if glucose >150 mg/dL. The main efficacy outcome was the mean of patients' median BG, and the safety outcome was the incidence of hypoglycemia (≤40 mg/dL).

Results

The mean of patients' median BG was 125.0, 127.1, and 158.5 mg/dL for CAIP, Leuven, and conventional treatment, respectively (P = .34, CAIP vs Leuven; P < .001, CAIP vs conventional). In CAIP, 12 patients (21.4%) had at least one episode of hypoglycemia vs 24 (41.4%) in Leuven and 2 (3.8%) in conventional treatment (P = .02, CAIP vs Leuven; P = .006, CAIP vs conventional).

Conclusions

The CAIP is safer than and as effective as the standard strict protocol for controlling glucose in MICU patients. Hypoglycemia was rare under conventional treatment. However, BG levels were higher than with IV insulin protocols.     

Evaluation of glucose variability when converting from insulin infusion to basal-bolus regimen in a surgical-trauma intensive care unit

Purpose

This study aimed to identify predictive factors resulting in glucose values greater than 200 mg/dL in patients with trauma transitioned from an insulin infusion to a basal-bolus subcutaneous insulin regimen.

Materials and Methods

Thirty-nine patients with trauma on goal enteral nutrition in the intensive care unit receiving an insulin infusion for at least 48 hours and transitioned to a basal-bolus regimen were retrospectively identified.

Results

Ten patients had hyperglycemic events after transition. Hyperglycemia was significantly associated with increased age (42 [17] years vs 56 [13] years, P = .02), admission glucose (128 [39] mg/dL vs 214 [91] mg/dL, P = .015), and insulin drip rate 48 hours before transition (87 [38] units/d vs 127 [49] units/d, P = .012). There was no difference between groups with respect to injury severity, demographics, or physiologic parameters. Multiple regression analysis revealed that increased age (odds ratio [OR], 1.215 [1.000-1.477]; P = .05), increased admission blood glucose (OR, 1.053 [1.006-1.101]; P = .025), and higher insulin infusion rates 48 hours before transition (OR, 1.061 [1.009-1.116]; P = .020) predisposed patients to severe hyperglycemic episodes.

Conclusions

Older patients with trauma and patients with higher blood glucose on admission are more likely to experience severe hyperglycemia when transitioned to basal-bolus glucose control. Higher insulin infusion rates at 48 hours before transition are also associated with severe hyperglycemia.     

Application of the Sequential Organ Failure Assessment (SOFA) score in patients with advanced cancer who present to the ED

Background

There is limited literature describing clinical predictors for critically ill patients with cancer who present to the emergency department (ED).

Purpose

The aim of this study was to investigate the usefulness of the Sequential Organ Failure Assessment (SOFA) score at the time of ED presentation for predicting short-term mortality in patients with advanced cancer.

Methods

This was a prospective observational study of 108 consecutive patients with advanced cancer who presented to the ED. The outcome was defined as death within 14 days after admission.

Results

The median survival time of the study subjects was 26.5 days (interquartile range, 9.0-78.0 days), and 31 patients (28.7%) died within 14 days after admission. In univariate analysis, SOFA score (≥4), previous chemotherapy, and altered mental status were predictive of 14-day mortality. Of those variables, only SOFA score was an independent predictor in multivariate analysis.

Conclusions

The use of the SOFA score is an acceptable method for risk stratification and prognosis of patients with advanced cancer in the ED. This score can help clinicians to predict 14-day mortality and plan appropriate treatment for critically ill patients with cancer who present to the ED.     

The Relationship of Plasma Glucose and HbA1c Levels among Emergency Department Patients with No Prior History of Diabetes Mellitus

Objectives: Patients without a history of diabetes mellitus may be incidentally found to be hyperglycemic in the emergency department (ED). If the hyperglycemia is due to undiagnosed diabetes, then an opportunity for detection exists. Hemoglobin A1c (HbA1c) provides a weighted average of blood glucose levels over the past several months; high HbA1c levels could indicate diabetes. The objective of this study was to determine whether hyperglycemia in ED patients without a history of diabetes was associated with higher HbA1c levels.
Methods: This was a prospective nonconsecutive case series of adults aged 18 years or older presenting to the ED with acute illness for whom a plasma glucose sample was drawn for clinical management. A history of diabetes/hyperglycemia or current symptoms of diabetes excluded patients. HbA1c levels were analyzed for a glucose cutoff of 110 mg/dL; the data were further analyzed using additional glucose cutoffs. Based on the Third National Health and Nutrition Examination Survey outpatient screening data, an HbA1c level ≥6.2% was considered elevated (sensitivity of 63% and specificity of 97% for identifying diabetes).
Results: There were 541 patients enrolled; the glucose level correlated with the HbA1c level ( r = 0.60, p < 0.001). Among the 331 patients with a glucose level ≥110 mg/dL, 22.4% had an elevated HbA1c level; among the 210 patients with a glucose level < 110 mg/dL, 7.6% had an elevated HbA1c level. There were few patients ( n = 13) with a glucose level ≥200 mg/dL, but most (85%) had an elevated HbA1c level. Among the 140 patients with a mildly elevated glucose level (110–125 mg/dL), 16.4% had an elevated HbA1c level.
Conclusions: Elevated HbA1c levels are found in ED patients with elevated random plasma glucose values. ED patients with hyperglycemia may warrant referral for diabetes testing.     

Hyperglycemia-Induced Hemiballismus Hemichorea: A Case Report and Brief Review of the Literature

Background

Metabolic conditions, including hyperglycemia, can have various neurological presentations. Hemiballismus hemichorea is a rare manifestation reported to occur with severe hyperglycemia and is reversed in most cases with control of sugars.

Case Report

We present a case of a patient with no known diabetes history who presented with uncontrolled jerky movements of one-half of her body, which resolved with achievement of euglycemia.

Conclusions

Important differential diagnoses that need to be evaluated are discussed.     

Fetal outcomes in first trimester pregnancies with an indeterminate ultrasound

Background

Pregnant women commonly present to the Emergency Department (ED) for evaluation during their first trimester. These women have many concerns, one of which is the viability of their pregnancy and the probability of miscarriage.

Study Objectives

We sought to determine fetal outcomes of women with an indeterminate ultrasound who present to the ED during the first trimester of pregnancy.

Methods

A retrospective analysis of consecutive ED patient encounters from December 2005 to September 2006 was performed to identify patients who were pregnant and who had an indeterminate transvaginal ultrasound performed by an emergency physician or through the Radiology Department during their ED visit. Demographic data, obstetric/gynecologic history, and presenting symptoms were recorded onto a standardized patient chart template designed to be used for any first trimester pregnancy. Outcomes (spontaneous abortion, ectopic pregnancy, and 20-week gestation) were determined via computerized medical records.

Results

During the study timeframe, a total of 1164 patients were evaluated in the ED during the first trimester of their pregnancy; 359 patients (30.8%) met inclusion criteria and had a diagnosis of indeterminate ultrasound. Outcome data were obtained for 293 patients. Carrying the pregnancy to ≥20 weeks occurred in 70 patients (23.9%). Spontaneous abortion occurred in 193 women (65.9%), and 30 women (10.2%) were treated for an ectopic pregnancy. Total fetal loss incidence was 89.2% in patients presenting with any vaginal bleeding, compared to 34.7% in patients with pain only.

Conclusion

Indeterminate ultrasounds in the setting of first trimester symptomatic pregnancy are indicative of poor fetal outcomes. Vaginal bleeding increased the risk of fetal loss. These data will assist emergency physicians in counseling women in the ED who are found to have an indeterminate ultrasound.     

Masked Hypoglycemia in the Presence of Icodextrin for Peritoneal Dialysis

Background

Handheld glucose meters remain a rapid means of excluding hypoglycemia as a cause of altered mental status in the Emergency Department. However, emergency physicians must be alert for factors that can mask hypoglycemia at the bedside.

Case Report

An 80-year-old man with diabetes mellitus and end-stage renal disease on peritoneal dialysis presents with altered mental status, hypotension, and a bedside handheld glucose meter reading of 99 mg/dL. His mental status failed to improve with treatment of hypotension and the patient was intubated for airway protection. Laboratory-measured serum glucose was 29 mg/dL. His mental status improved after glucose administration. It was subsequently determined that the patient used icodextrin (Extraneal^®, Baxter Healthcare Corporation, Deerfield, IL) as his peritoneal dialysate. This is partly absorbed into serum and hydrolyzed to oligosaccharides that are falsely detected as glucose by many handheld glucose meters.

Conclusion

The peritoneal dialysate icodextrin can produce falsely elevated bedside glucose meter values. As the prevalence of diabetic nephropathy and dialysis increases, emergency physicians must remain vigilant for such cases of unrecognized hypoglycemia.     

Derangements in blood glucose following initial resuscitation from in-hospital cardiac arrest: A report from the national registry of cardiopulmonary resuscitation

Study aims

Hyperglycemia is associated with poor outcomes in critically ill patients. We examined blood glucose values following in-hospital cardiac arrest (IHCA) to (1) characterize post-arrest glucose ranges, (2) develop outcomes-based thresholds of hyperglycemia and hypoglycemia, and (3) identify risk factors associated with post-arrest glucose derangements.

Methods

We retrospectively studied 17,800 adult IHCA events reported to the National Registry of Cardiopulmonary Resuscitation (NRCPR) from January 1, 2005 through February 1, 2007.

Results

Data were available from 3218 index events. Maximum blood glucose values were elevated in diabetics (median 226 mg/dL [IQR, 165–307 mg/dL], 12.5 mmol/L [IQR 9.2–17.0 mmol/L]) and non-diabetics (median 176 mg/dL [IQR, 135–239 mg/dL], 9.78 mmol/L [IQR 7.5–13.3 mmol/L]). Unadjusted survival to hospital discharge was higher in non-diabetics than diabetics (45.5% [95% CI, 43.3–47.6%] vs. 41.7% [95% CI, 38.9–44.5%], p = 0.037). Non-diabetics displayed decreased adjusted survival odds for minimum glucose values outside the range of 71–170 mg/dL (3.9–9.4 mmol/L) and maximum values outside the range of 111–240 mg/dL (6.2–13.3 mmol/L). Diabetic survival odds decreased for minimum glucose greater than 240 mg/dL (13.3 mmol/L). In non-diabetics, arrest duration was identified as a significant factor associated with the development of hypo- and hyperglycemia.

Conclusions

Hyperglycemia is common in diabetics and non-diabetics following IHCA. Survival odds in diabetics are relatively insensitive to blood glucose with decreased survival only associated with severe (>240 mg/dL, >13.3 mmol/dL) hyperglycemia. In non-diabetics, survival odds were sensitive to hypoglycemia (<70 mg/dL, <3.9 mmol/L).     

The value of procalcitonin level in community-acquired pneumonia in the ED

Objectives

The aim of this study was to investigate the value of procalcitonin (PCT) level in patients with community-acquired pneumonia (CAP) in the emergency department (ED).

Methods

We conducted a prospective study of patients with CAP in the ED. Patients presenting with a clinical and radiographic diagnosis of CAP were enrolled. The authors measured inflammatory biomarkers. The severity of CAP was assessed by 3 prediction rules. We performed an analysis to assess the value of each biomarker for the prediction of mortality and CAP severity.

Results

A total of 126 patients with CAP are included. Sixteen patients who were older and belonged to high-risk group died within 28 days. Nonsurvivors had significantly increased median PCT level (1.96 vs 0.18 ng/mL) and high-sensitivity C-reactive protein (158.57 vs 91.28 mg/dL) compared with survivors. The median PCT levels were significantly higher in more severe disease, on 3 prediction rules. In regression logistic analyses, the area under the receiver operating characteristic curve of PCT level were 0.828 (95% confidence interval, 0.750-0.889). The addition of PCT level to three prediction rules significantly increased the area under the receiver operating characteristic curve. These results suggest that PCT measurement is more versatile tool for predicting mortality and the severity of disease among patients with CAP in the ED.

Conclusions

Procalcitonin level is valuable for predicting mortality and the severity of disease among patients with CAP at ED admission. Procalcitonin level as an adjunct to CAP prediction rules may be valuable for prognosis and severity assessment.     

Amphetamine Abuse in Emergency Department Patients Undergoing Psychiatric Evaluation

Background

Amphetamine abuse accounts for numerous Emergency Department (ED) visits and is often associated with psychiatric disease, with many patients requiring involuntary psychiatric hold placement. It is a common practice in EDs to obtain a urine drug screen (UDS) as part of the “medical clearance” process for psychiatric patients. However, the prevalence of amphetamine-positive UDS in ED patients with psychiatric disease is unknown, as is the relationship of the UDS test to the final patient disposition.

Objectives

The objectives of this study were to determine the prevalence of amphetamine-positive UDS in ED patients undergoing psychiatric evaluation, and whether amphetamine-positive UDS is associated with involuntary psychiatric hold placement.

Methods

This was a retrospective study of adult patients seen in a single urban university ED who had a psychiatric evaluation and a UDS over a 1-year period. Eligible patients had results of the UDS, placement of involuntary holds, past psychiatric history, chief complaint, insurance status, and demographic information recorded. Regression analysis was performed, adjusting for the listed covariates, to evaluate the independent association of amphetamine-positive UDS and involuntary psychiatric hold placement.

Results

A total of 1207 patients were included for analysis. Amphetamine-positive UDS were found in 14.8% of patients. Multivariate analysis showed no association of a psychiatric hold due to presence of amphetamines on UDS (adjusted odds ratio [OR] 0.76, 95% confidence interval [CI] 0.55–1.05, p = 0.1). The only significant factor in placement of an involuntary hold was a past psychiatric history (adjusted OR 1.8, 95% CI 1.2–2.7, p = 0.005).

Conclusions

The prevalence of amphetamine-positive UDS was high in the study population; however, there was no independent association of amphetamine-positive UDS with involuntary psychiatric hospitalization.     

Risk factors for recurrent emergency department visits for hyperglycemia in patients with diabetes mellitus

Background

Patients with poorly controlled diabetes mellitus may present repeatedly to the emergency department (ED) for management and treatment of hyperglycemic episodes, including diabetic ketoacidosis and hyperosmolar hyperglycemic state. The objective of this study was to identify risk factors that predict unplanned recurrent ED visits for hyperglycemia in patients with diabetes within 30 days of initial presentation.

Methods

We conducted a 1-year health records review of patients ≥18 years presenting to one of four tertiary care EDs with a discharge diagnosis of hyperglycemia, diabetic ketoacidosis, or hyperosmolar hyperglycemic state. Trained research personnel collected data on patient characteristics and determined if patients had an unplanned recurrent ED visit for hyperglycemia within 30 days of their initial presentation. Multivariate logistic regression models using generalized estimating equations to account for patients with multiple visits determined predictor variables independently associated with recurrent ED visits for hyperglycemia within 30 days.

Results

There were 833 ED visits for hyperglycemia in the 1-year period. 54.6% were male and mean (SD) age was 48.8 (19.5). Of all visitors, 156 (18.7%) had a recurrent ED visit for hyperglycemia within 30 days. Factors independently associated with recurrent hyperglycemia visits included a previous hyperglycemia visit in the past month (odds ratio [OR] 3.5, 95% confidence interval [CI] 2.1–5.8), age <25 years (OR 2.6, 95% CI 1.5–4.7), glucose >20 mmol/L (OR 2.2, 95% CI 1.3–3.7), having a family physician (OR 2.2, 95% CI 1.0–4.6), and being on insulin (OR 1.9, 95% CI 1.1–3.1). Having a systolic blood pressure between 90–150 mmHg (OR 0.53, 95% CI 0.30–0.93) and heart rate >110 bpm (OR 0.41, 95% CI 0.23–0.72) were protective factors independently associated with not having a recurrent hyperglycemia visit.

Conclusions

This unique ED-based study reports five risk factors and two protective factors associated with recurrent ED visits for hyperglycemia within 30 days in patients with diabetes. These risk factors should be considered by clinicians when making management, prognostic, and disposition decisions for diabetic patients who present with hyperglycemia.

     

Death Caused by Ingestion of an Ethanol-Based Hand Sanitizer

Background

The use of hand sanitizer is effective in preventing the transmission of disease. Many hand sanitizers are alcohol-based, and significant intoxications have occurred, often in health care facilities, including the emergency department (ED).

Objectives

We present this case to highlight potential toxicity after the ingestion of an ethanol-based hand sanitizer.

Case Report

A 36-year-old man presented to the ED with ethanol intoxication. Ethanol breath analysis was measured at 278 mg/dL. After 4 h, the patient was less intoxicated and left the ED. Thirty minutes later, he was found apneic and pulseless in the ED waiting room bathroom after having ingested an ethanol-based hand sanitizer. Soon after a brief resuscitation, his serum ethanol was 526 mg/dL. He never regained consciousness and died 7 days later. No other cause of death was found.

Conclusion

The case highlights the potential for significant toxicity after the ingestion of a product found throughout health care facilities. Balancing the benefit of hand sanitizers for preventing disease transmission and their potential misuse remains a challenge.     

Evaluating the Emergency Department Observation Unit for the management of hyperglycemia in adults

Objective

To determine whether hyperglycemic patients can be successfully managed in the Emergency Department Observation Unit (EDOU), as determined by the frequency of inpatient admission following their EDOU stay.