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Open Access Highly Accessed Research

Diabetic status and the relation of the three domains of glycemic control to mortality in critically ill patients: an international multicenter cohort study

James S Krinsley1*, Moritoki Egi2, Alex Kiss3, Amin N Devendra4, Philipp Schuetz5, Paula M Maurer6, Marcus J Schultz7, Roosmarijn TM van Hooijdonk7, Morita Kiyoshi2, Iain MJ Mackenzie8, Djillali Annane9, Peter Stow10, Stanley A Nasraway11, Sharon Holewinski11, Ulrike Holzinger12, Jean-Charles Preiser13, Jean-Louis Vincent13 and Rinaldo Bellomo14

Author Affiliations

1 Division of Critical Care, Stamford Hospital and Columbia University College of Physicians and Surgeons, 190 West Broad Street, Stamford, CT, 06902, USA

2 Department of Anesthesiology and Resuscitology, Okayama University Hospital, 2-5-1 Shikatachou, Okayama, 700-8525, Japan

3 Institute of Health Policy, Management and Evaluation, University of Toronto, 155 College Street, Toronto, M5T 3M6, Ontario, Canada

4 Medical/Surgical Intensive Care Unit, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL 33756, USA

5 Privat Dozent for Endocrinology and Internal Medicine, Medical University Department, Kantonsspital Aarau, Tellstrasse CH -5001 Aarau, Switzerland

6 BayCare Health Systems, 300 Pinellas Street, Clearwater, FL 33756, USA

7 Department of Intensive Care, Academic Medical Center, Meibergrdeef 9, 1105AZ, Amsterdam, The Netherlands

8 Department of Anesthesia and Critical Care Medicine, University Hospital Birmingham NHS, Mindelsohn Way, Edgbaston, B15 2WB, Birmingham, UK

9 Critical Care Department, Service de Réanimation, Hopital Raymond Poincaré, Université de Versailles SQY, 104 Boulevard Raymond Poincare, 92830, Garches, France

10 Intensive Care Unit, The Geelong Hospital, Barwon Health, Ryrie Street, Geelong, Victoria, 3220, Australia

11 Surgical Intensive Care Units, Tufts Medical Center, 800 Washington Street, NEMC 4360, Boston, MA 02111, USA

12 Medical Intensive Care Unit, Department of Medicine III, Division of Gastroenterology and Hepatology, ICU 13H1, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria

13 Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, Brussels, 1070, Belgium

14 Department of Intensive Care, Austin Hospital and Monash University, Studley Road, Heidelberg, Victoria, 3084, Australia

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Critical Care 2013, 17:R37  doi:10.1186/cc12547

Published: 1 March 2013

Abstract

Introduction

Hyperglycemia, hypoglycemia, and increased glycemic variability have each been independently associated with increased risk of mortality in critically ill patients. The role of diabetic status on modulating the relation of these three domains of glycemic control with mortality remains uncertain. The purpose of this investigation was to determine how diabetic status affects the relation of hyperglycemia, hypoglycemia, and increased glycemic variability with the risk of mortality in critically ill patients.

Methods

This is a retrospective analysis of prospectively collected data involving 44,964 patients admitted to 23 intensive care units (ICUs) from nine countries, between February 2001 and May 2012. We analyzed mean blood glucose concentration (BG), coefficient of variation (CV), and minimal BG and created multivariable models to analyze their independent association with mortality. Patients were stratified according to the diagnosis of diabetes.

Results

Among patients without diabetes, mean BG bands between 80 and 140 mg/dl were independently associated with decreased risk of mortality, and mean BG bands

    >
140 mg/dl, with increased risk of mortality. Among patients with diabetes, mean BG from 80 to 110 mg/dl was associated with increased risk of mortality and mean BG from 110 to 180 mg/dl with decreased risk of mortality. An effect of center was noted on the relation between mean BG and mortality. Hypoglycemia, defined as minimum BG <70 mg/dl, was independently associated with increased risk of mortality among patients with and without diabetes and increased glycemic variability, defined as CV
    >
20%, was independently associated with increased risk of mortality only among patients without diabetes. Derangements of more than one domain of glycemic control had a cumulative association with mortality, especially for patients without diabetes.

Conclusions

Although hyperglycemia, hypoglycemia, and increased glycemic variability is each independently associated with mortality in critically ill patients, diabetic status modulates these relations in clinically important ways. Our findings suggest that patients with diabetes may benefit from higher glucose target ranges than will those without diabetes. Additionally, hypoglycemia is independently associated with increased risk of mortality regardless of the patient's diabetic status, and increased glycemic variability is independently associated with increased risk of mortality among patients without diabetes.

See related commentary by Krinsley, http://ccforum.com/content/17/2/131 webcite

See related commentary by Finfer and Billot, http://ccforum.com/content/17/2/134 webcite