Home About us Editorial board Search Ahead of print Current issue Archives Submit article Instructions Subscribe Contacts Login 


 
 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 3  |  Page : 935-939

Study of hyperglycemia in critically ill patients and its impact on the outcome


1 Internal Medicine Department, Faculty of Medicine, Menoufia University, Shebeen El-Kom, Egypt
2 Internal Medicine Department, Mit Ghamr General Hospital, Mit Ghamr, Egypt

Date of Submission01-Mar-2017
Date of Acceptance09-May-2017
Date of Web Publication31-Dec-2018

Correspondence Address:
Aliaa S Tawfiek
Mogama El-Mahakem, Mansura, Dakahlia
Egypt
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_157_17

Rights and Permissions
  Abstract 


Objective
The aim of this study was to evaluate the control of hyperglycemia in diabetic patients by evaluating glycosylated hemoglobin A1c (HbA1c), to differentiate between already diabetic patients and stress-induced hyperglycemia in patients who presented with first-time hyperglycemia, and to study the effect of hyperglycemia on mortality.
Background
Hyperglycemia is common in critically ill patients and has poor impact on the outcome. Therefore, it should be discovered early and controlled by evaluating glycosylated HbA1c.
Patients and methods
This cross-sectional study included 281 patients attending the ICU of Mit Ghamr General Hospital, Dakahlia, Egypt, for a period of 1 year from May 2015 to May 2016. These patients were classified as diabetic patients, patients with first-time hyperglycemia, and nondiabetic patients. After obtaining written informed consent from patients or from relatives of comatose patients, all patients were evaluated clinically and by means of routine laboratory investigations including the following: random blood sugar, fasting blood sugar, HbA1c, complete blood count, prothrombin time, international normalized ratio, serum creatinine, blood urea, and serum albumin for all patients and computed tomography of the brain, arterial blood gases, and cardiac enzyme for selected cases.
Results
Hyperglycemic patients with higher HbA1c showed worst outcomes with increased mortality. Stroke, renal impairment, and higher HbA1c were independent risk factors for mortality in ICU patients. There was a significant positive relationship between HbA1c and white blood cells, blood urea, and creatinine. Moreover, there was a negative relationship between HbA1c and red blood cells, hemoglobin, and albumin.
Conclusion
Hyperglycemia is a common phenomenon in critically ill patients regardless of whether or not the patients were diabetic; the higher the HbA1c, the higher the incidence of mortality and complications.

Keywords: critically ill patients, hyperglycemia, mortality, outcome


How to cite this article:
El-Nagar MG, El-Raouf MA, El-Dien WS, Nooh MZ, Tawfiek AS. Study of hyperglycemia in critically ill patients and its impact on the outcome. Menoufia Med J 2018;31:935-9

How to cite this URL:
El-Nagar MG, El-Raouf MA, El-Dien WS, Nooh MZ, Tawfiek AS. Study of hyperglycemia in critically ill patients and its impact on the outcome. Menoufia Med J [serial online] 2018 [cited 2019 Jun 20];31:935-9. Available from: http://www.mmj.eg.net/text.asp?2018/31/3/935/248725




  Introduction Top


Hyperglycemia or high blood sugar is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally characterized by the random blood sugar level higher than 11.1 mmol/1 (200 mg/dl), but symptoms may not start to become noticeable until even higher values such as 15–20 mmol/1 (250–300 mg/dl)[1].

Hyperglycemia in critically ill patients may be acute or chronic, and the most common cause of chronic hyperglycemia is diabetes mellitus and acute hyperglycemia, which may be due to stress as it is a common phenomenon in critically ill patients. Other causes of hyperglycemia are the long use of medications such as corticosteroids, β-blockers, and thiazied diuretics[2].

Stress hyperglycemia is mediated by the hypothalamic–pituitary–adrenal axis and the sympathy-adrenal system. In general, there is a graded response to the degree of stress. Cortisol and catecholamine levels correlate with the type of illness, severity of the condition, and Glasgow Coma Scale. Adrenal cortisol output increases up to 10-fold with severe stress (∼300 mg hydrocortisone/day). In patients with shock, plasma concentration of epinephrine increases 50-fold and norepinephrine level increases 10-fold, and the adrenal medulla is the main source of this released catecholamine. The increased release of stress hormones results in many effects (metabolic, cardiovascular, and immune) aimed at restoring homeostasis during stress. The hypothalamic–pituitary–adrenal axis, the sympathy-adrenal system, and proinflammatory cytokines (tumor necrotic factor, interlukin-1, and interlukin-6) all act collectively to induce stress hyperglycemia[3].

Hyperglycemia at the time of hospital admission predicts increased mortality in critically ill patients. The relation between blood glucose and mortality appears linear, escalating the risk associated with increasing blood glucose level, and is independent of a diagnosis of the diabetes. However, there are ongoing debates as to whether hyperglycemia directly contributes to the adverse outcomes or whether it is simply a marker of higher risk[4].

Intensive care medicine is a branch of medicine concerned with life support for critically ill patients. The ICU is a hospital facility for provision of intensive nursing and medical care for critically ill patients, characterized by high quality and quantity of continuous nursing and medical supervision using of sophisticated monitoring and resuscitative equipment organized for the care of specific patient group[5].


  Aim Top


This study aimed to evaluate the control of hyperglycemia in diabetic patients by evaluating glycosylated hemoglobin A1c (HbA1c) to differentiate between already diabetic patients and induced stress hyperglycemia in patients who presented with first-time hyperglycemia and to study the effect of hyperglycemia on mortality.


  Patients and Methods Top


After obtaining approval from the Hospital Ethics Committee and written informed patient consent with an explanation as regards the purpose, methods, effects, and complications, this cross-sectional study was conducted on 281 critically ill patients attending the ICU of Mit Ghamr General Hospital Dakahlia, Egypt, during the period of 1 year from May 2015 to May 2016. All patients were evaluated clinically and by means of routine laboratory investigations including the following: random blood sugar (RBS), fasting blood sugar, HbA1c, complete blood count, blood urea, serum creatinine, prothrombin time, international normalized ratio, and serum albumin for all patients and arterial blood gases, cardiac enzyme, and computed tomography of the brain for selected patients.

Statistical analysis

The data were collected, tabulated, and analyzed using statistical package for the social science (SPSS), version 17.0 on IBM compatible computer (SPSS Inc., Chicago, Illinois, USA).

Analytic statistics

Analytic statistics include the following tests: (I) the χ2 was used to study the association between two or more qualitative variables. (II) The F-test (analysis of variance) is a parametric test used for comparison between more than two groups of normally distributed quantitative variables. (III) Regression analysis is a statistical process for estimating the relationships among variables. It includes many techniques for modeling and analyzing several variables, when the focus is on the relationship between dependent variables and one or more independent variables. A P value of less than 0.05 was considered statistically significant. (IV) Pearson's correlation is a measure of the linear correlation or dependence between two variables X and Y, giving a value between +1 and −1 inclusive, where 1 is total positive correlation, 0 is no correlation, and −1 is total negative correlation. (V) Spearman's correlation (r) is a test used to measure the association between two not normally distributed quantitative variables or one quantitative and one qualitative ordinal variable. (VI) Odds ratio (OR) is a measure of association between an exposure and an outcome. The OR represents the odds that an outcome will occur given a particular exposure, compared with the odds of the outcome occurring in the absence of that exposure.


  Results Top


This study included 281 patients. Among them 113 (48.4%) patients died, 32 (11.4%) patients had complications, and 136 (40.2%) patients showed improvement [Figure 1].
Figure 1: Outcome of hyperglycaemia in critical ill patient.

Click here to view


This study included 281 patients, of whom 165 (58.7%) patients were known diabetic patients, 75 (26.7%) patients were nondiabetic patients, and 41 (14.6%) patients presented with first-time hyperglycemia.

According to HbA1c, of the 165 known diabetic patients, 25 (15.2%) patients had controlled diabetes with HbA1c ranging from 6.4 to 7% and 140 (74.8%) patients had uncontrolled diabetes with HbA1c more than 7%.

A total of 185 (65.8%) patients presented with hyperglycemia according to RBS more than 200 mg/dl. Among them, 144 (77.8%) patients known diabetic patients presented with hyperglycemia as not all diabetic patients presented with hyperglycemia, compared with 41 (22.2%) patients with first-time hyperglycemia. According to their HbA1c it was found that 31 (16.7%) patients were already diabetic and 10 (5.4%) patients were not diabetic and just suffered from stress-induced hyperglycemia.

Concerning baseline general characteristics, there was a significant relation between higher age and occurrence of complications and mortality (P = 0.001). However, there was a nonsignificant relation between sex and outcome [Figure 2].
Figure 2: Relationship between age, gender and outcome of the studied cases.

Click here to view


Differential outcome of diabetic and hyperglycemic patients according to HbA1c (206 patients doing HbA1c evaluation) shows that, the higher HbA1c, the higher occurrence of mortality and complication: HbA1C more than 10 (P = 0.001) [Table 1].
Table 1: Differential outcome of diabetic and hyperglycemic patients according to hemoglobin A1c (206 patients underwent hemoglobin A1c evaluation)

Click here to view


Multivariate regression analysis for independent risk factors of mortality among critically ill patients shows that HbA1c, stroke, and renal diseases are independent risk factors for mortality among critically ill patients (OR = 2.30, 4.59, and 2.60, respectively) [Table 2].
Table 2: Multivariate regression analysis for independent risk factors of mortality among critically ill patients

Click here to view


Correlation between HbA1c and investigations revealed the following: a significant negative correlation between HbA1C and red blood cells (P = 0.001); a significant positive correlation between HbA1C and white blood cells (P = 0.001); a significant negative correlation between HbA1C and Hb (P = 0.001); a significant negative correlation between HbA1C and albumin (P = 0.001); a significant positive correlation between HbA1C and urea (P = 0.001); and a significant positive correlation between HbA1C and creatinine (P = 0.001) [Figure 3] and [Figure 4].
Figure 3: The relationship between HbA1C and Leucocytes.

Click here to view
Figure 4: The relationship between HbA1C and Albumin.

Click here to view



  Discussion Top


In present study, the number of diabetic patient was 165 (58.7%); of them, 144 patients presented with hyperglycemia and it was more than the number of patients who presented with stress hyperglycemia (5.4%). This is in agreement with Al-Kassir[6], who reported the same results and confirmed that the number of known diabetic patients is more than the number of stress hyperglycemic patients. Moreover, in the present study the number of normoglycemic patients was 75 (26.7%) and this is less than the diabetic patients who entered the ICU. This result is not in agreement with Al-Kassir[6], who showed that the number of normoglycemic patients was higher than the number of diabetic patients. This is may be attributed to the fact that the number of patients in his study was less than that in the present study as in the present study there were 281 patients and in his study there were 179 patients[6].

In the present work, older patients with higher age had the worst outcomes and there was a significant relationship between age and the occurrence of mortality and complication; the mean age in the present study was 65.53 ± 12.84. Moreover, in the present work younger patients had better outcome. This is in agreement with the study by Soares et al.[7] who reported same result and confirmed the association of higher age with decreased survival rate and increased mortality.

In the present work there was no significant difference in the outcome among the studied patients as regards sex. This result is not in agreement with the study by Jneid et al.[8], who showed that the incidence of mortality is higher in men (39.7%) than in women (32.5%), and this may due to the longer duration in the study by Jneid et al.[8] compared with the duration in the present study.

In the present work, there was a significant relationship between HbA1c and mortality; the higher the HbA1c, the higher the mortality. This is in agreement with the study by Mahmood et al.[9], who reported the same result and confirmed the association between higher HbA1c and the incidence of higher mortality and complication. Moreover, in the present work there was a significant relationship between RBS and mortality rate. This is in agreement with the study by Mahmood et al.[9], who reported the same result and also confirmed the association between the RBS and increased mortality[9].

In the present study the multivariate regression analysis for independent risk factors of mortality among critically ill patients showed that HbA1c, stroke, and renal disease were the most independent risk factors for mortality. This is in agreement with the study by Mayr et al.[10], who reported the same result and confirmed that higher HbA1c, renal disease, and stroke were the most independent risk factors for mortality in ICU. Moreover, in the present study, cardiac patients showed improvement (58.8%), and this result is in disagreement with the study by Mayr et al.[10], who showed that the cardiac diseases were one of the most independent risk factors for mortality in ICU patients. This may be due to the large sample of patients (3700) in the study by Mayr et al.[10], but in the present study only 281 patients were included.

In the present study, there was a significant positive relationship between HbA1c and leukocytes. This is in agreement with the study by Damman et al.

In the present study there was a significant negative relationship between HbA1c and albumin level. This result is in agreement with El Saied et al.[12], who reported the same result and confirmed the significant negative relationship between HbA1c and albumin[12].

Current study showed that there was a significant positive relationship between HbA1c and serum creatinine. This result is in agreement with the study by Farasat et al.[13], who reported the same result and confirmed that there was a significant positive relationship between HbA1c and creatinine[13].

In the present work there was a significant positive relationship between HbA1c and blood urea. This result is in agreement with the study by Abdelsalam and Mohamed Elamin et al.[14], who reported the same result and confirmed that there was a significant positive relationship between HbA1c and blood urea[14].


  Conclusion Top


Hyperglycemia is a common phenomenon in critically ill patients regardless of whether or not the patients were diabetic; the higher the HbA1c, the higher the incidence of mortality and complication. HbA1c, coma, and renal impairment are independent risk factor for mortality in critically ill patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
American Diabetes Association guidelines. Diabetes experts issue new recommendation for inpatients glycemic control – call for systemic changes in Hospital Nationwide. Diabetes Care 2009; 20 (Suppl 2): S18–S76.  Back to cited text no. 1
    
2.
Sommerfield AJ, Deary IJ, Frier BM. Acute hyperglycemia alters mood state and impairs cognitive performance in people with type 2 diabetes. Diabetes Care 2004; 27:2335–2340.  Back to cited text no. 2
    
3.
Marik PE. Critical illness related corticoseroid insufficiency. Chest 2009; 135:181–193.  Back to cited text no. 3
    
4.
Agnelli G, Katz DL, Hulinsky I. Cryptogenic stroke: time to determine aetiology. J Thromb Haemost 2008; 6:549–554.  Back to cited text no. 4
    
5.
Chanques G, Pohlman A, Kress JP, Molinari N, de Jong A, Jaber S, Hall JB. Psychometric comparison of three behavior scales for the assessment of critically ill patients. Crit Care 2014; 18:R106.  Back to cited text no. 5
    
6.
Al-Kassir AH. The incidence of stress hyperglycemia in acute ischemic stroke patients in Al-Yarmouk teaching hospital. Mustansiriya Med J 2012; 11:46–51.  Back to cited text no. 6
    
7.
Soares M, Carvalho MS, Sallah T, Ferreira CG, Luiz RR. Effect of age on survival in critically ill patients. Intensive Care Med 2014; 31:408–415.  Back to cited text no. 7
    
8.
Jneid H, Fonarow GC, Cannon CP, Hernandez AF, Palacios IF, Maree AO, et al. Get With the Guidelines Steering Committee and Investigators. Sex differences in medical care and early death in intensive care unit patients. Circulation 2008; 118:2803–2810.  Back to cited text no. 8
    
9.
Mahmoodpoor A, Hamishehkar H, Beigmohammadi M, Iranpour A, Sanaie S. Relationship between glycated hemoglobin in intensive care unit admission blood sugar and glucose control with ICU mortality in critically ill patients. Indian J Crit Care Med 2008; 20:67–71.  Back to cited text no. 9
    
10.
Mayr VD, Dünser MW, Greil V, Jochberger S. Causes of death and determinants of outcome in critically ill patients. Crit Care 2006; 15:47–53.  Back to cited text no. 10
    
11.
Damman P, Beijk MA, Kuijt WJ, Verouden NJ, van Geloven N. Multiple biomarkers at admission significantly improve the prediction of mortality in patients undergoing primary percutaneous coronary intervention for acute ST-segment elevation myocardial infarction. J Am Coll Cardiol 2011; 57:29–36.  Back to cited text no. 11
    
12.
Tiwari S, Bothale M, Imtiaz H, Mahesh JK, Mehmood GS, et al. Association between serum albumin and glycated hemoglobin in Asian Indian subjects. Indian J Endocrinol Metab 2015; 19:52–55.  Back to cited text no. 12
    
13.
Farasat T, Sharif S, Naz S, Fazal S. Significant association of serum creatinine with HbA1C in impaired glucose tolerant. Pak J Med Sci 2015; 31:991–994.  Back to cited text no. 13
    
14.
Abdelsalam KA, Mohamed Elamien AE. Correlation between urea level and HbA1c level in type 2 diabetic patients. Sub Med Lab 2011; 1:1–6.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2]



 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
Abstract
Introduction
Aim
Patients and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed244    
    Printed0    
    Emailed0    
    PDF Downloaded13    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]