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Risk factors for hypoglycaemia in neurocritical care patients

Freya M. van Iersel| Arjen J. C. Slooter| Renee Vroegop| Annemiek E. Wolters| Charlotte A. M. Tiemessen| Rik H. J. Rösken| Johannes G. van der Hoeven| Linda M. Peelen| Cornelia W. E. Hoedemaekers
Original
Volume 38, Issue 12 / December , 2012

Pages 1999 - 2006

Abstract

Purpose

To identify risk factors for hypoglycaemia in neurocritical care patients receiving intensive insulin therapy (IIT).

Methods

We performed a nested case–control study. All first episodes of hypoglycaemia (glucose <80 mg/dL, <4.4 mmol/L) in neurocritical care patients between 1 March 2006 and 31 December 2007 were identified. Patients were treated according to the local IIT protocol, with target blood glucose levels between 4.5 and 6.0 mmol/L (81.0–108.0 mg/dL). The first hypoglycaemic event of every patient (index moment) was used to match to a control patient. Possible risk factors preceding the index moment were scored using hospital records and analysed with conditional logistic regression.

Results

Of 786 neurocritical care patients, 449 developed hypoglycaemia (57.1 %). Independent risk factors for hypoglycaemia were lowering nutrition 6 h before the index moment without insulin dose reduction (odds ratio (OR) 5.25, 95 % confidence interval (95 % CI) 1.32–20.88), mechanical ventilation (OR 2.59, 95 % CI 1.56–4.29), lowering the dosage of norepinephrine 3 h before the index moment (OR 2.44, 95 % CI 1.07–5.55), a hyperglycaemic event (>10 mmol/L, >180.0 mg/dL) in the 24 h preceding the index moment (OR 2.40, 95 % CI 1.26–4.58), gastric residual in the 6 h preceding the index moment without insulin dose reduction (OR 1.76, 95 % CI 1.05–2.96) and dosage of insulin at the index moment (OR 0.83, 95 % CI 0.76–0.90).

Conclusion

Hypoglycaemia occurs in a considerable proportion of neurocritical care patients. We recommend the identification of these risk factors in these patients to avoid the occurrence of hypoglycaemia.

Keywords

References

  1. Van den Berghe G, Schoonheydt K, Becx P, Bruyninckx F, Wouters PJ (2005) Insulin therapy protects the central and peripheral nervous system of intensive care patients. Neurology 64:1348–1353
    • View reference on PubMed
    • View reference on publisher's website
  2. Johnston KC, Hall CE, Kissela BM, Bleck TP, Conaway MR (2009) Glucose Regulation in Acute Stroke Patients (GRASP) trial: a randomized pilot trial. Stroke 40:3804–3809
    • View reference on PubMed
    • View reference on publisher's website
  3. Bilotta F, Caramia R, Cernak I, Paoloni FP, Doronzio A, Cuzzone V, Santoro A, Rosa G (2008) Intensive insulin therapy after severe traumatic brain injury: a randomized clinical trial. Neurocrit Care 9:159–166
    • View reference on PubMed
    • View reference on publisher's website
  4. Bilotta F, Spinelli A, Giovannini F, Doronzio A, Delfini R, Rosa G (2007) The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: a randomized prospective pilot trial. J Neurosurg Anesthesiol 19:156–160
    • View reference on PubMed
    • View reference on publisher's website
  5. Bruno A, Kent TA, Coull BM, Shankar RR, Saha C, Becker KJ, Kissela BM, Williams LS (2008) Treatment of hyperglycemia in ischemic stroke (THIS): a randomized pilot trial. Stroke 39:384–389
    • View reference on PubMed
    • View reference on publisher's website
  6. Coester A, Neumann CR, Schmidt MI (2010) Intensive insulin therapy in severe traumatic brain injury: a randomized trial. J Trauma 68:904–911
    • View reference on PubMed
  7. Green DM, O’Phelan KH, Bassin SL, Chang CWJ, Stern TS, Asai SM (2010) Intensive versus conventional insulin therapy in critically ill neurologic patients. Neurocrit Care 13:299–306
    • View reference on PubMed
    • View reference on publisher's website
  8. Oksanen T, Skrifvars MB, Varpula T, Kuitunen A, Pettila V, Nurmi J, Castrén M (2007) Strict versus moderate glucose control after resuscitation from ventricular fibrillation. Intensive Care Med 33:2093–2100
  9. Thiele RH, Pouratian N, Zuo Z, Scalzo DC, Dobbs HA, Dumont AS, Kassell NF, Nemergut EC (2009) Strict glucose control does not affect mortality after aneurysmal subarachnoid hemorrhage. Anesthesiology 110:603–610
    • View reference on PubMed
    • View reference on publisher's website
  10. Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Hedenstierna G, Joannidis M, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Preiser JC, Pugin J, Wernerman J, Zhang H (2010) Year in review in Intensive Care Medicine 2009: I. Pneumonia and infections, sepsis, outcome, acute renal failure and acid base, nutrition and glycaemic control. Intensive Care Med 36:196–209
  11. Eslami S, Abu-Hanna A, de Keizer NF, Bosman RJ, Spronk PE, de Jonge E, Schultz MJ (2010) Implementing glucose control in intensive care: a multicenter trial using statistical process control. Intensive Care Med 36:1556–1565
  12. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K, German Competence Network Sepsis (SepNet) (2008) Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358:125–139
    • View reference on PubMed
    • View reference on publisher's website
  13. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297
  14. Kreisel SH, Berschin UM, Hammes H-P, Leweling H, Bertsch T, Hennerici MG, Schwarz S (2009) Pragmatic management of hyperglycaemia in acute ischaemic stroke: safety and feasibility of intensive intravenous insulin treatment. Cerebrovasc Dis 27:167–175
    • View reference on PubMed
    • View reference on publisher's website
  15. Mechanick JI, Handelsman Y, Bloomgarden ZT (2007) Hypoglycemia in the intensive care unit. Curr Opin Clin Nutr Metab Care 10:193–196
    • View reference on PubMed
    • View reference on publisher's website
  16. Tiemessen CA, Hoedemaekers CW, van Iersel FM, Rösken GH, van der Hoeven J, Biessels GJ, Slooter AJ (2011) Intensive insulin therapy increases the risk of hypoglycemia in neurocritical care patients. J Neurosurg Anesthesiol 23:206–214
    • View reference on PubMed
    • View reference on publisher's website
  17. Wiener RS, Wiener DC, Larson RJ (2008) Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 300:933–944
    • View reference on PubMed
    • View reference on publisher's website
  18. Shan L, Hao PP, Chen YG (2011) Efficacy and safety of intensive insulin therapy for critically ill neurologic patients: a meta-analysis. J Trauma 71:1460–1464
    • View reference on PubMed
    • View reference on publisher's website
  19. Oddo M, Schmidt JM, Carrera E, Badjatia N, Connolly ES, Presciutti M, Ostapkovich ND, Levine JM, Le Roux P, Mayer SA (2008) Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: a microdialysis study. Crit Care Med 36:3233–3238
    • View reference on PubMed
    • View reference on publisher's website
  20. Schlenk F, Nagel A, Graetz D, Sarrafzadeh AS (2008) Hyperglycemia and cerebral glucose in aneurysmal subarachnoid hemorrhage. Intensive Care Med 34:1200–1207
  21. Vespa P, Boonyaputthikul R, McArthur DL, Miller C, Etchepare M, Bergsneider M, Glenn T, Martin N, Hovda D (2006) Intensive insulin therapy reduces microdialysis glucose values without altering glucose utilization or improving the lactate/pyruvate ratio after traumatic brain injury. Crit Care Med 34:850–856
    • View reference on PubMed
    • View reference on publisher's website
  22. Naidech AM, Levasseur K, Liebling S, Garg RK, Shapiro M, Ault ML, Afifi S, Batjer HH (2010) Moderate hypoglycemia is associated with vasospasm, cerebral infarction, and 3-month disability after subarachnoid hemorrhage. Neurocrit Care 12:181–187
    • View reference on PubMed
    • View reference on publisher's website
  23. Schmutzhard E, Rabinstein AA (2011) Spontaneous subarachnoid hemorrhage and glucose management. Neurocrit Care 15:281–286
    • View reference on PubMed
    • View reference on publisher's website
  24. Arabi YM, Tamim HM, Rishu AH (2009) Hypoglycemia with intensive insulin therapy in critically ill patients: predisposing factors and association with mortality. Crit Care Med 37:2536–2544
    • View reference on PubMed
    • View reference on publisher's website
  25. Krinsley JS, Grover A (2007) Severe hypoglycemia in critically ill patients: risk factors and outcomes. Crit Care Med 35:2262–2267
    • View reference on PubMed
    • View reference on publisher's website
  26. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461
    • View reference on PubMed
    • View reference on publisher's website
  27. Vriesendorp TM, van Santen S, DeVries JH, de Jonge E, Rosendaal FR, Schultz MJ, Hoekstra JB (2006) Predisposing factors for hypoglycemia in the intensive care unit. Crit Care Med 34:96–101
    • View reference on PubMed
    • View reference on publisher's website
  28. Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: a severity of disease classification system. Crit Care Med 13:818–829
    • View reference on PubMed
    • View reference on publisher's website
  29. Robertshaw M, Lai KN, Swaminathan R (1989) Prediction of creatinine clearance from plasma creatinine: comparison of five formulae. Br J Clin Pharmacol 28:275–280
    • View reference on PubMed
    • View reference on publisher's website
  30. Hermanides J, Vriesendorp TM, Bosman RJ, Zandstra DF, Hoekstra JB, Devries JH (2010) Glucose variability is associated with intensive care unit mortality. Crit Care Med 38:838–842
    • View reference on PubMed
    • View reference on publisher's website
  31. Krinsley JS (2008) Glycemic variability: a strong independent predictor of mortality in critically ill patients. Crit Care Med 36:3008–3013
    • View reference on PubMed
    • View reference on publisher's website
  32. Meyfroidt G, Keenan DM, Wang X, Wouters PJ, Veldhuis JD, Van den Berghe G (2010) Dynamic characteristics of blood glucose time series during the course of critical illness: effects of intensive insulin therapy and relative association with mortality. Crit Care Med 38:1021–1029
    • View reference on PubMed
    • View reference on publisher's website
  33. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive insulin therapy in critically ill patients. N Engl J Med 345:1359–1367
    • View reference on PubMed
    • View reference on publisher's website
  34. Schlenk F, Vajkoczy P, Sarrafzadeh A (2009) Inpatient hyperglycemia following aneurysmal subarachnoid hemorrhage: relation to cerebral metabolism and outcome. Neurocrit Care 11:56–63
    • View reference on PubMed
    • View reference on publisher's website
  35. Meierhans R, Béchir M, Ludwig S, Sommerfeld J, Brandi G, Haberthür C, Stocker R, Stover JF (2010) Brain metabolism is significantly impaired at blood glucose below 6 mM and brain glucose below 1 mM in patients with severe traumatic brain injury. Crit Care 14:R13
    • View reference on PubMed
    • View reference on publisher's website
  36. Su YY, Li X, Li SJ, Luo R, Ding JP, Wang L, Cao GH, Wang DY, Gao JX (2009) Predicting hospital mortality using APACHE II scores in neurocritically ill patients: a prospective study. J Neurol 256:1427–1433
    • View reference on PubMed
    • View reference on publisher's website
  37. Hoedemaekers CWE, Klein Gunnewiek JMT, Prinsen MA, Willems JL, Van der Hoeven JG (2008) Accuracy of bedside glucose measurement from three glucometers in critically ill patients. Crit Care Med 36:3062–3066
    • View reference on PubMed
    • View reference on publisher's website

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