Time in blood glucose range 70 to 140 mg/dl >80% is strongly associated with increased survival in non-diabetic critically ill adults

Abstract

Introduction: Hyperglycemia, hypoglycemia and increased glucose variability are independently associated with increased risk of death in critically ill adults. The relationship between time in targeted blood glucose range (TIR) and mortality is not well described and may be a factor that has confounded the results of the major interventional trials of intensive insulin therapy.

Methods: We conducted a retrospective analysis of prospectively collected data involving 3,297 patients with intensive care unit (ICU) lengths of stay (LOS) of ≥ 1.0 day who were admitted between 1 January 2009 and 31 December 2013 to a single mixed medical-surgical ICU. We investigated the relationship between TIR 70 to 140 mg/dl with mortality and compared outcomes of non-diabetics (NON) and individuals with diabetes mellitus (DM), including stratifying by TIR above (TIR-hi) and below (TIR-lo) the median value for the NON and DM groups.

Results: There were 85,799 blood glucose (BG) values for the NON group and 32,651 for the DM group, and we found that 75.5% and 54.8%, respectively, were between 70 and 140 (P < 0.0001). The median (interquartile range) TIR (%) values for the NON and DM groups were 80.6% (61.4% to 94.0%) and 55.0% (35.5% to 71.1%), respectively (P < 0.0001). For the NON group, mortality was 8.47% and 15.71% for TIR-hi and TIR-lo, respectively (P < 0.0001). For the DM group, mortality was 16.09% and 14.44% for TIR-hi and TIR-lo, respectively (P = NS). We observed similar relationships for the NON group when we stratified by ICU LOS or severity of illness, especially in the most severely ill patients. There was a cumulative interaction of indices of hypoglycemia, hyperglycemia or glucose variability with TIR. Multivariable analysis demonstrated, for the NON group, that TIR-hi was independently associated with increased survival (P = 0.0019). For the NON group, the observed-to-expected mortality ratios for TIR-hi and TIR-lo, based on Acute Physiology and Chronic Health Evaluation IV methodology, were 0.53 and 0.78, respectively. In contrast, among those in the DM group, there was no clear relationship between TIR 70 to 140 mg/dl and survival.

Conclusions: Independently of ICU LOS and severity of illness, TIR 70 to 140 mg/dl > 80% is strongly associated with survival in critically ill patients without diabetes. These findings have implications for the design of clinical protocols for glycemic control in critically ill patients as well for the design of future interventional trials of intensive insulin therapy.

Figure 1

Distribution of percentages time in targeted blood glucose range for patients without or with diabetes. DM, Diabetes mellitus group; NON, Patients without diabetes mellitus; TIR, Time in targeted blood glucose range.

Figure 2

Relationship of time in range to mortality, stratified by intensive care unit length of stay, in the group of patients without diabetes. ICU LOS, Intensive care unit length of stay; TIR-hi, Time in targeted blood glucose range above median value for non-diabetic and diabetes mellitus groups; TIR-lo, Time in targeted blood glucose range below median value for non-diabetic and diabetes mellitus groups.

Figure 3

Relationship of time in range to mortality, stratified by Acute Physiology Score, in the group of patients without diabetes. APS, Acute Physiology Score component of the Acute Physiology and Chronic Health Evaluation IV severity scoring system; TIR-hi, Time in targeted blood glucose range above median value for non-diabetic and diabetes mellitus groups; TIR-lo, Time in targeted blood glucose range below median value for non-diabetic and diabetes mellitus groups.

Figure 4

Observed-to-expected mortality ratio for of time above and below targeted blood glucose range in the group of patients without diabetes. TIR-hi, Time in targeted blood glucose range above median value for non-diabetic and diabetes mellitus groups; TIR-lo, Time in targeted blood glucose range below median value for non-diabetic and diabetes mellitus groups.