Blood Glucose To Predict Critical Illness Requiring Hospitalization
Overview
This retrospective single-center cohort study aimed to assess the potential utility of prehospital blood glucose (PBG) levels as a tool for risk assessment in critical illness.
Analyzing records of 970 patients admitted to a university hospital by emergency physicians, the study classified patients into two groups based on PBG levels: those with PBG ≥ 140 mg/dL (G1, n=394) and those with PBG < 140 mg/dL (G2, n=576). Multivariable logistic regression models were applied to adjust for age, pre-diagnosed diabetes, and sex.
The results indicated that 55% of the patients were hospitalized, and hyperglycemic patients (G1) demonstrated a higher likelihood of hospitalization compared to normoglycemic patients (G2), with an adjusted odds ratio (OR) of 1.48 (95% confidence interval [CI] 1.11–1.97).
Additionally, hyperglycemic patients were more prone to intensive care unit (ICU) admission, with an adjusted OR of 1.74 (95% CI 1.31–2.31), and exhibited an increased likelihood of in-hospital mortality, although not statistically significant, with an adjusted OR of 1.84 (95% CI 0.96–3.53).
Among hospitalized hyperglycemic patients, the median length of stay was significantly longer at 6.0 days (interquartile range [IQR] 8.0) compared to 3.0 days (IQR 6.0) in the normoglycemic group (P<0.001).
Subgroup analysis, focusing on cases without known diabetes, revealed that patients with PBG ≥ 140 mg/dL were more likely to be hospitalized (adjusted OR 1.49, 95% CI 1.10–2.03) and admitted to ICU/intermediate care (adjusted OR 1.80, 95% CI 1.32–2.45) compared to normoglycemic patients.
These findings suggest a potential association between elevated prehospital blood glucose levels and adverse outcomes in critically ill patients, emphasizing the importance of considering PBG as a risk assessment tool in emergency medicine.
Introduction
Stress hyperglycemia (SH) is commonly observed in patients admitted to emergency departments (EDs) or intensive care units (ICUs) and is associated with adverse outcomes, including increased morbidity, prolonged hospital stays, and higher mortality rates.
The exact mechanisms leading to SH are not fully understood but likely involve a combination of factors such as increased gluconeogenesis, elevated hormone levels (glucagon, cortisol, catecholamines), insulin resistance, and acute stress-induced inflammation.
Inflammatory cytokines like TNF-α, IL-1, and IL-6 play a crucial role in activating the hypothalamic–pituitary–adrenal (HPA) axis, contributing to elevated blood glucose levels.
Moreover, hyperglycemia itself can stimulate the production of proinflammatory cytokines, creating a self-perpetuating cycle. This cascade of events may lead to a procoagulator state, ultimately increasing the risk of cardiovascular events and mortality.
The study emphasizes the significance of hyperglycemia, noting its higher prevalence in patients with known diabetes mellitus. Importantly, even non-diabetic patients with elevated blood glucose levels exhibit a greater mortality risk, especially in the context of conditions such as myocardial infarction.
The primary objective of the study is to analyze the relevance of prehospital blood glucose (PBG) levels in predicting outcomes for patients admitted to the ED.
The focus is on assessing hospitalization rates and in-hospital mortality. The hypothesis suggests that detecting elevated glucose levels pre-hospitalization could serve as an important indicator for predicting clinical outcomes, potentially warranting inclusion in risk assessment scores for better patient management and care.
Methods
In this single-center retrospective cohort study conducted at the Medical Emergency Unit of the University Hospital of Wuerzburg, Germany, the research focused on the association between prehospital blood glucose (PBG) levels and various clinical outcomes in patients admitted to the hospital.
The study spanned a year, from January 1, 2020, to December 31, 2020, and involved the analysis of records from 970 adult patients admitted by emergency physicians.
The study excluded self-admitted patients to the Emergency Department (ED) and applied rigorous criteria to eliminate confounders associated with worsened prognosis and increased mortality. This included patients with hypoglycemia, prehospital intubation, ventilation, end-staged disease, and cases involving resuscitation and defibrillation.
The final cohort of 970 patients was characterized based on prehospital blood glucose levels, and a hyperglycemia cutoff of ≥140 mg/dL (7.8 mmol/L) was used.
Results indicated that patients with elevated prehospital blood glucose (G1, n=394) had a 48% increased risk of hospitalization, a 74% increased risk of ICU admission, and an 84% increased risk of in-hospital mortality compared to those without elevated prehospital blood glucose (G2, n=576). These findings suggest that elevated PBG may be a significant indicator of worse outcomes, potentially serving as a valuable component in risk assessment scores.
Statistical analyses, including chi-square tests, Mann–Whitney U-tests, and multivariable logistic regression models, were employed to ensure robust and comprehensive evaluations. Furthermore, the study received ethical approval from the University of Wuerzburg, emphasizing its adherence to ethical standards and research protocols.
The findings contribute valuable insights into the potential utility of prehospital blood glucose measurements as a predictive tool in emergency medicine, aiding in risk assessment and patient management strategies.
Results
The study, conducted at the medical emergency unit of the University Hospital of Wuerzburg, provided a comprehensive analysis of 970 adult patients, emphasizing the role of prehospital blood glucose (PBG) levels in predicting clinical outcomes. The median PBG was 130 mg/dL, indicating a potential correlation with in-hospital serum glucose measurements. Notably, hyperglycemic patients were characterized as older and predominantly male, exhibiting similar initial symptoms as their normoglycemic counterparts, with specific symptoms like falls and syncope/orthostatic symptoms being more prevalent among hyperglycemic cases.
Analysis of preclinical vital signs revealed significant differences between hyperglycemic and normoglycemic patients, including lower oxygen saturation, higher heart rate, lower sodium, and hemoglobin levels in the former. Elevated leukocyte levels and C-reactive protein further indicated a correlation between inflammation and hyperglycemia. Subgroup analyses based on prediagnosed diabetes status highlighted variations in preclinical vital signs between hyperglycemic and normoglycemic non-diabetic individuals.
Clinical outcomes demonstrated that hyperglycemic patients faced higher hospitalization rates, increased admissions to ICU/IMC, prolonged hospital stays, and an elevated risk of in-hospital mortality compared to normoglycemic patients. These associations remained significant after adjusting for confounding factors, emphasizing the independent predictive value of hyperglycemia for adverse clinical outcomes.
However, the study acknowledged limitations, such as reporting only in-hospital mortality, lack of information on glucose-lowering therapies, and the inability to distinguish chronic from acute hyperglycemic states in diabetic patients. Despite these limitations, the findings underscore the potential utility of prehospital PBG measurements as indicators for risk assessment and clinical outcome prediction in emergency medicine, contributing valuable insights to the existing medical literature.
Conclusion
The study establishes a connection between prehospital blood glucose measurement and patients’ mortality risk, focusing on those admitted to an internal medicine department by an emergency physician. Unlike previous research concentrating on specific medical conditions, this study encompassed a broader patient population. The median prehospital blood glucose (PBG) in the analyzed cohort aligned with prior studies, revealing a significantly higher hospitalization rate in patients with PBG ≥140 mg/dL compared to those with lower PBG. However, the mortality effect was confounded by age, sex, and prediagnosed diabetes, suggesting that moderate PBG elevation (140-180 mg/dL) may not be as predictive of adverse outcomes as higher levels.
Consistent with existing literature, elevated blood glucose was associated with increased length of stay in the hospital, in-hospital complications, and mortality in the context of general surgery. The study recommended considering elevated PBG in prognosis assessments and highlighted its potential role in predicting 90-day mortality in viral pneumonia. Notably, the elevated hospitalization and ICU/IMC admission rates in non-diabetic patients with PBG ≥140 mg/dL were not observed in diabetic patients with a similar PBG level. The impact of elevated in-hospital mortality in non-diabetic patients with PBG ≥140 mg/dL was mitigated by age and sex, consistent with findings suggesting a stronger association of elevated blood glucose with mortality in non-diabetic individuals.
The study delved into potential links between hyperglycemia and arrhythmias, noting a lower proportion of patients with normal sinus rhythm in those with PBG ≥140 mg/dL. Higher levels of leukocytes and C-reactive protein in hyperglycemic patients suggested a potential contribution to the vicious circle in stress hyperglycemia. The study also highlighted the importance of evaluating patients with previously detected hyperglycemic states regularly to detect early manifestations of diabetes.
The differentiation between chronic hyperglycemia and acute hyperglycemic states, particularly stress hyperglycemia, was acknowledged as challenging in emergency medicine. Despite observed associations with increased mortality, the study suggested that stress hyperglycemia might be a necessary adaptation of the organism in severe sickness.
The conclusion that more intensive blood sugar control would improve patient outcomes was deemed misleading, as randomized controlled trials have shown higher mortality with tight glycemic control in critically ill patients compared to conventional glucose management.
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