Effect of glycemic state on hospital mortality in critically ill surgical patients.

Intensive insulin therapy can reduce mortality. Hypoglycemia related to intensive therapy may worsen outcomes. This study compared risk adjusted mortality for different glycemic states. A retrospective review of patients admitted to a surgical intensive care unit over 4 years was performed. Patients were divided into glycemic groups: HYPER (≥1 episode > 180 mg/dL, any <60), HYPO (≥1 episode < 60 mg/dL, any >180), BOTH (≥1 episode < 60 and ≥1 episode > 180 mg/dL), NORMO (all episodes 60-180 mg/dL), HYPER-Only (≥1 episode > 180, none <60 mg/dL), and HYPO-Only (≥1 episode < 60, none >180 mg/dL). Observed to expected Acute Physiology and Chronic Health Evaluation (APACHE) III mortality ratios (O/E) were studied. Number of adverse glycemic events was compared with mortality. Hypoglycemia and hyperglycemia occurred in 18 per cent and 50 per cent of patients. Mortality was 12.4 per cent (O/E = 0.88). BOTH had the highest O/E ratio (1.43) with HYPO the second highest (1.30). Groups excluding hypoglycemia (NORMO and HYPER-only) had the lowest O/E ratios: 0.56 and 0.88. Increasing number of hypoglycemic events were associated with increasing O/E ratio: 0.69 O/E for no events, 1.19 for 1-3 events, 1.35 for 4-6 events, 1.9 for 7-9 events, and 3.13 for ≥ 10 events. Ten or more hyperglycemic events were needed to significantly associate with worse mortality (O/E 1.53). Hyper- and hypoglycemia increase mortality compared with APACHE III expected mortality, with highest mortality risk if both are present. Hypoglycemia is associated with worse risk. Glucose control may need to be loosened to prevent hypoglycemia and reduce glucose variability.

Patient characteristics associated with end-of-life decision making in critically ill surgical patients.

BACKGROUND: Palliative care is an important and necessary humanistic facet of ICU care. Wide variations exist in selection and implementation of palliative care decisions. Understanding patient factors associated with these decisions is crucial. STUDY DESIGN: Consecutive deaths (n = 151 patients) in a tertiary care surgical ICU during a 2-year period were reviewed. All data had been entered into the APACHE IV database. Patients were divided into groups: Withhold (WH), which included patients who had potentially lifesaving therapies withheld or withdrawn, and Full Care (FC), which included patients who had full resuscitative efforts before death. Patient factors including demographics, severity of illness, admission source, and history were compared between groups. RESULTS: Of 151 patients, 111 (74%) had potentially lifesaving therapy withheld or withdrawn (WH group). Forty patients (26%) had full treatment, including CPR, until time of death (FC group). Compared with WH, FC patients had a higher degree of illness at ICU admission (APACHE IV score 103.4 ± 36.6 vs 90.6 ± 29.3; p < 0.02) and were less likely to be male (35% vs 62%; p < 0.005). There were no differences between groups with regard to age, requirement for intubation on admission, medical history, admission source (emergency room vs operating room vs recovery room) or the number of patients admitted status post emergent vs elective surgery or admitted for nonsurgical diagnoses. In a multivariable regression model, male sex (odds ratio = 3.22; 95% CI, 1.45-7.19) and severity of illness (odds ratio = 0.98; 95% CI, 0.97-0.99) retained independent associations with decisions to limit care. CONCLUSIONS: Higher severity of illness and history play no role in the decision to limit care. Sex plays a strong and independent role. Factors influencing end-of-life care require additional study.