Risk Factors for Hypoglycemia During Treatment of Hyperglycemic Crises.

Objective: Diabetic ketoacidosis and hyperosmolar hyperglycemic state are life-threatening hyperglycemic crises often requiring intensive care unit (ICU) management. Treatment includes intravenous (IV) insulin with a transition to subcutaneous (SC) insulin upon resolution. Hypoglycemia is a common complication associated with treatment of hyperglycemic crises, but risk factors have not been well established. This study aimed to assess risk factors associated with hypoglycemia during treatment for hyperglycemic crises. Methods: This case-control study included ICU patients admitted with hyperglycemic crises at a single Veterans Affairs health system from 1 January 2013 to 31 March 2020. Patients who developed hypoglycemia during insulin treatment were compared with a control group. Odds of hypoglycemia were assessed based on risk factors, including BMI, comorbidities, and type of SC insulin used. Results: Of the 216 cases of hyperglycemic crises included, hypoglycemia occurred in 61 cases (44 on SC insulin, 11 on IV insulin, and 6 on both). Odds for hypoglycemia were significantly higher for underweight patients (odds ratio 4.52 [95% CI 1.05-19.55]), type 1 diabetes (4.02 [2.09-7.73]), chronic kidney disease (1.94 [1.05-3.57]), those resumed on the exact chronic SC insulin regimen following resolution (2.91 [1.06-7.95]), and patients who received NPH versus glargine insulin (5.13 [1.54-17.06]). No significant differences were seen in the other evaluated variables. Conclusion: This study found several factors associated with hypoglycemia during hyperglycemic crises treatment, many of which are not addressed in consensus statement recommendations. These findings may help ICU clinicians prevent complications related to hyperglycemic crisis management and generate hypotheses for future studies.

Severe hyperglycemia following transition from octreotide to lanreotide in a patient with enterocutaneous fistula receiving parenteral nutrition.

Somatostatin analogues, suchas octreotide and lanreotide, are commonly used in the management of enterocutaneous fistula. We report a case of severe and prolonged hyperglycemia that occurred in a patient after receiving a one-time dose of lanreotide, who had previously been stable on octreotide and did not have a history of diabetes mellitus. Management of the patient's hyperglycemia while receiving parenteral nutrition is described.

Disparities in hemodynamic resuscitation of the obese critically ill septic shock patient.

BACKGROUND: With a growing obesity epidemic, the approach to care of this patient remains controversial and in many circumstances different than the general population. Appropriate hemodynamic support, although still controversial, remains a cornerstone of septic shock therapy. Catecholamines are currently recommended by guidelines without a preferred dosing strategy. However, the use of weight-based (µg kg-1 min-1) or nonweight-based (µg/min) vasopressor drip rates may impact patient care in these populations. METHODS: A multicenter retrospective chart review was conducted. Patients receiving nonweight-based catecholamine infusions for septic shock were grouped into nonobese (n = 112) or obese (n = 196), and evaluated based on hemodynamic resuscitation. For the primary outcome, groups were analyzed for the requirement of a secondary hemodynamic support agent to obtain a goal mean arterial pressure of greater than or equal to 65 mm Hg. Secondary outcomes included an evaluation of time to a secondary hemodynamic support agent, time to hemodynamic stability (HDS), ability to obtain HDS at 24 hours, and death due to cardiovascular collapse. RESULTS: With the exception of weight and sex, baseline characteristics were similar among groups. Early resuscitative fluids were given at a lower weight based, but not total volume dose in the obese group (nonobese, 34.8 mL/kg vs obese, 22.4 mL/kg; P < .0001). The primary end point of addition of any secondary hemodynamic support agent was significantly greater in obese patients when adjusted for institution (nonobese, 19% vs obese, 27%; adjusted odds ratio, 0.42; 95% confidence interval, 0.23-0.77). Time to HDS was also prolonged (nonobese, 3.5 hours vs obese, 5.3 hours; P = .006). CONCLUSION: This study calls into question the adequacy of a nonweight-based approach to hemodynamic support of critically ill obese patients. This strategy seems to result in less aggressive, lower weight-based vasopressor and fluid doses, and more diverse approach than their nonobese counterparts.