The Interaction of Acute and Chronic Glycemia on the Relationship of Hyperglycemia, Hypoglycemia, and Glucose Variability to Mortality in the Critically Ill.

OBJECTIVES: To determine the relationship between preadmission glycemia, reflected by hemoglobin A1c level, glucose metrics, and mortality in critically ill patients. DESIGN: Retrospective cohort investigation. SETTING: University affiliated adult medical-surgical ICU. PATIENTS: The investigation included 5,567 critically ill patients with four or more blood glucose tests and hemoglobin A1c level admitted between October 11, 2011 and November 30, 2019. The target blood glucose level was 90-120 mg/dL for patients admitted before September 14, 2014 (n = 1,614) and 80-140 mg/dL or 110-160 mg/dL for patients with hemoglobin A1c less than 7% or greater than or equal to 7% (n = 3,953), respectively, subsequently. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were stratified by hemoglobin A1c: less than 6.5.(n = 4,406), 6.5-7.9% (n = 711), and greater than or equal to 8.0% (n = 450). Increasing hemoglobin A1c levels were associated with significant increases in mean glycemia, glucose variability, as measured by coefficient of variation, and hypoglycemia (p for trend < 0.0001, < 0.0001, and 0.0010, respectively). Among patients with hemoglobin A1c less than 6.5%, mortality increased as mean glycemia increased; however, among patients with hemoglobin A1c greater than or equal to 8.0%, the opposite relationship was observed (p for trend < 0.0001 and 0.0027, respectively). Increasing glucose variability was independently associated with increasing mortality only among patients with hemoglobin A1c less than 6.5%. Hypoglycemia was independently associated with higher mortality among patients with hemoglobin A1c less than 6.5% and 6.5-7.9% but not among those with hemoglobin A1c greater than or equal to 8.0%. Mean blood glucose 140-180 and greater than or equal to 180 mg/dL were independently associated with higher mortality among patients with hemoglobin A1c less than 6.5% (p < 0.0001 for each). Among patients with hemoglobin A1c greater than or equal to 8.0% treated in the second era, mean blood glucose greater than or equal to 180 mg/dL was independently associated with decreased risk of mortality (p = 0.0358). CONCLUSIONS: Preadmission glycemia, reflected by hemoglobin A1c obtained at the onset of ICU admission, has a significant effect on the relationship of ICU glycemia to mortality. The different responses to increasing mean glycemia support a personalized approach to glucose control practices in the ICU.

The burden of implementation: A mixed methods study on barriers to an ICU follow-up program.

PURPOSE: It has been suggested that ICU follow-up clinics can offer support for ICU survivors and their relatives. However, implementation of such clinics can be challenging. We explored the barriers to implementation of an ICU follow-up program from the healthcare providers' perspective. METHODS: This was a mixed methods study with a triangulation design conducted over the 7-month pilot period of an ICU follow-up program. RESULTS: The quantitative analysis showed that two main tasks within the program took the most time to be completed: training and tracking. Training new healthcare professionals to acquire the necessary competences for the follow-up clinic was the most time-consuming task [30 min (IQR 13-56)]. Tracking patients, which consists of keeping records of a patient during the hospital stay and when discharged, was the second most time-consuming task [15 min (IQR 10-20)]. We recorded 291 items of qualitative data from the 12 team members who participated. The qualitative analysis identified three domains that were crucial barriers for program implementation: Luhr et al. (2019) [1] organization (37.1%), Máca et al. (2017) [2] engagement (38.5%), and (Gayat et al., 2018 [3]) resources (24%). In agreement with the quantitative data, training and tracking were perceived by participants as laborious tasks and key barriers to implementation of the ICU follow-up program. Despite the expectation that resources would be the most important barrier, they were not considered as such by our participants being only mentioned in 13.4% of our qualitative reports; when mentioned, this barrier was related mostly to insufficient numbers of staff members. CONCLUSIONS: Awareness of those barriers can help healthcare providers and ICU managers in developing strategies adapted to overcome constraints, thus facilitating the implementation process.

Intensive care units follow-up: a scoping review protocol.

INTRODUCTION: Increasing numbers of patients are surviving critical illness, leading to growing concern about the potential impact of the long-term consequences of intensive care on patients, families and society as a whole. These long-term effects are together known as postintensive care syndrome and their presence can be evaluated at intensive care unit (ICU) follow-up consultations. However, the services provided by these consultations vary across hospitals and units, in part because there is no validated standard model to evaluate patients and their quality of life after ICU discharge. We describe a protocol for a scoping review focusing on models of ICU follow-up and the impact of such strategies on improving patient quality of life. METHODS AND ANALYSIS: In this scoping review, we will search the literature systematically using electronic databases (MEDLINE - from database inception to June 15th 2020) and a grey literature search. We will involve stakeholders as recommended by the Joanna Briggs Institute approach developed by Peters et al. The research will be conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews guidelines. ETHICS AND DISSEMINATION: This study does not require ethics approval, because data will be obtained through a review of published primary studies. The results of our evaluation will be published in a peer-reviewed journal and will also be disseminated through presentations at national and international conferences.

Update on glucose in critical care.

The aim of this review is to summarize recent developments on the mechanisms involved in stress hyperglycemia associated with critical illness. Different aspects of the consequences of stress hyperglycemia as well as the therapeutic approaches tested so far are discussed: the physiological regulations of blood glucose, the mechanisms underlying stress hyperglycemia, the clinical associations, and the results of the prospective trials and meta-analyses to be taken into consideration when interpreting the available data. Current recommendations, challenges, and technological hopes for the future are be discussed.