Acute and Chronic Glucose Control in Critically Ill Patients With Diabetes: The Impact of Prior Insulin Treatment

Background: Emerging data highlight the interactions of preadmission glycemia, reflected by admission HbA1c levels, glycemic control during critical illness, and mortality. The association of preadmission insulin treatment with outcomes is unknown. Methods: This observational cohort study includes 5245 patients admitted to the medical-surgical intensive care unit of a university-affiliated teaching hospital. Three groups were analyzed: patients with diabetes with prior insulin treatment (DM-INS, n=538); patients with diabetes with no prior insulin treatment (DM-No-INS, n=986); no history of diabetes (NO-DM, n=3721). Groups were stratified by HbA1c level: <6.5%; 6.5%-7.9% and >8.0%. Results: Among the three strata of HbA1c, mean blood glucose (BG), coefficient of variation (CV), and hypoglycemia increased with increasing HbA1c, and were higher for DM-INS than for DM-No-INS. Among patients with HbA1c < 6.5%, mean BG >= 180 mg/dL and CV > 30% were associated with lower severity-adjusted mortality in DM-INS compared to patients with mean BG 80-140mg/dL and CV < 15%, (P=.0058 and<.0001, respectively), but higher severity-adjusted mortality among DM-No-INS (P=.0001 and < .0001, respectively) and NON-DM (P<.0001 and < .0001, respectively). Among patients with HbA1c >= 8.0%, mean BG >= 180 mg/dL was associated with lower severity-adjusted mortality for both DM-INS and DM-No-INS than was mean BG 80-140mg/dL (p<0.0001 for both comparisons). Conclusions: Significant differences in mortality were found among patients with diabetes based on insulin treatment and HbA1c at home and post-admission glycemic control. Prospective studies need to confirm an individualized approach to glycemic control in the critically ill.