title: Pre-morbid glycemic control modifies the interaction between acute hypoglycemia and mortality.
abstract: OBJECTIVE
  To study the impact of pre-morbid glycemic control on the association between acute hypoglycemia in intensive care unit (ICU) patients and subsequent hospital mortality in critically ill patients.
  
  
  METHODS
  We performed a multicenter, multinational, retrospective observational study of patients with available HbA1c levels within the 3-month period preceding ICU admission. We separated patients into three cohorts according to pre-admission HbA1c levels (<6.5, 6.5-7.9, ≥8.0%, respectively). Based on published data, we defined a glucose concentration of 40-69 mg/dL (2.2-3.8 mmol/L) as moderate hypoglycemia and <40 mg/dL (<2.2 mmol/L) as severe hypoglycemia. We applied logistic regression analysis to study the impact of pre-morbid glycemic control on the relationship between acute hypoglycemia and mortality.
  
  
  RESULTS
  A total of 3084 critically ill patients were enrolled in the study. Among these patients, with increasing HbA1c levels from <6.5, to 6.5-7.9, and to ≥8.0%, the incidence of both moderate (3.8, 11.1, and 16.4%, respectively; p < 0.001) and severe (0.9, 2.5, and 4.3%, respectively; p < 0.001) hypoglycemia progressively and significantly increased. The relationship between the occurrence of hypoglycemic episodes in the ICU and in-hospital mortality was independently and significantly affected by pre-morbid glucose control, as assessed by adjusted odds ratio (OR) and 95 % confidence interval (CI) for hospital mortality: (1) moderate hypoglycemia: in patients with <6.5, 6.5-7.9, and ≥8.0 % of HbA1c level-OR 0.54, 95% CI 0.25-1.16; OR 0.82, 95 % CI 0.33-2.05; OR 3.42, 95 % CI 1.29-9.06, respectively; (2) severe hypoglycemia: OR 1.50, 95% CI 0.42-5.33; OR 1.59, 95% CI 0.36-7.10; OR 23.46, 95% CI 5.13-107.28, respectively (interaction with pre-morbid glucose control, p = 0.009). We found that the higher the glucose level before admission to the ICU, the higher the mortality risk when patients experienced hypoglycemia.
  
  
  CONCLUSIONS
  In critically ill patients, chronic pre-morbid hyperglycemia increases the risk of hypoglycemia and modifies the association between acute hypoglycemia and mortality.
authors: Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan. moriori@tg8.so-net.ne.jp.|Department of Anesthesiology, Kobe University Hospital, 7-5-2 Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan. moriori@tg8.so-net.ne.jp.
authors: Moritoki
authors: M
authors: Egi
authors: Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, USA.
authors: James S
authors: JS
authors: Krinsley
authors: BayCare Health Systems, Clearwater, FL, USA.
authors: Paula
authors: P
authors: Maurer
authors: Medical/Surgical Intensive Care Unit, Morton Plant Hospital, 300 Pinellas Street, Clearwater, FL, 33756, USA.
authors: Devendra N
authors: DN
authors: Amin
authors: Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan.
authors: Tomoyuki
authors: T
authors: Kanazawa
authors: Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, USA.
authors: Shruti
authors: S
authors: Ghandi
authors: Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan.
authors: Kiyoshi
authors: K
authors: Morita
authors: Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors: Michael
authors: M
authors: Bailey
authors: Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
authors: Rinaldo
authors: R
authors: Bellomo
mesh_terms: D000208:Acute Disease; D000368:Aged; D001786:Blood Glucose / Q000032:analysis*; D016638:Critical Illness; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D017052:Hospital Mortality; D006801:Humans; D007003:Hypoglycemia / Q000097:blood / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D001786:Blood Glucose; D006442:Glycated Hemoglobin
keywords: Diabetes mellitus; HbA1c; Hyperglycemia; Intensive care; Mortality