1530: STRESS HYPERGLYCEMIA, NOT DIABETES, IS ASSOCIATED WITH INCREASED MORTALITY AND VENTILATION IN TRAUMA

IntroductionInnovative approaches are needed to design robust clinical decision support (CDS) to optimize hospital glycemic management. We piloted an electronic medical record (EMR), evidence-based algorithmic CDS tool in an academic center to alert clinicians in real time about gaps in care related to inpatient glucose control and insulin utilization, and to provide management recommendations.Research design and methodsThe tool was designed to identify clinical situations in need for action: (1) severe or recurrent hyperglycemia in patients with diabetes: blood glucose (BG) ≥13.88 mmol/L (250 mg/dL) at least once or BG ≥10.0 mmol/L (180 mg/dL) at least twice, respectively; (2) recurrent hyperglycemia in patients with stress hyperglycemia: BG ≥10.0 mmol/L (180 mg/dL) at least twice; (3) impending or established hypoglycemia: BG 3.9–4.4 mmol/L (70–80 mg/dL) or ≤3.9 mmol/L (70 mg/dL); and (4) inappropriate sliding scale insulin (SSI) monotherapy in recurrent hyperglycemia, or anytime in patients with type 1 diabetes. The EMR CDS was active (ON) for 6 months for all adult hospital patients and inactive (OFF) for 6 months. We prospectively identified and compared gaps in care between ON and OFF periods.ResultsWhen active, the hospital CDS tool significantly reduced events of recurrent hyperglycemia in patients with type 1 and type 2 diabetes (3342 vs 3701, OR=0.88, p=0.050) and in patients with stress hyperglycemia (288 vs 506, OR=0.60, p<0.001). Hypoglycemia or impending hypoglycemia (1548 vs 1349, OR=1.15, p=0.050) were unrelated to the CDS tool on subsequent analysis. Inappropriate use of SSI monotherapy in type 1 diabetes (10 vs 22, OR=0.36, p=0.073), inappropriate use of SSI monotherapy in type 2 diabetes (2519 vs 2748, OR=0.97, p=0.632), and in stress hyperglycemia subjects (1617 vs 1488, OR=1.30, p<0.001) were recognized.ConclusionEMR CDS was successful in reducing hyperglycemic events among hospitalized patients with dysglycemia and diabetes, and inappropriate insulin use in patients with type 1 diabetes.

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Lack of recognition and documentation of stress hyperglycemia is a disruptor of optimal continuity of care

Scientific Reports ◽

10.1038/s41598-021-89945-3 ◽

2021 ◽

Vol 11 (1) ◽

Author(s):

Eric D. Moyer ◽

Erik B. Lehman ◽

Matthew D. Bolton ◽

Jennifer Goldstein ◽

Ariana R. Pichardo-Lowden

Keyword(s):

Blood Glucose ◽

Continuity Of Care ◽

Clinical Documentation ◽

Stress Hyperglycemia ◽

Optimal Care ◽

Continuity Clinic ◽

Altered Glucose ◽

Discharge Summaries

AbstractStress hyperglycemia (SH) is a manifestation of altered glucose metabolism in acutely ill patients which worsens outcomes and may represent a risk factor for diabetes. Continuity of care can assess this risk, which depends on quality of hospital clinical documentation. We aimed to determine the incidence of SH and documentation tendencies in hospital discharge summaries and continuity notes. We retrospectively examined diagnoses during a 12-months period. A 3-months representative sample of discharge summaries and continuity clinic notes underwent manual abstraction. Over 12-months, 495 admissions had ≥ 2 blood glucose measurements ≥ 10 mmol/L (180 mg/dL), which provided a SH incidence of 3.3%. Considering other glucose states suggestive of SH, records showing ≥ 4 blood glucose measurements ≥ 7.8 mmol/L (140 mg/dL) totaled 521 admissions. The entire 3-months subset of 124 records lacked the diagnosis SH documentation in discharge summaries. Only two (1.6%) records documented SH in the narrative of hospital summaries. Documentation or assessment of SH was absent in all ambulatory continuity notes. Lack of documentation of SH contributes to lack of follow-up after discharge, representing a disruptor of optimal care. Activities focused on improving quality of hospital documentation need to be integral to the education and competency of providers within accountable health systems.

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Stress hyperglycemia as a prognostic factor in acute ischemic stroke patients: a prospective observational cohort study

Ain-Shams Journal of Anesthesiology ◽

10.1186/s42077-020-00122-6 ◽

2021 ◽

Vol 13 (1) ◽

Author(s):

Hanaa A. El-Gendy ◽

Mahmoud A. Mohamed ◽

Amr E. Abd-Elhamid ◽

Mohammed A. Nosseir

Keyword(s):

Ischemic Stroke ◽

Acute Ischemic Stroke ◽

Prognostic Value ◽

Area Under The Curve ◽

Hemorrhagic Transformation ◽

Diabetic Patients ◽

Stroke Patients ◽

Stress Hyperglycemia ◽

Discrimination Power ◽

Observational Cohort

Abstract Background Hyperglycemia is a risk factor for infarct expansion and poor outcome for both diabetic and non-diabetic patients. We aimed to study the prognostic value of stress hyperglycemia on the outcome of acute ischemic stroke patients as regards National Institutes of Health Stroke Scale (NIHSS) as a primary outcome. Results Patients with high random blood sugar (RBS) on admission showed significantly higher values of both median NIHSS score and median duration of hospital stay. There were significant associations between stress hyperglycemia and the risk of 30-day mortality (p < 0.001), the need for mechanical ventilation (p < 0.001) and vasopressors (p < 0.001), and the occurrence of hemorrhagic transformation (p = 0.001). The 24-h RBS levels at a cut off > 145 mg/dl showed a significantly good discrimination power for 30-day mortality (area under the curve = 0.809). Conclusions Stress hyperglycemia had a prognostic value and was associated with less-favorable outcomes of acute stroke patients. Therefore, early glycemic control is recommended for those patients.

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Predictive value of stress hyperglycemia ratio for the occurrence of acute kidney injury in acute myocardial infarction patients with diabetes

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-01962-2 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Side Gao ◽

Qingbo Liu ◽

Hui Chen ◽

Mengyue Yu ◽

Hongwei Li

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Acute Kidney Injury ◽

Cardiogenic Shock ◽

Predictive Value ◽

Kidney Injury ◽

Left Ventricular Ejection ◽

Diabetic Patients ◽

Stress Hyperglycemia ◽

Patients With Diabetes

Abstract Background Acute hyperglycemia has been recognized as a robust predictor for occurrence of acute kidney injury (AKI) in nondiabetic patients with acute myocardial infarction (AMI), however, its discriminatory ability for AKI is unclear in diabetic patients after an AMI. Here, we investigated whether stress hyperglycemia ratio (SHR), a novel index with the combined evaluation of acute and chronic glycemic levels, may have a better predictive value of AKI as compared with admission glycemia alone in diabetic patients following AMI. Methods SHR was calculated with admission blood glucose (ABG) divided by the glycated hemoglobin-derived estimated average glucose. A total of 1215 diabetic patients with AMI were enrolled and divided according to SHR tertiles. Baseline characteristics and outcomes were compared. The primary endpoint was AKI and secondary endpoints included all-cause death and cardiogenic shock during hospitalization. The logistic regression analysis was performed to identify potential risk factors. Accuracy was defined with area under the curve (AUC) by a receiver-operating characteristic (ROC) curve analysis. Results In AMI patients with diabetes, the incidence of AKI (4.4%, 7.8%, 13.0%; p < 0.001), all-cause death (2.7%, 3.6%, 6.4%; p = 0.027) and cardiogenic shock (4.9%, 7.6%, 11.6%; p = 0.002) all increased with the rising tertile levels of SHR. After multivariate adjustment, elevated SHR was significantly associated with an increased risk of AKI (odds ratio 3.18, 95% confidence interval: 1.99–5.09, p < 0.001) while ABG was no longer a risk factor of AKI. The SHR was also strongly related to the AKI risk in subgroups of patients. At ROC analysis, SHR accurately predicted AKI in overall (AUC 0.64) and a risk model consisted of SHR, left ventricular ejection fraction, N-terminal B-type natriuretic peptide, and estimated glomerular filtration rate (eGFR) yielded a superior predictive value (AUC 0.83) for AKI. Conclusion The novel index SHR is a better predictor of AKI and in-hospital mortality and morbidity than admission glycemia in AMI patients with diabetes.

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Proposal of a New Approach to Study and Categorize Stress Hyperglycemia in Acute Myocardial Infarction

Journal of Emergency Medicine ◽

10.1016/j.jemermed.2015.03.047 ◽

2016 ◽

Vol 51 (1) ◽

pp. 31-36 ◽

Cited By ~ 6

Author(s):

Goran P. Koracevic

Keyword(s):

Myocardial Infarction ◽

Acute Myocardial Infarction ◽

Stress Hyperglycemia ◽

New Approach

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Stress hyperglycemia and enhanced sensitivity to myocardial infarction

Current Hypertension Reports ◽

10.1007/s11906-008-0015-0 ◽

2008 ◽

Vol 10 (1) ◽

pp. 78-84 ◽

Cited By ~ 15

Author(s):

Keith A. Webster

Keyword(s):

Myocardial Infarction ◽

Stress Hyperglycemia ◽

Enhanced Sensitivity

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A comparison of the Stress Hyperglycemia Ratio, Glycemic Gap, and glucose to assess the impact of stress‐induced hyperglycemia on ischemic stroke outcome.

Journal of Diabetes ◽

10.1111/1753-0407.13223 ◽

2021 ◽

Author(s):

Gregory Roberts ◽

James Sires ◽

Angela Chen ◽

Tilenka Thynne ◽

Cheyne Sullivan ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Outcome ◽

Stress Hyperglycemia ◽

The Impact

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Association of Stress hyperglycemia and adverse cardiac events in acute myocardial infarction – A cohort study

Cardiovascular & Haematological Disorders - Drug Targets ◽

10.2174/1871529x22666211221152546 ◽

2021 ◽

Vol 22 ◽

Author(s):

Annu Rajpurohit ◽

Bharat Sejoo ◽

Rajendra Bhati ◽

Prakash Keswani ◽

Shrikant Sharma ◽

...

Keyword(s):

Myocardial Infarction ◽

Heart Failure ◽

Acute Myocardial Infarction ◽

Blood Glucose ◽

Clinical Outcomes ◽

P Value ◽

Cardiac Events ◽

Stress Hyperglycemia ◽

Adverse Cardiac Events ◽

Hba1c Levels

Background: Stress hyperglycemia is a common phenomenon in patients presenting with acute myocardial infarction (MI). We aim to evaluate the association of stress hyperglycemia at the time of hospital presentation and adverse cardiac events in myocardial infarction during the course of hospital stay. Methods: Subjects with age ≥18 years with acute MI were recruited on hospital admission and categorized based on admission blood glucose (<180 and ≥180 mg/dl, 50 patients in each group). Both groups were compared for clinical outcomes, adverse cardiac events and mortality. We also compared the adverse cardiac outcomes based on HbA1c levels (<6% and ≥6%). Results: Patients with high blood glucose on admission (stress hyperglycemia) had significant increased incidences of severe heart failure (Killip class 3 and 4), arrythmias, cardiogenic shock and mortality (p value = 0.001, 0.004, 0.044, and 0.008 respectively). There was no significant association between adverse cardiac events and HbA1c levels (heart failure 18.8% vs. 25%, p value = 0.609 and mortality 16.7% vs. 17.3%, p value = 0.856). Conclusions: Stress hyperglycemia is significantly associated with adverse clinical outcomes in patients with MI irrespective of previous diabetic history or glycemic control. Clinicians should be vigilant for admission blood glucose while treating MI patients.

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