OBJECTIVES: 

To determine the associations of relative hypoglycemia and hemoglobin A1c-adjusted time in blood glucose (BG) band (HA-TIB) with mortality in critically ill patients.

DESIGN: 

Retrospective cohort investigation.

SETTING: 

University-affiliated adult medical-surgical ICU.

PATIENTS: 

Three thousand six hundred fifty-five patients with at least four BG tests and hemoglobin A1c (HbA1c) level admitted between September 14, 2014, and November 30, 2019.

INTERVENTIONS: 

None.

MEASUREMENTS AND MAIN RESULTS: 

Patients were stratified for HbA1c bands of <6.5%; 6.5–7.9%; greater than or equal to 8.0% with optimal affiliated glucose target ranges of 70–140, 140–180, and 180–250 mg/dL, respectively. HA-TIB, a new glycemic metric, defined the HbA1c-adjusted time in band. Relative hypoglycemia was defined as BG 70–110 mg/dL for patients with HbA1c ≥ 8.0%. Further stratification included diabetes status-no diabetes (NO-DM, n = 2,616) and preadmission treatment with or without insulin (DM-INS, n = 352; DM-No-INS, n = 687, respectively). Severity-adjusted mortality was calculated as the observed:expected mortality ratio (O:EMR), using the Acute Physiology and Chronic Health Evaluation IV prediction of mortality. Among NO-DM, mortality and O:EMR, decreased with higher TIB 70–140 mg/dL (p < 0.0001) and were lowest with TIB 90–100%. O:EMR was lower for HA-TIB greater than or equal to 50% than less than 50% and among all DM-No-INS but for DM-INS only those with HbA1 greater than or equal to 8.0%.Among all patients with hba1c greater than or equal to 8.0% And no bg less than 70 mg/dl, mortality was 18.0% For patients with relative hypoglycemia (bg, 70–110 mg/dl) (p < 0.0001) And was 0.0%, 12.9%, 13.0%, And 34.8% For patients with 0, 0.1–2.9, 3.0–11.9, And greater than or equal to 12.0 Hours of relative hypoglycemia (p < 0.0001).

CONCLUSIONS: 

These findings have considerable bearing on interpretation of previous trials of intensive insulin therapy in the critically ill. Moreover, they suggest that BG values in the 70–110 range may be deleterious for patients with HbA1c greater than or equal to 8.0% and that the appropriate target for BG should be individualized to HbA1c levels. These conclusions need to be tested in randomized trials.

中文翻译：

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相对低血糖和较低的血红蛋白 A1c 调整时间与危重患者死亡率增加密切相关

目标： 

旨在确定相对低血糖和血红蛋白 A1c 调整血糖 (BG) 带时间 (HA-TIB) 与危重患者死亡率的关系。

设计： 

回顾性队列研究。

环境： 

大学附属成人内外科重症监护室。

患者： 

2014年9月14日至2019年11月30日期间，入院的三千六百五十五名患者至少进行了四次血糖测试和糖化血红蛋白（HbA1c）水平。

干预措施： 

没有任何。

测量和主要结果： 

患者根据 HbA1c 条带 <6.5% 进行分层；6.5–7.9%；大于或等于 8.0%，最佳相关葡萄糖目标范围分别为 70–140、140–180 和 180–250 mg/dL。HA-TIB 是一种新的血糖指标，定义了带内HbA1c 调整时间。对于 HbA1c ≥ 8.0% 的患者，相对低血糖定义为 BG 70–110 mg/dL。进一步分层包括糖尿病状态-无糖尿病（NO-DM，n = 2,616）和入院前使用或不使用胰岛素的治疗（DM-INS，n = 352；DM-No-INS，n = 687）。使用急性生理学和慢性健康评估 IV 对死亡率的预测，将严重程度调整后的死亡率计算为观察到的死亡率：预期死亡率比 (O:EMR)。在 NO-DM 中，死亡率和 O:EMR 随着 TIB 70-140 mg/dL 的升高而降低（p < 0.0001），并且在 TIB 90-100% 时最低。O：HA-TIB 大于或等于 50% 的 EMR 低于小于 50%，并且在所有 DM-No-INS 中，但对于 DM-INS，仅 HbA1 大于或等于 8.0% 的患者。 hba1c 大于或等于 8.0% 且血糖值不低于 70 mg/dl，死亡率为 18.0% 对于相对低血糖患者（bg，70–110 mg/dl）（p < 0.0001），死亡率为 0.0%、12.9 %， 13.0% 和 34.8% 对于相对低血糖时间为 0、0.1–2.9、3.0–11.9 和大于或等于 12.0 小时的患者 ( p < 0.0001)。

结论： 

这些发现对于解释先前针对重症患者的强化胰岛素治疗试验具有相当大的影响。此外，他们建议 70-110 范围内的 BG 值对于 HbA1c 大于或等于 8.0% 的患者可能是有害的，并且适当的 BG 目标应根据 HbA1c 水平进行个体化。这些结论需要在随机试验中进行检验。