Changes in insulin resistance (IR) cause stress-induced hyperglycemia after trauma, but the numerous factors involved in IR have not been delineated clearly. We hypothesized that a statistical model could help determine the relative contribution of different clinical co-variates to IR in critically injured patients.
Patients and Methods:
We retrospectively studied 726 critically injured patients managed with a computer-assisted glycemic protocol at an academic level I trauma center (639 ventilated controls without pneumonia (VWP) and 87 patients with ventilator-associated pneumonia (VAP). Linear regression using age, gender, body mass index (BMI), diabetes mellitus, pneumonia, and glycemic provision was used to estimate M, a marker of IR that incorporates both the serum blood glucose concentration (BG) and insulin dose.
Results:
Increasing M (p < 0.001) was associated with age (1.62%; 95% confidence interval [CI] 1.27%–1.97% per decade), male gender (9.78%; 95% CI 8.28%–12.6%), BMI (4.32% [95% CI 4.02%–4.62%] per 5 points), diabetes mellitus (21.2%; 95% CI 19.2%–23.2%), pneumonia (10.9%; 95% CI 9.31%–12.6%), and glycemic provision (27.3% [95% CI 6.6%–28.1%] per 100 g of glucose). Total parenteral nutrition was associated with a decrease in M of 10.3%; 95% CI 8.52%–12.1%; p < 0.001.
Conclusions:
Clinical factors can be used to construct a model of IR. Prospective validation might enable early detection and treatment of infection or other conditions associated with increased IR.
Get full access to this article
View all access options for this article.
References
1.
KauffmannRM, HayesRM, BuskeBD, et al.Increasing blood glucose variability heralds hypoglycemia in the critically ill. J Surg Res, 2011; 170:257–264.
2.
MoweryNT, CarnevaleRJ, GunterOL, et al.Insulin resistance heralds positive cultures after severe injury. Surg Infect, 2009; 10:503–509.
3.
BochicchioGV, BochicchioKM, JoshiM, et al.Acute glucose elevation is highly predictive of infection and outcome in critically injured trauma patients. Ann Surg, 2010; 252:597–602.
4.
MoweryNT, GunterOL, DossettLA, et al.Failure to achieve euglycemia despite aggressive insulin control signals abnormal physiologic response to trauma. J Crit Care, 2011; 26:295–302.
5.
MayAK, KauffmannRM, CollierBR. The place for glycemic control in the surgical patient. Surg Infect, 2011; 12:405–418.
6.
MartinRS, SmithJS, HothJJ, et al.Increased insulin requirements are associated with pneumonia after severe injury. J Trauma, 2007; 63:358–364.
7.
MukherjeeK, SowardsKJ, BrooksSE, et al.Insulin resistance increases before ventilator-associated pneumonia in euglycemic trauma patients. Surg Infect, 2014; 15:713–720.
8.
KollefMH. Inadequate antimicrobial treatment of infections: A risk factor for hospital mortality among critically ill patients. Chest, 1999; 115:462–474.
9.
Van den BergheG, WoutersP, WeekersF, et al.Intensive insulin therapy in critically ill patients. N Engl J Med, 2001; 345:1359–1367.
10.
JackmanRP, BochicchioGV, BochicchioGV, et al.Admission preoperative glucose is predictive of morbidity and mortality in trauma patients who require immediate operative intervention. Am Surg, 2005; 71:171–174.
11.
RichardsJE, KauffmannRM, ObremskeyWT, MayAK. Stress-induced hyperglycemia as a risk factor for surgical-site infection in non-diabetic orthopaedic trauma patients admitted to the intensive care unit. J Orthop Trauma, 2013; 27:16–21.
12.
KrinsleyJS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc, 2004; 79:992–1000.
13.
KerbyJD, GriffinRL, MacLennanP, RueLWIII. Stress-induced hyperglycemia, not diabetic hyperglycemia, is associated with higher mortality in trauma. Ann Surg, 2012; 256:446–452.
14.
DossettLA, DossettLA, CaoH, et al.Blood glucose variability is associated with mortality in the surgical intensive care unit. Am Surg, 2008; 74:679–685.
15.
LairdAM, MillerPR, KilgoPD, et al.Relationship of early hyperglycemia to mortality in trauma patients. J Trauma, 2004; 56:1058–1062.
16.
GriesdaleDEG, de SouzaRJ, van DamRM, et al.Intensive insulin therapy and mortality among critically ill patients: A meta-analysis including NICE-SUGAR study data. Can Med Assoc J, 2008; 180:821–827.
17.
TurinaM, TurinaM, FryDE, et al.Acute hyperglycemia and the innate immune system: Clinical, cellular, and molecular aspects. Crit Care Med, 2005; 33:1624–1633.
18.
The NICE-SUGAR Study Investigators, FinferS, ChittockDR, SuSY, et al.Intensive versus conventional glucose control in critically ill patients. N Engl J Med, 2009; 360:1283–1297.
19.
MukherjeeK, NorrisPR, SowardsKJ, et al.Temporal changes in insulin resistance precede the fulfillment of CDC criteria for ventilator associated pneumonia in critically ill trauma patients. Presented at the Society of Critical Care Medicine Meeting. San Juan, Puerto Rico. 2013.
20.
DeFronzoRA, TobinJD, AndresR. Glucose clamp technique: A method for quantifying insulin secretion and resistance. Am J Physiol, 1979; 237:E214–E223.
21.
SolomkinJS, RistagnoRL, DasAF, et al.Source control review in clinical trials of anti-infective agents in complicated intra-abdominal infections. Clin Infect Dis, 2013; 56:1765–1773.
22.
GastinneH, Centers for Disease Control, WolffM, DelatourF, FaurissonF, et al.A controlled trial in intensive care units of selective decontamination of the digestive tract with nonabsorbable antibiotics. The French Study Group on Selective Decontamination of the Digestive Tract. N Engl J Med, 1992; 326:594–599. Available atwww.cdc.gov/nhsn/PDFs/pscManual/6pscVAPcurrent.pdf
BoordJB, SharifiM, GreevyRA, et al.Computer-based insulin infusion protocol improves glycemia control over manual protocol. J Am Med Inform Assoc, 2007; 14:278–287.
25.
DortchMJ, MoweryNT, OzdasA, et al.A computerized insulin infusion titration protocol improves glucose control with less hypoglycemia compared to a manual titration protocol in a trauma intensive care unit. JPEN J Parenter Enteral Nutr, 2008; 32:18–27.
26.
WhiteNH, SkorD, SantiagoJV. Practical closed-loop insulin delivery: A system for the maintenance of overnight euglycemia and the calculation of basal insulin requirements in insulin-dependent diabetics. Ann Intern Med, 1982; 97:210–213.
27.
DavidsonPC, SteedRD, BodeBW. Glucommander: A computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation. Diabet Care, 2005; 28:2418–2423.
28.
JacobiJ, BircherN, KrinsleyJ, et al.Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med, 2012; 40:3251–3276.
29.
KauffmannRM, HayesRM, JenkinsJM, et al.Provision of balanced nutrition protects against hypoglycemia in the critically ill surgical patient. JPEN J Parenter Enteral Nutr, 2011; 35:686–694.
30.
SoubaWW, SoubaWW. Nutritional support. N Engl J Med, 1997; 336:41–48.
31.
BrooksSE, MukherjeeK, GunterOL, et al.Do models incorporating comorbidities outperform those incorporating vital signs and injury pattern for prediction of mortality in geriatric trauma?. J Am Coll Surg, 2014; 219:1020–1027.
32.
KopelmanTR, O'NeillPJ, KannegantiSR, et al.The relationship of plasma glucose and glycosylated hemoglobin A1c levels among nondiabetic trauma patients. J Trauma, 2008; 64:30–34.
