Among patients without diabetes, mortalitywas selleck products lowest when mean BG was 80 to 110 and 110 and 140 mg/dl and increased athigher levels. The mortality rate of the 200 patients with mean BG <80 mg/dl(0.62% of the total of 32,084 patients without diabetes) was 47.0%. Among patientswith diabetes, the shape of the relation between mean BG and mortality wascharacterized as a shallow trough, with modestly higher mortality in the aggregatewith mean BG 80 to 110 and >180 mg/dl than with mean BG in the 110- to180-mg/dl range. The mortality rate of the 71 patients with mean BG <80 mg/dl(0.55% of the total of 12,880 patients with diabetes) was 42.3%.Figure 1Mean blood glucose (BG) and mortality. The relation of mean BG(milligrams per deciliter) during ICU stay to mortality in those without(A) and those with diabetes (B), for each of the ninecohorts as well as the entire population.

HypoglycemiaFigure Figure2A2A and and2B2B illustrates theunadjusted relation between hypoglycemia and mortality. Hypoglycemia wasassociated with increased mortality in patients with diabetes as well as inpatients without diabetes, although the relation was stronger among patientswithout diabetes.Figure 2Minimum BG and mortality. The relation of minimum BG (milligrams perdeciliter) during ICU to mortality in nondiabetes (A) and diabetes(B) patients, for each of the nine cohorts as well as the entirepopulation. Cohorts with fewer than 20 patients in …Glycemic variabilityFigure Figure3A3A and and3B3B displays theunadjusted relation between CV and mortality.

Among patients without diabetes, therelation between increasing CV and increasing mortality was steep, with more thana threefold higher mortality among the entire cohort with CV >40%compared with those with CV <20%. This relation was similar, albeit attenuated,among patients with diabetes.Figure 3Coefficient of variation and mortality. The relationp of coefficientof variation (%) to mortality in nondiabetes (A) and diabetes (B)patients for each of the nine cohorts as well as the entire population.Cohorts with fewer than 20 patients in a particular ...Cumulative derangements in the three domains of glycemic control and theirassociation with mortalityFigure Figure4A4A and and4B4B illustrates thecumulative impact of derangements in the three domains of glycemic control.

Amongpatients without diabetes who had mean BG between 80 and 110, 110 and 140, and 140and 180 mg/dl, Carfilzomib increasing CV and the occurrence of hypoglycemia were associated withincreased mortality, and their effect was cumulative. Among patients without diabeteswith mean BG >180 mg/dl, no incremental impact was found of additionalderangements of glycemic control. Among patients with diabetes, hypoglycemia wasconsistently associated with increased mortality, but mean BG and CV did not have aconsistent, cumulative impact on mortality.Figure 4Cumulative derangements of three domains.

The blood glucose concentration can be measured in vitro by sensors that sit in the vascular or interstitial space or ex vivo by drawing blood samples or a dialysate to a sensor from an indwelling vascular catheter never or dialysis membrane. Systems that intermittently draw blood to an externally based sensor may be described as automated intermittent monitors rather than continuous glucose monitors. Potential advantages of continuous glucose monitors include the ability to observe trends in blood glucose concentration and to intervene before the blood glucose concentration enters an unacceptable range, and removal of operator error both in the timing of blood glucose measurements and in the sampling and analysis of blood.

Can we use the same measures for assessment of glucose control with continuous and intermittent monitoring?As noted in the first section of this paper, almost all monitoring of the blood glucose concentration in critically ill patients is by intermittent measurement. Although intermittent measurement is current standard practice, there is no agreed metric for reporting glycemic control and many of the metrics currently reported are affected by the frequency of measurement. Current systems for continuous or automated intermittent monitoring may measure the blood glucose concentration at a frequency varying from every minute to every 15 minutes. Such monitors will not only increase the number of measurements, but will also standardize the frequency of measurements amongst patients monitored with each device.

This may allow for a better reporting of glucose control metrics, and if sufficiently accurate may offer a better understanding of the association between those metrics and outcomes.Possible metrics available from continuous glucose monitoring systems include the following (Figure (Figure22 and Table Table22):Figure 2Schematic representation of the performance of continuous blood glucose concentration. Area A, possible measure of hyperglycemia (when defined as blood glucose concentration >10.0 mmol/l). Area B, possible measure of moderate hypoglycemia (when …Table 2Metrics to report glycemic control using continuous glucose monitoring systems1. Measures of central tendency:a. The mean and Batimastat median blood glucose per patient, per day and during stay in the ICU.2. Measures of dispersion and variability:a. The standard deviation and coefficient of variation of blood glucose.b. Analysis of the rate of change of the blood glucose concentration.c. The peak blood glucose concentration reached within a set time period after correction of hypoglycemia.3. Hypoglycemia and lowest blood glucose concentration:a. The lowest blood glucose concentration recorded.b.