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Table of Contents
LETTER TO THE EDITOR
Year : 2011  |  Volume : 15  |  Issue : 4  |  Page : 349-350

Intensive care management of critically sick diabetic patients


Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Ram Nagar, Banur, Punjab, India

Date of Web Publication30-Sep-2011

Correspondence Address:
Sukhminder Jit Singh Bajwa
House No-27-A, Ratan Nagar, Tripuri, Patiala, Punjab - 147 001
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2230-8210.85603

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How to cite this article:
Bajwa SS. Intensive care management of critically sick diabetic patients. Indian J Endocr Metab 2011;15:349-50

How to cite this URL:
Bajwa SS. Intensive care management of critically sick diabetic patients. Indian J Endocr Metab [serial online] 2011 [cited 2019 Dec 7];15:349-50. Available from: http://www.ijem.in/text.asp?2011/15/4/349/85603

Sir,

Diabetes mellitus (DM) is a major endocrine epidemic of modern times. [1] India accounts for 16%-17% of the world's total diabetics, which corresponds to almost 43 million patients. [2],[3] These statistics are a challenging reflection of what our physicians are going to face in the coming years. Yet, most published data on DM focuses on outdoor patient morbidity, without examining the impact of this disease on the health of critically ill patients.

Admission of DM patients in intensive care units (ICU) can be due to various acute complications attributable to DM (diabetic ketoacidosis, hyperosmolar coma, and hypoglycemia), or some other underlying pathology and co-morbidity. Invariably, the associated co-morbidities are the decisive factors responsible for such critical admissions and DM is a secondary contributor or sometimes an accidental finding. [4],[5],[6] Till date, we have not come across any study in an Indian intensive care unit setup where major emphasis is given to the effect of DM on mortality and morbidity statistics of ICU. The paucity of such important data is mainly responsible for the failure in framing our own guidelines and protocols. This in turn leads to lack of uniform management policies across the country.

Over the last 4-year period, there have been 1283 admissions in our ICU out of which 179 (13.95%) were established cases of DM, while 64 (4.99%) were diagnosed as diabetes after admission. A total of 497 patients (38.73%) had hyperglycemia (BS > 140 mg/dL) at one time or the other during the ICU stay, including the diabetic patients. Forty-six patients having established DM succumbed to their underlying severe clinical disorder. Majority of these diabetic patients were admitted with varied clinical presentation, such as severe ischemic heart disease, respiratory failure and aspiration, acute renal shutdown, diabetic ketoacidosis, polytrauma with craniofacial and blunt abdominal injuries, poisoning, and status epilepticus, and so on. The glycemic control in these patients was achieved with insulin administration as per the established protocols of our ICU. The mortality rates in patients with DM and hyperglycemia were higher, which may be attributed to multiple pathophysiological derangements.

Whatever the clinical presentation, tight glycemic control definitely decreases the mortality and morbidity in both diabetics and non-diabetics. [7] The fluctuating uncontrolled glycemia causes much more oxidative injury than the sustained hyperglycemia. Hyperglycemia at cellular level enhances the quantity of clotting factors, causes endothelial dysfunction, platelet activation, and inhibition of protective fibrinolytic system, thus predisposing the patient to multi-organ failure. [8],[9],[10],[11],[12] The various organ systems are highly vulnerable to hyperglycemic insults, and organ protection strategies should be the goal while simultaneously maintaining euglycemia. Intensive insulin therapy (IIT) in critically ill hyperglycemic patients with prolonged stay >5 days is associated with marked reduction in mortality varying from 40% to 50%, while reducing the morbidity ratio from acute renal failure, hepatic dysfunction, nosocomial infection, neuromuscular weakness, polyneuropathy of critical illness and severe anemia. [13]

This letter is an attempt to stimulate our medical fraternity to come forward on a common platform in providing useful and significant information regarding the DM statistics of their respective ICUs. The purpose of this letter will be fulfilled if more and more data from various ICUs of our country, revealing the current status of DM and hyperglycemia, is documented. Such an effort will definitely help in designing a more comprehensive approach to treat critically sick DM patients.

 
   References Top

1.King H, Rewers M. Diabetes in adults is now a Third World problem. The WHO Ad Hoc Diabetes Reporting Group. Bull World Health Organ 1991;69:643-8.  Back to cited text no. 1
    
2.Ramachandran A, Snehalatha C, Kapur A, Vijay V, Mohan V, Das AK, et al. High prevalence of diabetes and impaired glucose tolerance in India: National Urban Diabetes Survey. Diabetologia 2001;44:1094-101.  Back to cited text no. 2
    
3.Mohan V, Mathur P, Deepa R, Deepa M, Shukla DK, Menon GR, et al. Urban rural differences in prevalence of self-reported diabetes in India - The WHO-ICMR Indian NCD risk factor surveillance. Diabetes Res Clin Pract 2008;80:159-68.  Back to cited text no. 3
    
4.Wahab NN, Cowden EA, Pearce NJ, Gardner MJ, Merry H, Cox JL. ICONS Investigators: Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll Cardiol 2002;40:1748-54.   Back to cited text no. 4
    
5.Gray CS, Taylor R, French JM, Alberti KG, Venables GS, James OF, et al. The prognostic value of stress hyperglycaemia and previously unrecognized diabetes mellitus in acute stroke. Diabet Med 1987;4:237-40.  Back to cited text no. 5
    
6.Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: An independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978-82.  Back to cited text no. 6
    
7.Van den Berghe G. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med 2003;31:359-66.  Back to cited text no. 7
    
8.Williams E, Timperley WR, Ward JD, Duckworth T. Electron microscopical studies of vessels in diabetic peripheral neuropathy. J Clin Pathol 1980;33:462-70.  Back to cited text no. 8
    
9.Patrassi GM, Vettor R, Padovan D, Girolami A. Contact phase of blood coagulation in diabetes mellitus. Eur J Clin Invest 1982;12:307-11.  Back to cited text no. 9
    
10.Carmassi F. Coagulation and fibrinolytic system impairment in insulin dependent diabetes mellitus. Thromb Res 1992;67:643-54.  Back to cited text no. 10
    
11.Hughes A. Diabetes, a hypercoagulable state? Hemostatic variables in newly diagnosed type 2 diabetic patients. Acta Haematol 1983;69:254-9.  Back to cited text no. 11
    
12.Garcia Frade LJ. Diabetes mellitus as a hypercoagulable state: Its relationship with fibrin fragments and vascular damage. Thromb Res 1987;47:533-40.  Back to cited text no. 12
    
13.Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-67.  Back to cited text no. 13
    



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