Ir al contenido principal Ir al menú de navegación principal Ir al pie de página del sitio
Revista de la Facultad de Medicina

Vol. 1 Núm. 32 (2022)

Variabilidad de la Glicemia y Morbimortalidad del Paciente Crítico

Artículos
Publicado: 30-06-2022

Resumen

Introducción: Los pacientes ingresados al área de cuidado crítico están sujetos a monitoreo constante con el fin de optimizar su manejo médico y ofrecer el mejor pronóstico posible. Dentro de las estrategias de monitoreo, los niveles de glicemia han sido altamente estudiados ya que se consideran factor de riesgo significativo para aumento de la morbimortalidad de estos pacientes. Objetivo: Correlacionar la variabilidad de glucosa capilar con la morbimortalidad intrahospitalaria de pacientes en la unidad de cuidados críticos del Hospital General de Enfermedades del Instituto Guatemalteco de Seguridad Social.  Metodología: Se realizó un estudio descriptivo y analítico de tipo prospectivo, por medio del análisis estadístico de correlación.  Se incluyeron un total de 290 pacientes ingresados en la unidad de cuidados intensivos del IGSS, a los cuáles se les realizaron pruebas de glucosa capilar para luego determinar la variabilidad de glucosa capilar utilizando la desviación estándar. Esta se correlacionó con la morbimortalidad.  Resultados: Los pacientes que presentan una mayor desviación estándar de glucosa se correlaciona con una mayor mortalidad (R=0.249, R2=0.06, p<0.001) y morbilidad dada por la escala SOFA (R=0.27, R2=0.07, p<0.001).  Conclusión: El estudio demostró que un aumento en la variabilidad de glucosa capilar, se correlaciona con un aumento en la morbimortalidad de los pacientes durante su estadía en el área de cuidado crítico.

Citas

  1. Adhikari, N., Fowler, R., Bhagwanjee, S., Rubenfeld, G. Critical care and the global burden of critical illness in adults. The Lancet. 2010, Oct.; 376(9749): 1339-1346. https://doi.org/10.1016/S0140-6736(10)60446-1 DOI: https://doi.org/10.1016/S0140-6736(10)60446-1
  2. Cavalcanti, A.B., Bozza, F.A., Machado, F.R., Salluh, J., Pelisser Campagnucci, V., Vendramim, P., Guimaraes, H.P., Normilio-Silva, K., Petri Damiani, L., Romano, E., Carrara, F., Lubarino Diniz de Sousa, J., Reis Silva, A., Ramos, G. V., Teixeira, C., Da silva, N.B., Chang-Chou, C.C., Angus, D.C., Berwanger, O. Effect of a quality improvement intervention with daily round checklists, goal setting, and clinician prompting on mortality of critically ill patients: a randomized clinical trial. JAMA. 2016, April; 315(2): 1480-1490. https://doi.org/10.1001/jama.2016.3463 DOI: https://doi.org/10.1001/jama.2016.3463
  3. World Health Organization. Global Health Risks: mortality and burden of disease attributable to selected major risks. WHO, 2009; 62 p. https://apps.who.int/iris/handle/10665/44203
  4. Finney, S.J., Zekveld, C., Elia, A., Evans, T.W. Glucose control and mortality in critically ill patients. JAMA. 2003, Oct.; 290(15): 2041-2047. https://doi.org/10.1001/jama.290.15.2041 DOI: https://doi.org/10.1001/jama.290.15.2041
  5. Brownlee M. Biochemistry and molecular cell biology of diabetic complications. Nature. 2001, Dec.; 414(6865): 813–820. https://doi.org/10.1038/414813a DOI: https://doi.org/10.1038/414813a
  6. Brownlee, M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes. 2005, June.; 54(6): 1615–1625. https://doi.org/10.2337/diabetes.54.6.1615 DOI: https://doi.org/10.2337/diabetes.54.6.1615
  7. Brownlee, M., Hirsch, I.B. Glycemic variability: a hemoglobin A1c-independent risk factor for diabetic complications. JAMA. 2006, April; 295(14): 1707–1708. https://doi.org/10.1001/jama.295.14.1707 DOI: https://doi.org/10.1001/jama.295.14.1707
  8. Chao, H.Y., Liu, P.-H., Lin, S.C., Chen, C.K., Chen, J.C., Chan, Y.L., Wu, C.C., Blaney, G.N., Liu, Z.Y., Wu, C.J., Chen, K.-F. Association of In-Hospital Mortality and Dysglycemia in Septic Patients. PLOS One. 2017, January; 12, e0170408. https://doi.org/10.1371/journal.pone.0170408 DOI: https://doi.org/10.1371/journal.pone.0170408
  9. Wiener RS, Wiener DC, Larson RJ. (2008) Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA. 2008, Aug.; 300(8): 933–944. https://doi.org/10.1001/jama.300.8.933 DOI: https://doi.org/10.1001/jama.300.8.933
  10. Griesdale, D.E., de Souza, R.J., van Dam, R.M., Heyland, D.K., Cook, D.J., Malhotra, A., Dhaliwal, R., Henderson, W.R., Chittock, D.R., Finfer, S., Talmor, D. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. Canadian Medical Association Journal. 2009, April; 180(8): 821-827. https://doi.org/10.1503/cmaj.090206 DOI: https://doi.org/10.1503/cmaj.090206
  11. DeVries, J.H. Glucose Variabilty: Where it is Important and How to Measure It. Diabetes. 2013, May; 62(5): 1405-1408. https://doi.org/10.2337/db12-1610 DOI: https://doi.org/10.2337/db12-1610
  12. Krinsley, J.S., Grover A. Severe hypoglycemia in critically ill patients: risk factors and outcomes. Crit Care Med. 2017, Oct.; 35(10): 2262-2267. https://doi.org/10.1097/01.CCM.0000282073.98414.4B DOI: https://doi.org/10.1097/01.CCM.0000282073.98414.4B
  13. Bagshaw, S.M., Bellomo, R., Jacka, M.J., Egi, M., Hart, G.K. George, C., The impact of early hypoglycemia and blood glucose variability on outcome in critical illness. Crit Care. 2009, June; 13(3): R91 https://doi.org/10.1186/cc7921 DOI: https://doi.org/10.1186/cc7921
  14. Jay, D., Hitomi, H., Griendling, K.K.. Oxidative stress and diabetic cardiovascular complications. Free Radic Biol Med. 2006, Jan.; 40(2): 183–192. https://doi.org/10.1016/j.freeradbiomed.2005.06.018 DOI: https://doi.org/10.1016/j.freeradbiomed.2005.06.018
  15. Piconi, L., Quagliaro, L., Assaloni, R., Da Ros, R., Maier, A., Zuodar, G., Ceriello, A. Constant and intermittent high glucose enhances endothelial cell apoptosis through mitochondrial superoxide overproduction. Diabetes Metab Res Rev. 2006, May-June; 22(3): 198 –203. https://doi.org/10.1002/dmrr.613 DOI: https://doi.org/10.1002/dmrr.613
  16. Takeuchi, A., Throckmorton, D.C., Brogden, A.P., Yoshizawa, N., Rasmussen, H., Kashgarian, M. Periodic high extracellular glucose enhances production of collagens III and IV by mesangial cells. Am J Physiol. 1995, Jan.; 268(1 Pt 2): F13-9. https://doi.org/10.1152/ajprenal.1995.268.1.F13 DOI: https://doi.org/10.1152/ajprenal.1995.268.1.F13
  17. Monnier, L., Mas, E., Ginet, C., Michel, F., Villon, L., Cristol, J.P., Colette, C. Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes. JAMA. 2006, April; 295(14): 1681-1687. https://doi.org/10.1001/jama.295.14.1681 DOI: https://doi.org/10.1001/jama.295.14.1681
  18. Kilpatrick, E.S., Rigby, A.S., Atkin, S.L. Variability in the relationship between mean plasma glucose and HbA1c: implications for the assessment of glycemic control. Clin Chem. 2007, May; 53(5): 897-901. https://doi.org/10.1373/clinchem.2006.079756 DOI: https://doi.org/10.1373/clinchem.2006.079756
  19. Siegelaar, S.E., Holleman, F., Hoekstra, J.B.L., & DeVries, J.H. Glucose Variability: Does it matter? Endocrine Reviews. 2010, April; 31(2): 171-182. https://doi.org/10.1210/er.2009-0021 DOI: https://doi.org/10.1210/er.2009-0021
  20. Eslami, S., Taherzadeh, Z., Schultz, M., & Abu-Hanna, A. Glucose variability measures and their effect on mortality: a systematic review. Intensive Care Medicine. 2011, April; 37(4): 583-593. https://doi.org/10.1007/s00134-010-2129-5 DOI: https://doi.org/10.1007/s00134-010-2129-5
  21. Todi, S., & Bhattacharya, M. Glycemic variability and outcome in critically ill. Indian Journal of Critical Care Medicine. 2014, May; 18(5): 285–290. https://doi.org/10.4103/0972-5229.132484 DOI: https://doi.org/10.4103/0972-5229.132484
  22. Vincent, J.L. Blood glucose control in 2010: 110 to 150 mg/dL and minimal variability. Critical Care Medicine. 2010, March; 38(3): 993–995. https://doi.org/10.1097/CCM.0b013e3181d16b2e DOI: https://doi.org/10.1097/CCM.0b013e3181d16b2e
  23. Ali, N.A., O’Brien, Jr., J.M., Dungan, K., Phillips, G., Marsh, C.B., Lemeshow, S., Connors, Jr., A.F., Preiser. J.C. Glucose variability and mortality in patients with sepsis. Critical Care Medicine. 2008, August; 36(8): 2316-2321. https://doi.org/10.1097/CCM.0b013e3181810378 DOI: https://doi.org/10.1097/CCM.0b013e3181810378
  24. Dossett LA, Cao H, Mowery NT, Dortch MJ, Morris JM Jr, May AK. Blood glucose variability is associated with mortality in the surgical intensive care unit. Am., Surg. 2008, August; 74(8): 679-685; discussion 685. https://doi.org/10.1177/000313480807400802 DOI: https://doi.org/10.1177/000313480807400802
  25. Egi, M., Bellomo, R., Stachowski, E., French, C.J., Hart, G. Variability of blood glucose concentration and short-term mortality in critically ill patients. Anesthesiology. 2006, August; 105(2): 244-252. https://doi.org/10.1097/00000542-200608000-00006 DOI: https://doi.org/10.1097/00000542-200608000-00006
  26. Wintergerst KA, Buckingham B, Gandrud L, Wong BJ, Kache S, Wilson DM. Association of hypoglycemia, hyperglycemia, and glucose variability with morbidity and death in the pediatric intensive care unit. Pediatrics; 2006, July; 118(1): 173-179. https://doi.org/10.1542/peds.2005-1819 DOI: https://doi.org/10.1542/peds.2005-1819
  27. Akirov, A., Diker-Cohen, T., Masri-Iraqi, H., & Shimon, I. High Glucose Variability Increases Mortality Risk in Hospitalized Patients. J. Clinical Endocrinology Metabolism. 2017, July; 102(7): 2230-2241. https://doi.org/10.1210/jc.2017-00450 DOI: https://doi.org/10.1210/jc.2017-00450
  28. Mendez, C.E., Mok, K.T., Ata, A., Tanenberg, R.J., Calles-Escandon, J., Umpierrez, G.E. Increased glycemic variability is independently associated with length of stay and mortality in noncritically ill hospitalized patients. Diabetes Care; 2013, Dec.; 36(12): 4091–4097. https://doi.org/10.2337/dc12-2430 DOI: https://doi.org/10.2337/dc12-2430
  29. NICE-SUGAR Study Investigators, Finfer, S., Chittock, D.R., Intensive versus conventional glucose control in critically ill patients. N Engl J Me; 2009, March; 360(13): 1283-1297. https://doi.org/10.1056/NEJMoa0810625 DOI: https://doi.org/10.1056/NEJMoa0810625
  30. Papachristoforou, E., Lambadiari, V., Maratou, E., Makrilakis, K. Association of Glycemic
  31. Indices (Hyperglycemia, Glucose Variability, and Hypoglycemia) with Oxidative Stress and Diabetic Complications. J Diabetes Res; 2020; October; 7489795795. https://doi.org/10.1155/2020/7489795 DOI: https://doi.org/10.1155/2020/7489795
  32. Mendez, C.E., Mok, K.T., Ata, A., Tanenberg, R.J., Calles-Escandon,, J., Umpierrez, G.E. Increased glycemic variability is independently associated with length of stay and mortality in noncritically ill hospitalized patients. Diabetes Care. 2013, December; 36(12): 4091–4097. https://doi.org/10.2337/dc12-2430 DOI: https://doi.org/10.2337/dc12-2430
  33. Hemanides, J., Vriesendrop, T.M., Bosman, R.J., Zandstra, D.F., Hoekstra, J.B., & DeVries, J.H. Glucose variability is associated with intensive care unit mortality. Critical Care Medicine. 2010, Mar; 38(3):838-842. https://doi.org/10.1097/CCM.0b013e3181cc4be9 DOI: https://doi.org/10.1097/CCM.0b013e3181cc4be9
  34. Cook, D. J. Approach to the Patient in a Critical Care Setting. In L. Goldman, & A. Schafer, Goldman-Cecil Medicine. 26th ed. Part 10: Critical care medicine. Cecil. 2020;1(26). https://booksite.elsevier.com/samplechapters/9781437716047/Sample%20Chapters%20and%20Table%20of%20Contents.pdf

  • Alejandro Bautista Hurtarte
    Universidad Francisco Marroquín
  • Sergy Melissa Campos Martínez
    Universidad Francisco Marroquín
  • Jorge Luis Ranero Meneses
    Universidad Francisco Marroquín
Palabras clave: glucosa variabilidad de glucosa capilar mortalidad morbilidad

Cómo citar

Bautista Hurtarte, A., Campos Martínez, S. M., & Ranero Meneses, J. L. (2022). Variabilidad de la Glicemia y Morbimortalidad del Paciente Crítico. Revista De La Facultad De Medicina, 1(32), 67–86. https://doi.org/10.37345/23045329.v1i32.82