Admission glycemic gap and other glycemic indices in assessing the need for mechanical ventilation among neurocritical patients with diabetes mellitus
Authors
- Manas Kanti MazumderDepartment of Anesthesia, Analgesia & Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University), Dhaka, Bangladesh
- Kazi Tuba-E MozazfiaDepartment of Anesthesia and Intensive Care Unit, National Institute of Traumatology and Orthopaedic Rehabilitation, Dhaka, Bangladesh
- Mostak AhmedNational Institute of Burn and Plastic Surgery, Dhaka, Bangladesh
- Mohammad Abdul HannanDepartment of Anesthesia, Analgesia & Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University), Dhaka, Bangladesh
- AKM HabibullahDepartment of Anesthesia, Analgesia & Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University), Dhaka, Bangladesh
- Montosh Kumar MondolDepartment of Anesthesia, Analgesia & Intensive Care Medicine, Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University), Dhaka, Bangladesh
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Published by Bangabandhu Sheikh Mujib Medical University (currently, Bangladesh Medical University).
Conclusion: Among neurocritical patients with diabetes mellitus, all of the evaluated glycemic indices affect the need for MV. The AGG cut-off of 3.2 mmol/L is an acceptable value to predict the need for MV.
Data collection, biochemical measurements, and glycemic indices
A pre-tested, semi-structured questionnaire for obtaining data was created. The investigating team came to a consensus before finalizing the data collection instrument. Glasgow coma score, pulse, temperature, blood pressure (BP), mean arterial pressure (MAP), respiratory rate (RR), and partial pressure of oxygen in arterial blood (SpO2) were among the initial patient assessments that were pertinent to this investigation at the time of admission. The enrolled participants' medical records were reviewed, and notes were made regarding their age, sex, place of residence, primary diagnoses, comorbidities, medication history, and duration of DM. All these variables were considered for this study, as our literature review prior to and during the study showed these as potential factors that affect the need for MV among ICU patients. Within 24 hours of ICU admission, laboratory investigations were sent to the Department of Biochemistry and Molecular Biology, BSMMU, including the arterial blood gas analysis (ABG), complete blood count, A1c (ion-exchange HPLC method), and serum urea and creatinine, with results noted. The ABG was done using Easy Blood Gas Analyzer (MEDICA, USA), A1c with Abott premium (Hb 9210, USA), blood count with 6 MAX Auto Analyzer (Germany), and serum urea/ creatinine with Diamentian Auto Analyzer (USA).
Statistical analysis
Continuous data were expressed as mean (standard deviation), and categorical data were expressed as frequencies (percentages). Independent variables were compared between those who needed MV and those who did not. Analyses were performed using the 2-tailed Student's t-test for normally distributed continuous variables, or the Mann-Whitney U test for skewed data, and the Chi-square test or Fisher's exact test for categorical variables as appropriate. A logistic regression analysis was performed on those independent variables found statistically significant in the above analysis. Predictor variables were entered as continuous variables, except RRT, which had a binary category and coded '0' for no and '1' for yes response. Receiver operating characteristic (ROC) curves were plotted to analyze the discernibility of the predictive indices, and the area under the curve (AUC) and its 95% confidence interval (CI) were calculated to quantify the discriminative ability of AGG in predicting these outcomes. Youden’s index was used to calculate the best possible cut-off values of the glycemic gap, which can predict adverse outcomes. Data were analysed using STATA MP Version 16. A significance α level of 0.05 was used for statistical testing.
Ethics
The patients/ their consenting guardians were given an easy-to-understand explanation in the local language of the study's goals, risks, and advantages. Every participant/ their guardian was given the assurance that their treatment would not be hampered if they chose not to participate in the research or if they chose to withdraw at any point. Additionally, they received assurances that all information would be kept private and used only for the study.


Sixty ICU-admitted patients were included in the study, with a mean age (standard deviation) of 57.7 (2.0) years, and about half of them were from the 60 or more years’ age group. The majority (63.3%) of the patients were male, and more than half (55.0%) were from rural residences. Ischemic stroke (35.0%), traumatic brain injury (21.7%), and hemorrhagic stroke (20.0%) were the prevalent diagnoses. Hypertension (65.0%) was the commonest comorbid condition.
Baseline characteristics of patients were classified based on the provision of invasive MV. Among the 60 patients, 39 (65.0%) required MV. A significantly greater number of patients who were on MV were male and receiving insulin treatment (Table 1).
Characteristics | Total
(n=60) | Need for MV | P | |
No (n=21) | Yes (n=39) | |||
Age (years) mean (SD) | 57.7 (2.0) | 62.5 (2.5) | 55.3 (2.6) | 0.07 |
Age group |
| |||
<60 years | 27 (45.0) | 7 (33.3) | 20 (51.3) | 0.18 |
≥60 years | 33 (55.0) | 14 (66.7) | 19 (48.7) | |
Sex |
| |||
Female | 22 (36.8) | 12 (57.1) | 10 (25.6) | 0.02 |
Male | 38 (63.3) | 9 (42.9) | 29 (74.4) | |
Residence |
| |||
Rural | 33 (55.0) | 13 (61.9) | 20 (51.3) | 0.43 |
Urban | 27 (45.0) | 8 (38.1) | 19 (48.7) | |
Primary diagnosis |
| |||
Ischemic stroke | 21 (35.0) | 11 (52.4) | 10 (25.6) | 0.04 |
Traumatic brain injury | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Hemorrhagic stroke | 12 (20.0) | 3 (14.3) | 9 (23.1) | 0.51 |
Othersa | 14 (23.3) | 5 (23.8) | 9 (23.1) | 0.95 |
Co-morbidities |
| |||
Hypertension | 39 (65.0) | 15 (71.4) | 24 (61.5) | 0.44 |
Asthma/COPD | 8 (13.3) | 3 (14.3) | 5 (12.8) | 0.99 |
Ischemic heart disease | 4 (6.7) | 1 (4.8) | 3 (7.7) | 0.99 |
Drug history |
| |||
Anti-hypertensive | 35 (58.3) | 13 (61.9) | 22 (56.4) | 0.68 |
Insulin | 25 (41.7) | 5 (23.8) | 20 (51.3) | 0.04 |
Oral anti-diabetic | 33 (55.0) | 14 (66.7) | 19 (48.7) | 0.18 |
Oral anticoagulant | 4 (6.7) | 2 (9.2) | 2 (5.13) | 0.61 |
Results are in number (%), unless indicated otherwise. COPD indicates chronic obstructive pulmonary disease; SD, standard deviation. aSubarachnoid hemorrhage, Guillain Barre Syndrome, motor neuron disease, and meningoencephalitis. |
Characteristics | Total
(n=60) | Need for MV | ||
No (n=21) | Yes (n=39) | P | ||
Age (years) mean (SD) | 57.7 (2.0) | 62.5 (2.5) | 55.3 (2.6) | 0.07 |
Age group, n (%) |
| |||
<60 years | 27 (45.0) | 7 (33.3) | 20 (51.3) | 0.18 |
≥60 years | 33 (55.0) | 14 (66.7) | 19 (48.7) | |
Sex, n (%) |
| |||
Female | 22 (36.8) | 12 (57.1) | 10 (25.6) | 0.02 |
Male | 38 (63.3) | 9 (42.9) | 29 (74.4) | |
Residence, n (%) |
| |||
Rural | 33 (55) | 13 (61.9) | 20 (51.3) | 0.43 |
Urban | 27 (45) | 8 (38.1) | 19 (48.7) | |
Primary diagnosis, n (%) |
| |||
Ischemic stroke | 21 (35.0) | 11 (52.4) | 10 (25.6) | 0.04 |
TBI | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Hemorrhagic stroke | 12 (20.0) | 3 (14.3) | 9 (23.1) | 0.51 |
Othersa | 14 (23.3) | 5 (23.8) | 9 (23.1) | 0.95 |
Co-morbidities, n (%) |
| |||
Hypertension | 39 (65.0) | 15 (71.4) | 24 (61.5) | 0.44 |
Asthma/COPD | 8 (13.3) | 3 (14.3) | 5 (12.8) | 0.99 |
IHD | 4 (6.7) | 1 (4.8) | 3 (7.7) | 0.99 |
Drug history, n (%) |
| |||
Anti-hypertensive | 35 (58.3) | 13 (61.9) | 22 (56.4) | 0.68 |
Insulin | 25 (41.7) | 5 (23.8) | 20 (51.3) | 0.04 |
Oral anti-diabetic | 33 (55.0) | 14 (66.7) | 19 (48.7) | 0.18 |
Oral anticoagulant | 4 (6.7) | 2 (9.2) | 2 (5.13) | 0.61 |
TBI indicates traumatic brain injury; COPD, chronic obstructive pulmonary disease; IHD, ischemic heart disease; SD, standard deviation. aOthers include subarachnoid hemorrhage, Guillain Barre Syndrome, motor neuron disease, and meningoencephalitis. |
Characteristics | Total (n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Age (years) mean (SD) | 57.7 (2.0) | 62.5 (2.5) | 55.3 (2.6) | 0.07 |
Age group, n (%) |
| |||
<60 years | 27 (45.0) | 7 (33.3) | 20 (51.3) | 0.18 |
≥60 years | 33 (55.0) | 14 (66.7) | 19 (48.7) | |
Sex, n (%) |
| |||
Female | 22 (36.8) | 12 (57.1) | 10 (25.6) | 0.02 |
Male | 38 (63.3) | 9 (42.9) | 29 (74.4) | |
Residence, n (%) |
| |||
Rural | 33 (55) | 13 (61.9) | 20 (51.3) | 0.43 |
Urban | 27 (45) | 8 (38.1) | 19 (48.7) | |
Primary diagnosis, n (%) |
| |||
Ischemic stroke | 21 (35.0) | 11 (52.4) | 10 (25.6) | 0.04 |
TBI | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Hemorrhagic stroke | 12 (20.0) | 3 (14.3) | 9 (23.1) | 0.51 |
Othersa | 14 (23.3) | 5 (23.8) | 9 (23.1) | 0.95 |
Co-morbidities, n (%) |
| |||
Hypertension | 39 (65.0) | 15 (71.4) | 24 (61.5) | 0.44 |
Asthma/COPD | 8 (13.3) | 3 (14.3) | 5 (12.8) | 0.99 |
IHD | 4 (6.7) | 1 (4.8) | 3 (7.7) | 0.99 |
Drug history, n (%) |
| |||
Anti-hypertensive | 35 (58.3) | 13 (61.9) | 22 (56.4) | 0.68 |
Insulin | 25 (41.7) | 5 (23.8) | 20 (51.3) | 0.04 |
Oral anti-diabetic | 33 (55.0) | 14 (66.7) | 19 (48.7) | 0.18 |
Oral anticoagulant | 4 (6.7) | 2 (9.2) | 2 (5.13) | 0.61 |
TBI indicatesTraumatic brain injury; COPD, Chronic obstructive pulmonary disease; IHD, ischemic heart disease; SD, standard deviation. aOthers include subarachnoid hemorrhage, Guillain Barre Syndrome, motor neuron disease, and meningoencephalitis. |
Characteristics | Total (n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Age (years) | 57.7 (2.0) | 62.5 (2.5) | 55.3 (2.6) | 0.07 |
Age group, n (%) |
| |||
<60 years | 27 (45.0) | 7 (33.3) | 20 (51.3) | 0.18 |
≥60 years | 33 (55.0) | 14 (66.7) | 19 (48.7) | |
Sex, n (%) |
| |||
Female | 22 (36.8) | 12 (57.1) | 10 (25.6) | 0.02 |
Male | 38 (63.3) | 9 (42.9) | 29 (74.4) | |
Residence, n (%) |
| |||
Rural | 33 (55) | 13 (61.9) | 20 (51.3) | 0.43 |
Urban | 27 (45) | 8 (38.1) | 19 (48.7) | |
Primary diagnosis, n (%) |
| |||
Ischemic stroke | 21 (35.0) | 11 (52.4) | 10 (25.6) | 0.04 |
TBI | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Hemorrhagic stroke | 12 (20.0) | 3 (14.3) | 9 (23.1) | 0.51 |
Othersa | 14 (23.3) | 5 (23.8) | 9 (23.1) | 0.95 |
Co-morbidities, n (%) |
| |||
Hypertension | 39 (65.0) | 15 (71.4) | 24 (61.5) | 0.44 |
Asthma/COPD | 8 (13.3) | 3 (14.3) | 5 (12.8) | 0.99 |
IHD | 4 (6.7) | 1 (4.8) | 3 (7.7) | 0.99 |
Drug history, n (%) |
| |||
Anti-hypertensive | 35 (58.3) | 13 (61.9) | 22 (56.4) | 0.68 |
Insulin | 25 (41.7) | 5 (23.8) | 20 (51.3) | 0.04 |
Oral anti-diabetic | 33 (55.0) | 14 (66.7) | 19 (48.7) | 0.18 |
Oral anticoagulant | 4 (6.7) | 2 (9.2) | 2 (5.13) | 0.61 |
TBI indicatesTraumatic brain injury; COPD, Chronic obstructive pulmonary disease; IHD, ischemic heart disease; SD, standard deviation. aOthers include subarachnoid hemorrhage, Guillain Barre Syndrome, motor neuron disease, and meningoencephalitis. |
Background characteristics | Number (%) |
Age at presentation (weeks)a | 14.3 (9.2) |
Gestational age at birth (weeks)a | 37.5 (2.8) |
Birth weight (grams)a | 2,975.0 (825.0) |
Sex |
|
Male | 82 (41) |
Female | 118 (59) |
Affected side |
|
Right | 140 (70) |
Left | 54 (27) |
Bilateral | 6 (3) |
Delivery type |
|
Normal vaginal delivery | 152 (76) |
Instrumental delivery | 40 (20) |
Cesarean section | 8 (4) |
Place of delivery |
|
Home delivery by traditional birth attendant | 30 (15) |
Hospital delivery by midwife | 120 (60) |
Hospital delivery by doctor | 50 (25) |
Prolonged labor | 136 (68) |
Presentation |
|
Cephalic | 144 (72) |
Breech | 40 (20) |
Transverse | 16 (8) |
Shoulder dystocia | 136 (68) |
Maternal diabetes | 40 (20) |
Maternal age (years)a | 27.5 (6.8) |
Parity of mother |
|
Primipara | 156 (78) |
Multipara | 156 (78) |
aMean (standard deviation), all others are n (%) |
Background characteristics | Number (%) |
Age at presentation (weeks)a | 14.3 (9.2) |
Gestational age at birth (weeks)a | 37.5 (2.8) |
Birth weight (grams)a | 2,975.0 (825.0) |
Sex |
|
Male | 82 (41) |
Female | 118 (59) |
Affected side |
|
Right | 140 (70) |
Left | 54 (27) |
Bilateral | 6 (3) |
Delivery type |
|
Normal vaginal delivery | 152 (76) |
Instrumental delivery | 40 (20) |
Cesarean section | 8 (4) |
Place of delivery |
|
Home delivery by traditional birth attendant | 30 (15) |
Hospital delivery by midwife | 120 (60) |
Hospital delivery by doctor | 50 (25) |
Prolonged labor | 136 (68) |
Presentation |
|
Cephalic | 144 (72) |
Breech | 40 (20) |
Transverse | 16 (8) |
Shoulder dystocia | 136 (68) |
Maternal diabetes | 40 (20) |
Maternal age (years)a | 27.5 (6.8) |
Parity of mother |
|
Primipara | 156 (78) |
Multipara | 156 (78) |
aMean (standard deviation), all others are n (%) |
Mean escape latency of acquisition day | Groups | ||||
NC | SC | ColC | Pre-SwE Exp | Post-SwE Exp | |
Days |
|
|
|
|
|
1st | 26.2 (2.3) | 30.6 (2.4) | 60.0 (0.0)b | 43.2 (1.8)b | 43.8 (1.6)b |
2nd | 22.6 (1.0) | 25.4 (0.6) | 58.9 (0.5)b | 38.6 (2.0)b | 40.5 (1.2)b |
3rd | 14.5 (1.8) | 18.9 (0.4) | 56.5 (1.2)b | 34.2 (1.9)b | 33.8 (1.0)b |
4th | 13.1 (1.7) | 17.5 (0.8) | 53.9 (0.7)b | 35.0 (1.6)b | 34.9 (1.6)b |
5th | 13.0 (1.2) | 15.9 (0.7) | 51.7 (2.0)b | 25.9 (0.7)b | 27.7 (0.9)b |
6th | 12.2 (1.0) | 13.3 (0.4) | 49.5 (2.0)b | 16.8 (1.1)b | 16.8 (0.8)b |
Average of acquisition days | |||||
5th and 6th | 12.6 (0.2) | 14.6 (0.8) | 50.6 (0.7)b | 20.4 (2.1)a | 22.4 (3.2)a |
NC indicates normal control; SC, Sham control; ColC, colchicine control; SwE, swimming exercise exposure. aP <0.05; bP <0.01. |
Among the clinical and laboratory findings, MAP was significantly lower in ventilated patients, while ABGL, A1c, ADAG, and serum creatinine were significantly higher in those patients. AGG of mechanically ventilated patients (4.9 (1.8) mmol/L) was considerably higher (P <0.01) than that of non-ventilated patients (2.8 (1.5) mmol/L) (Table 2).
Categories | Number (%) |
Sex |
|
Male | 36 (60.0) |
Female | 24 (40.0) |
Age in yearsa | 8.8 (4.2) |
Education |
|
Pre-school | 20 (33.3) |
Elementary school | 24 (40.0) |
Junior high school | 16 (26.7) |
Cancer diagnoses |
|
Acute lymphoblastic leukemia | 33 (55) |
Retinoblastoma | 5 (8.3) |
Acute myeloid leukemia | 4 (6.7) |
Non-Hodgkins lymphoma | 4 (6.7) |
Osteosarcoma | 3 (5) |
Hepatoblastoma | 2 (3.3) |
Lymphoma | 2 (3.3) |
Neuroblastoma | 2 (3.3) |
Medulloblastoma | 1 (1.7) |
Neurofibroma | 1 (1.7) |
Ovarian tumour | 1 (1.7) |
Pancreatic cancer | 1 (1.7) |
Rhabdomyosarcoma | 1 (1.7) |
aMean (standard deviation) |
Characteristics | Total
(n=60) | Need for MV | P | |
No (n=21) | Yes (n=39) | |||
Clinical Findings | ||||
Pulse (beats/min) | 91.4 (16.3) | 90.1 (16.5) | 92.0 (16.3) | 0.67 |
Temperature |
|
|
|
|
<100.40 F | 49 (81.7) | 19 (90.1) | 30 (76.9) | 0.20 |
≥100.40 F | 11 (18.3) | 2 (9.5) | 9 (23.1) |
|
Oedema | 2 (3.3) | 1 (4.8) | 1 (2.6) | 0.65 |
Glasgow coma scorea | 8 (5.5–11.0) | 11 (6.0–14.0) | 7 (5.0–10.0) | 0.07 |
Respiratory rate (breaths/min)a | 20 (18.0–22.0) | 20 (16.0–20.0) | 20 (18.0–22.0) | 0.24 |
Laboratory findings | ||||
MAP (mmHg) | 92.1 (14.7) | 98.4 (13.6) | 88.7 (14.3) | 0.01 |
Oxygen saturationa | 97 (95.5–98.0) | 97 (95.0–98.0) | 97 (96.0–99.0) | 0.78 |
PaO2: FiO2 ratio | 263.9 (227.1) | 288.4 (128.1) | 250.7 (149.9) | 0.33 |
ABGL (mmol/L) | 13.6 (2.9) | 11.4 (2.3) | 14.7 (2.6) | <0.01 |
A1c (%)a | 7.3 (6.9–8.1) | 7 (6.6–7.2) | 7.8 (7.0–8.2) | <0.01 |
ADAG (mmol/L)a | 9 (8.4–10.3) | 8.5 (7.9–8.9) | 9.8 (8.5–10.4) | <0.01 |
AGG (mmol/L) | 4.16 (1.9) | 2.8 (1.5) | 4.9 (1.8) | <0.01 |
Haemoglobin (g/dL) | 11.7 (1.3) | 11.6 (1.3) | 11.7 (1.3) | 0.98 |
WBC count (x109/L) | 13.3 (4.0) | 12.3 (3.5) | 13.8 (4.2) | 0.16 |
Platelet count (x109/L)a | 210 (170.0–250.0) | 210 (165.0–250.0) | 210 (170.0–300.0) | 0.52 |
pHa | 7.5 (7.4–7.5) | 7.5 (7.4–7.5) | 7.5 (7.4–7.5) | 0.90 |
Serum urea (mg/dL)a | 39 (28.0–68.4) | 35 (26.0–62.0) | 40 (30.0–77.0) | 0.59 |
Serum creatinine (mg/dL)a | 1.0 (0.9–1.8) | 0.9 (0.7–1.2) | 1.0 (0.9–4.4) | <0.01 |
MAP, mean arterial pressure; ABGL, admission blood glucose level; ADAG, A1c derived average glucose; AGG, admission glycemic gap; TC, total count; PaO2, partial pressure of oxygen in arterial blood; FiO2, fraction of inspired oxygen; WBC, white blood cells aMedian (interquartile range), others are mean (standard deviation) |
Characteristics | Total
(n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Clinical Findings | ||||
Pulse (beats/min) | 91.4 (16.3) | 90.1 (16.5) | 92.0 (16.3) | 0.67 |
Temperature |
|
|
|
|
<100.40 F | 49 (81.7) | 19 (90.1) | 30 (76.9) | 0.20 |
≥100.40 F | 11 (18.3) | 2 (9.5) | 9 (23.1) |
|
Oedema | 2 (3.3) | 1 (4.8) | 1 (2.6) | 0.65 |
Glasgow coma scorea | 8 (5.5–11.0) | 11 (6.0–14.0) | 7 (5.0–10.0) | 0.07 |
Respiratory rate (breaths/min)a | 20 (18.0–22.0) | 20 (16.0–20.0) | 20 (18.0–22.0) | 0.24 |
Laboratory findings | ||||
MAP (mmHg) | 92.1 (14.7) | 98.4 (13.6) | 88.7 (14.3) | 0.01 |
Oxygen saturationa | 97 (95.5–98.0) | 97 (95.0–98.0) | 97 (96.0–99.0) | 0.78 |
PaO2: FiO2 ratio | 263.9 (227.1) | 288.4 (128.1) | 250.7 (149.9) | 0.33 |
ABGL (mmol/L) | 13.6 (2.9) | 11.4 (2.3) | 14.7 (2.6) | <0.01 |
HbA1c (%)a | 7.3 (6.9–8.1) | 7 (6.6–7.2) | 7.8 (7.0–8.2) | <0.01 |
ADAG (mmol/L)a | 9 (8.4–10.3) | 8.5 (7.9–8.9) | 9.8 (8.5–10.4) | <0.01 |
AGG (mmol/L) | 4.16 (1.9) | 2.8 (1.5) | 4.9 (1.8) | <0.01 |
Haemoglobin (g/dL) | 11.7 (1.3) | 11.6 (1.3) | 11.7 (1.3) | 0.98 |
WBC (TC) (x109/L) | 13.3 (4.0) | 12.3 (3.5) | 13.8 (4.2) | 0.16 |
Platelet count (x109/L)a | 210 (170.0–250.0) | 210 (165.0–250.0) | 210 (170.0–300.0) | 0.52 |
pHa | 7.5 (7.4–7.5) | 7.5 (7.4–7.5) | 7.5 (7.4–7.5) | 0.90 |
Serum urea (mg/dL)a | 39 (28.0–68.4) | 35 (26.0–62.0) | 40 (30.0–77.0) | 0.59 |
Serum creatinine (mg/dL)a | 1.0 (0.9–1.8) | 0.9 (0.7–1.2) | 1.0 (0.9–4.4) | <0.01 |
MAP, mean arterial pressure; ABGL, admission blood glucose level; ADAG, A1c derived average glucose; AGG, admission glycemic gap; TC, total count; PaO2, partial pressure of oxygen in arterial blood; FiO2, fraction of inspired oxygen. aMedian (interquartile range), others are mean (standard deviation) |
Characteristics | Total (n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Clinical Findings | ||||
Pulse (beats/min) | 91.4 (16.3) | 90.1 (16.5) | 92.0 (16.3) | 0.67 |
Temperature |
|
|
|
|
<100.40 F >=100.40 F | 49 (81.7) 11 (18.3) | 19 (90.1) 2 (9.5) | 30 (76.9) 9 (23.1) | 0.20 |
Oedema | 2 (3.3) | 1 (4.8) | 1 (2.6) | 0.65 |
Glasgow coma score | 8.5 (3.8) | 38.7 | 26.1 | 0.07 |
Respiratory rate (breaths/min) | 20.2 (3.8) | 26.9 | 32.4 | 0.24 |
Laboratory findings (mean SD) | ||||
MAP (mmHg) | 92.1 (14.7) | 98.4 (13.6) | 88.7 (14.3) | 0.01 |
Oxygen saturation | 96.6 (2.6) | 28.9 | 30.9 | 0.78 |
PaO2: FiO2 ratio | 263.9 (227.1) | 288.4 (128.1) | 250.7 (149.9) | 0.33 |
ABGL (mmol/L) | 13.6 (2.9) | 11.4 (2.3) | 14.7 (2.6) | <0.01 |
HbA1c (%) | 7.6 (1.1) | 20.9 | 35.7 | 0.02 |
ADAG (mmol/L) | 9.4 (1.7) | 20.8 | 35.7 | 0.02 |
AGG (mmol/L) | 4.16 (1.9) | 2.8 (1.5) | 4.9 (1.8) | <0.01 |
Haemoglobin (g/dL) | 11.7 (1.3) | 11.6 (1.3) | 11.7 (1.3) | 0.98 |
WBC (TC) (x109/L) | 13.3 (4.0) | 12.3 (3.5) | 13.8 (4.2) | 0.16 |
Platelet count (x109/L) | 237.7 (117.1) | 28.5 | 31.5 | 0.52 |
pH | 7.5 (0.1) | 30.3 | 30.9 | 0.90 |
Serum urea (mg/dL) | 58.7 (46.7) | 28.9 | 31.4 | 0.59 |
Serum creatinine (mg/dL) | 1.9 (1.9) | 21.3 | 35.2 | 0.04 |
SD indicates Standard deviation; MAP, Mean arterial pressure; ABGL, Admission blood glucose level; ADAG, A1c derived average glucose; AGG, Admission glycemic gap; TC, total count; PaO2, Partial pressure of oxygen in arterial blood; FiO2, Fraction of inspired oxygen. |
Characteristics | Total (n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Clinical Findings | ||||
Pulse (beats/min) | 91.4 (16.3) | 90.1 (16.5) | 92.0 (16.3) | 0.67 |
Temperature |
|
|
|
|
<100.40 F >=100.40 F | 49 (81.7) 11 (18.3) | 19 (90.1) 2 (9.5) | 30 (76.9) 9.0 (23.1) | 0.20 |
Oedema | 2 (3.3) | 1 (4.8) | 1 (2.6) | 0.65 |
Glasgow coma score | 8.5 (3.8) | 38.7 | 26.1 | 0.07 |
Respiratory rate (breaths/min) | 20.2 (3.8) | 26.9 | 32.4 | 0.24 |
Laboratory findings (mean SD) | ||||
MAP (mmHg) | 92.1 (14.7) | 98.4 (13.6) | 88.7 (14.3) | 0.01 |
Oxygen saturation | 96.6 (2.6) | 28.9 | 30.9 | 0.78 |
PaO2: FiO2 ratio | 263.9 (227.1) | 288.4 (128.1) | 250.7 (149.9) | 0.33 |
ABGL (mmol/L) | 13.6 (2.9) | 11.4 (2.3) | 14.7 (2.6) | <0.01 |
HbA1c (%) | 7.6 (1.1) | 20.9 | 35.7 | 0.02 |
ADAG (mmol/L) | 9.4 (1.7) | 20.8 | 35.7 | 0.02 |
AGG (mmol/L) | 4.16 (1.9) | 2.8 (1.5) | 4.9 (1.8) | <0.01 |
Haemoglobin (g/dL) | 11.7 (1.3) | 11.6 (1.3) | 11.7 (1.3) | 0.98 |
WBC (TC) (x109/L) | 13.3 (4.0) | 12.3 (3.5) | 13.8 (4.2) | 0.16 |
Platelet count (x109/L) | 237.7 (117.1) | 28.5 | 31.5 | 0.52 |
pH | 7.5 (0.1) | 30.3 | 30.9 | 0.90 |
Serum urea (mg/dL) | 58.7 (46.7) | 28.9 | 31.4 | 0.59 |
Serum creatinine (mg/dL) | 1.9 (1.9) | 21.3 | 35.2 | 0.04 |
RR indicates Respiratory rate; MAP, Mean arterial pressure; ABGL, Admission blood glucose level; ADAG, A1c derived average glucose; AGG, Admission glycemic gap; TC, total count. aPartial pressure of oxygen in arterial blood; bFraction of inspired oxygen. |
Narakas classification | Total 200 (100%) | Grade 1 72 (36%) | Grade 2 64 (32%) | Grade 3 50 (25%) | Grade 4 14 (7%) |
Complete recoverya | 107 (54) | 60 (83) | 40 (63) | 7 (14) | - |
Near complete functional recovery but partial deformitya | 22 (11) | 5 (7) | 10 (16) | 6 (12) | 1 (7) |
Partial recovery with gross functional defect and deformity | 31 (16) | 7 (10) | 13 (20) | 10 (20) | 1 (7) |
No significant improvement | 40 (20) | - | 1 (1.5) | 27 (54) | 12 (86) |
aSatisfactory recovery bGrade 1, C5, 6, 7 improvement; Grade 2, C5, 6, 7 improvement; Grade 3, panpalsy C5, 6, 7, 8, 9, Grade 4, panpalsy with Hornon’s syndrome. |
Narakas classification | Total 200 (100%) | Grade-1 72 (36%) | Grade-2 64 (32%) | Grade-3 50 (25%) | Grade-4 14 (7%) |
Complete recoverya | 107 (54) | 60 (83) | 40 (63) | 7 (14) | - |
Near complete functional recovery but partial deformitya | 22 (11) | 5 (7) | 10 (16) | 6 (12) | 1 (7) |
Partial recovery with gross functional defect and deformity | 31 (16) | 7 (10) | 13 (20) | 10 (20) | 1 (7) |
No significant improvement | 40 (20) | - | 1 (1.5) | 27 (54) | 12 (86) |
aSatisfactory recovery bGrade 1, C5, 6, 7 improvement; Grade 2, C5, 6, 7 improvement; Grade 3, panpalsy C5, 6, 7,8,9, Grade 4, panpalsy with Hornon’s syndrome. |
Variables in probe trial day | Groups | ||||
NC | SC | ColC | Pre-SwE Exp | Post-SwE Exp | |
Target crossings | 8.0 (0.3) | 7.3 (0.3) | 1.7 (0.2)a | 6.0 (0.3)a | 5.8 (0.4)a |
Time spent in target | 18.0 (0.4) | 16.2 (0.7) | 5.8 (0.8)a | 15.3 (0.7)a | 15.2 (0.9)a |
NC indicates normal control; SC, Sham control; ColC, colchicine control; SwE, swimming exercise exposure. aP <0.01. |
Pain level | Number (%) | P | ||
Pre | Post 1 | Post 2 | ||
Mean (SD)a pain score | 4.7 (1.9) | 2.7 (1.6) | 0.8 (1.1) | <0.001 |
Pain categories | ||||
No pain (0) | - | 1 (1.7) | 31 (51.7) | <0.001 |
Mild pain (1-3) | 15 (25.0) | 43 (70.0) | 27 (45.0) | |
Moderete pain (4-6) | 37 (61.7) | 15 (25.0) | 2 (3.3) | |
Severe pain (7-10) | 8 (13.3) | 2 (3.3) | - | |
aPain scores according to the visual analogue scale ranging from 0 to 10; SD indicates standard deviation |
The number of patients who developed MODS was higher among the mechanically ventilated patients (P 0.03). Mechanically ventilated patients’ survival rates were found to be significantly lower (P =0.01) than those who did not require MV (Table 3).
Clinical outcomes | All patients
(n=60) | Need for MV | P | |
No (n=21) | Yes (n=39) | |||
Needed renal replacement therapy | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Developed acute respiratory distress syndrome | 19 (31.7) | 4 (19.1) | 15 (38.5) | 0.15 |
Developed multiple organ dysfunction syndrome | 30 (50.0) | 5 (23.8) | 25 (64.1) | 0.03 |
Survival | 25 (41.7) | 15 (71.4) | 10 (25.6) | 0.01 |
Clinical outcomes | All patients
(n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Needed renal replacement therapy | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Developed acute respiratory distress syndrome | 19 (31.7) | 4 (19.1) | 15 (38.5) | 0.15 |
Developed multiple organ dysfunction syndrome | 30 (50.0) | 5 (23.8) | 25 (64.1) | <0.01 |
Survival | 25 (41.7) | 15 (71.4) | 10 (25.6) | <0.01 |
Clinical outcomes | All patients (n=60) | Need for mechanical ventilation | ||
No (n=21) | Yes (n=39) | P | ||
Needed renal replacement therapy | 13 (21.7) | 2 (9.5) | 11 (28.2) | 0.11 |
Developed acute respiratory distress syndrome | 19 (31.7) | 4 (19.1) | 15 (38.5) | 0.15 |
Developed multiple organ dysfunction syndrome | 30 (50.0) | 5 (23.8) | 25 (64.1) | 0.03 |
Survival | 25 (41.7) | 15 (71.4) | 10 (25.6) | 0.01 |
Surgeries | Number (%) | Satisfactory outcomes n (%) |
Primary surgery (n=24) |
|
|
Upper plexus | 6 (25) | 5 (83) |
Pan-palsy | 18 (75) | 6 (33) |
All | 24 (100) | 11 (46) |
Secondary Surgery (n=26) |
|
|
Shoulder deformity | 15 (58) | 13 (87) |
Wrist and forearm deformity | 11 (42) | 6 (54) |
All | 26 (100) | 19 (73) |
Primary and secondary surgery | 50 (100) | 30 (60) |
Mallet score 14 to 25 or Raimondi score 2-3 or Medical Research grading >3 to 5. |
Narakas classification | Total 200 (100%) | Grade-1 72 (36%) | Grade-2 64 (32%) | Grade-3 50 (25%) | Grade-4 14 (7%) |
Complete recoverya | 107 (54) | 60 (83) | 40 (63) | 7 (14) | - |
Near complete functional recovery but partial deformitya | 22 (11) | 5 (7) | 10 (16) | 6 (12) | 1 (7) |
Partial recovery with gross functional defect and deformity | 31 (16) | 7 (10) | 13 (20) | 10 (20) | 1 (7) |
No significant improvement | 40 (20) | - | 1 (1.5) | 27 (54) | 12 (86) |
aSatisfactory recovery bGrade 1, C5, 6, 7 improvement; Grade 2, C5, 6, 7 improvement; Grade 3, panpalsy C5, 6, 7,8,9, Grade 4, panpalsy with Hornon’s syndrome. |
Trials | Groups | ||||
NC | SC | ColC | Pre-SwE Exp | Post-SwE Exp | |
1 | 20.8 (0.6) | 22.1 (1.8) | 41.1 (1.3)b | 31.9 (1.9)b | 32.9 (1.8)a, b |
2 | 10.9 (0.6) | 14.9 (1.7) | 37.4 (1.1)b | 24.9 (2.0)b | 26.8 (2.5)b |
3 | 8.4 (0.5) | 9.9 (2.0) | 32.8 (1.2)b | 22.0 (1.4)b | 21.0 (1.4)b |
4 | 7.8 (0.5) | 10.4 (1.3) | 27.6(1.1)b | 12.8 (1.2)b | 13.0 (1.4)b |
Savings (%)c | 47.7 (3.0) | 33.0 (3.0) | 10.0 (0.9)b | 23.6 (2.7)b | 18.9 (5.3)b |
NC indicates normal control; SC, Sham control; ColC, colchicine control; SwE, swimming exercise exposure. aP <0.05; bP <0.01. cThe difference in latency scores between trials 1 and 2, expressed as the percentage of savings increased from trial 1 to trial 2 |
Variables related to the primary outcome (MV) were screened out during univariate analysis. The logistic regression analysis revealed the statistically significant association of ABGL, A1c, ADAG, and AGG with MV. One unit increase in the variable was associated with a 2.1 times (95% CI 1.4–3.1) higher requirement for MV (P <0.01). An increase of 1 mmol/L ADAG was associated with an 81% increase in the requirement for MV. Elevation of all four glycaemic indices (ABGL, A1c, ADAG, and AGG) significantly increased the risk of MV in neurocritical ICU patients with DM. A1c showed the greatest risk (OR 2.6; 95% CI 1.2–5.4) (Table 4).


Predictors | OR (95% CI) |
Admission blood glucose level (mmol/L) | 1.8 (1.3–2.5) |
Hemoglobin A1C (%) | 2.6 (1.2–5.4) |
A1C-derived admission glucose (mmol/L) | 1.8 (1.1–2.9) |
Admission glycemic gap (mmol/L) | 2.1 (1.4–3.1) |
Renal replacement therapy | 3.7 (0.7–18.8) |
All predictor variables were continuous except for renal replacement therapy, which was a binary category (coded '0' for no and '1' for yes). OR indicates odds ratio; CI, confidence interval |
Predictors | Mechanical ventilation (n=39) |
OR (95% CI) | |
Admission blood glucose level (mmol/L) | 1.8 (1.3–2.5) |
Hemoglobin A1c (%) | 2.6 (1.2–5.4) |
A1c-derived admission glucose (mmol/L) | 1.8 (1.1–2.9) |
Admission glycemic gap (mmol/L) | 2.1 (1.4–3.1) |
Renal replacement therapy | 3.7 (0.7–18.8) |
All predictor variables were continuous except for renal replacement therapy, which was a binary category (coded '0' for no and '1' for yes). OR indicates odds ratio; CI, confidence interval |
Predictors | Youden Index | Cut-off values | Sensitivity | Specificity | AUC (95% CI) |
Admission blood glucose level (mmol/L) | 0.63 | >12.2 | 0.87 | 0.76 | 0.84 ( 0.72–0.96) |
Hemoglobin A1C (%) | 0.47 | >7.4 | 0.62 | 0.86 | 0.75 (0.61–0.88) |
A1C-derived admission glucose (mmol/L) | 0.47 | >9.1 | 0.62 | 0.86 | 0.75 (0.61–0.88) |
Admission glycemic gap (mmol/L) | 0.60 | >3.2 | 0.79 | 0.81 | 0.79 (0.66–0.91) |
AUC indicates area under the curve; CI, confidence interval |
Predictors | Mechanical ventilation (n=39) | ||||
Youden Index | Cut-off values | Sensitivity | Specificity | AUC (95% CI) | |
Admission blood glucose level (mmol/L) | 0.63 | >12.2 | 0.87 | 0.76 | 0.84 ( 0.72–0.96) |
Hemoglobin A1c (%) | 0.47 | >7.4 | 0.62 | 0.86 | 0.75 (0.61–0.88) |
A1c-derived admission glucose (mmol/L) | 0.47 | >9.1 | 0.62 | 0.86 | 0.75 (0.61–0.88) |
Admission glycemic gap (mmol/L) | 0.60 | >3.2 | 0.79 | 0.81 | 0.79 (0.66–0.91) |
AUC indicates area under the curve; CI, confidence interval |
Predictors | Mechanical ventilation (n=39) | ||||
Youden Index | Cut-off values | Sensitivity | Specificity | AUC (95% CI) | |
Admission blood glucose level (mmol/L) | 0.63 | >12.2 | 0.87 | 0.76 | 0.84 ( 0.72–0.96) |
Hemoglobin A1c (%) | 0.47 | >7.4 | 0.62 | 0.86 | 0.75 (0.61–0.88) |
A1c-derived admission glucose (mmol/L) | 0.47 | >9.1 | 0.62 | 0.86 | 0.75 (0.61–0.88) |
Admission glycemic gap (mmol/L) | 0.60 | >3.2 | 0.79 | 0.81 | 0.79 (0.66–0.91) |
AUC indicates area under the curve; CI, confidence interval |
Predictors | Mechanical ventilation (n=39) | ||||||
Sensitivity | Specificity | AUC | 95% CI | Cut-off values | Youden Index | Standard Error | |
ABGL (mmol/L) | 0.87 | 0.76 | 0.84 | 0.72–0.96 | >12.2 | 0.63 | 0.10 |
Hemoglobin A1c (%) | 0.62 | 0.86 | 0.75 | 0.61–0.88 | >7.4 | 0.47 | 0.11 |
ADAG (mmol/L) | 0.62 | 0.86 | 0.75 | 0.61–0.88 | >9.1 | 0.47 | 0.11 |
AGG (mmol/L) | 0.79 | 0.81 | 0.79 | 0.66–0.91 | >3.2 | 0.60 | 0.10 |
ABGL indicates Admission Blood Glucose Level; ADAG, A1c derived admission glucose; AGG, Admission glycemic gap; AUC, Area under the curve; CI, Confidence interval. |


Findings from this study suggest that admission glucose level, A1c level, A1c-derived admission glucose, and AGG can predict the need for MV among the neurocritical patients with DM in the ICU. An AGG >3.2 mmol/L may be considered a marker to predict the need for MV in the defined patient pool.