-The association between blood glucose level, diabetes and mortality for patient with sepsis remained a highly debated issue. -Previous studies have investigated but no current definite result has been drawn.

• To investigate the association between underlying of diabetes, initial blood sugar level and in-hospital mortality in patients with suspected sepsis from the ED.

-Diabetes mellitus seems to be a protective factor for patients with sepsis -Initial normal sugar level (ranging from 100~200) seems also to be a protective factor also for both DM or non-DM patients -The effect modification of diabetes on blood sugar level and mortality was not statistically significant.

Hsiao-Yun Chao MD1, Sheng-Che Lin MD1, Chun-Kuei Chen MD1, Peng-Hui Liu MD1, Jih-Chang Chen MD1, Yi-Lin Chan MD1, Kuan-Fu Chen MD PhD2. 1Chang-Gung Memorial Hospital, Taoyuan county, Taiwan; 2Chang-Gung Memorial Hospital, Keelung City, Taiwan

Contact Information: Kuan-Fu Chen, MD, PhD; phone: 886-975-360714; email: kfchen@cgmh.org.tw

INTRODUCTION

OBJECTIVES

CURRENT CONCLUSIONS

RESULTS

Normal Initial Blood Sugar Level and History of Diabetes Might Reduce in-hospital Mortality of Septic Patients Visited the Emergency Department

METHODS

-Sub-cohort from a retrospective cohort study -History of diabetes is defined by self-reported DM and the ICD-9 code from previous OPD record -Electronic chart review incorporating Microsoft Access SQL and Stata Manual chart review for infection confirmation Statistical analysis -Bivariate analysis: Wilcoxon Rank-sum test for continuous variables, Chi-square test for binary variables to evaluate any difference of patient characteristics. -Multivariate logistic regressions for risk factors, initial blood sugar level and history of diabetes and Mortality, as well as effect modification

-Possible confounders between diabetes and mortality was adjusted in this study, however, there still might be some measurable and unmeasurable confounders left. -Glycohemoglobin data were not available in most of the diabetes patients, which might be the evidence of appropriate diabetes control.

LIMITATIONS

RESULTS

Table 1 baseline characteristic of patients

• Patients with underlying diabetes tended to be older, female, and more likely to have lower sepsis severity (MEDS score), higher initial sugar level, ESRD with hemodialysis and positive blood culture test results (all P<0.05)

Diabetes p’t tended to have lower in-hospital mortality, controlling initial blood sugar level (aOR: 0.76, 95% CI 0.62-0.94, p=0.01)

DISCUSSIONS

-Initial hyperglycemia(>200) seems to possess much more trend for mortality for patient without diabetes comparing to those with diabetes.

-The effect modification of diabetes on blood sugar level and mortality, was found to be not statistically significant (p=0.51) in both low and high initial blood sugar level groups, which could be explained by fewer observation in the higher sugar level group.

-Patients with diabetes might be more aware of their health condition, which may have influence on the outcome and could not be verified in this study.

-About 5% underestimation if using self-reported history of diabetes only

RESULTS -Total patient: 6111, 57.2% (3495/6111) had diabetes -The mortality was 6.95% (425/6111) Overall

• Among the multivariate for the association with mortality… -Patients with older age, bandemia, higher MEDS score and bacteremia seems to have high mortality rate -Underlying of diabetes seems to be a protective factor

-Mortality seems not to be related to initial sugar level or gender

0.2

.4.6

Mor

tality

0 500 1000 1500Blood sugar

DM no DM

　 Median IQR

　 or N or %

Age1 66 (51-78)

> 65 years 3090 50.6%

Male 3308 54.1%

Diabetes 3495 57.2%

CKD 265 4.3%

Hemodialysis 426 7.0%

Liver disease 608 9.9%

Malignancy 1211 19.8%

Chemotherapy 521 8.5%

Terminal stage 15 0.2%

Immunosuppressed 339 5.5%

　 Median IQR 　 or N or % Body temperature 37.7 (36.8-38.5) Pulse rate 104 (90-119) Respiratory rate 20 (18-22) Systolic BP 140 (117-159) Diastolic BP 82 (71-94) Hemoglobin 11.9 (10.2-13.6) Hematocrit 36 (31.1-40.4) Platelet 203 (147-270) WBC 11 (7.7-15) Band 2 (1-5) C-RP 66.65 (22.9-154.) Sugar 134 (111-184) MEDS 7 (5-10) SIRS >2 3037 49.7% Fever 5741 93.9% Bacteremia 1227 20.1%

Death n=425 Survivor n=5686 　

　 Median IQR Median IQR p-value 　 or N or % or N or % 　

Age 72 (56-81) 65 (50-78) <0.001 > 65 years 261 61.4% 2829 49.8% <0.001

Male 247 58.1% 3061 53.8% 0.087 Diabetes 215 50.6% 3280 57.7% 0.004 CKD 23 5.4% 242 4.3% 0.259

Hemodialysis 43 10.1% 383 6.7% 0.008 Malignancy 175 41.2% 1036 18.2% <0.001 Platelet 167 (94-269) 204 (151-270) <0.001 WBC 11.8 (7.7-16.3) 11 (7.7-14.9) 0.061 MEDS 9 (6-12) 6 (5-10) <0.001 SIRS >2 228 53.6% 2809 49.4% 0.091 Bacteremia 126 29.6% 1101 19.4% <0.001

DM n=3495 Non-DM n=2616 　

　 Median IQR(1-3) Median IQR(1-3) p-value 　 or N or % or N or % 　

Age 66 (52-78) 64 (48-79) 0.046 > 65 years 1814 51.9% 1276 48.8% 0.016

Male 1837 52.6% 1471 56.2% 0.004 Diabetes 3495 100.0% 0 0.0% <0.001 CKD 181 5.2% 84 3.2% <0.001

Hemodialysis 280 8.0% 146 5.6% <0.001 Malignancy 564 16.1% 647 24.7% <0.001 Platelet 206 (154-274) 199 (139-264) <0.001 WBC 11.3 (8-15.1) 10.6 (7.3-14.8) <0.001 MEDS 6 (5-9) 8 (5-11) <0.001 SIRS >2 1606 46.0% 1431 54.7% <0.001 Fever 3287 94.0% 2454 93.8% 0.696 Bacteremia 665 19.0% 562 21.5% 0.018

Variables Odds Ratio p-value [95% C.I.] DM 0.76 0.01 (1.63-2.46) Sugar <100 2.00 <0.001 (1.63-2.46) Sugar>200 1.59 <0.001 (1.63-2.46) Malignancy 2.60 <0.001 (1.63-2.46) Age>65 1.82 <0.001 (1.63-2.46) Hemodialysis 1.54 0.01 (1.63-2.46) Chemotherapy 1.60 <0.001 (1.63-2.46) Liver disease 1.44 0.02 (1.63-2.46)