Table 1 baseline characteristic of patients

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

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

RESULTS
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)
IQR or % (36.8-38.5) (90-119) (18-22) (117-159) (71-94) (10.2-13.6) (31.1-40.4) (147-270) (7.7-15) (1-5) (22.9-154.) (111-184) (5-10) 49.7% 93.9% 20.1%

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

Overall
Median or N Age1 66 > 65 years 3090 Male 3308 Diabetes 3495 CKD 265 Hemodialysis 426 Liver disease 608 Malignancy 1211 Chemotherapy 521 Terminal stage 15 Immunosuppressed 339 IQR or % (51-78) 50.6% 54.1% 57.2% 4.3% 7.0% 9.9% 19.8% 8.5% 0.2% 5.5% Body temperature Pulse rate Respiratory rate Systolic BP Diastolic BP Hemoglobin Hematocrit Platelet WBC Band C-RP Sugar MEDS SIRS >2 Fever Bacteremia Median or N 37.7 104 20 140 82 11.9 36 203 11 2 66.65 134 7 3037 5741 1227

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

METHODS
-Sub-cohort from a retrospective cohort study

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
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 Median or N 66 > 65 years 1814 Male 1837 Diabetes 3495 CKD 181 Hemodialysis 280 Malignancy 564 Platelet 206 WBC 11.3 MEDS 6 SIRS >2 1606 Fever 3287 Bacteremia 665 Age

n=3495 IQR(1-3) or % (52-78) 51.9% 52.6% 100.0% 5.2% 8.0% 16.1% (154-274) (8-15.1) (5-9) 46.0% 94.0% 19.0%

Non-DM Median or N 64 1276 1471 0 84 146 647 199 10.6 8 1431 2454 562

n=2616 IQR(1-3) or % (48-79) 48.8% 56.2% 0.0% 3.2% 5.6% 24.7% (139-264) (7.3-14.8) (5-11) 54.7% 93.8% 21.5%

p-value 0.046 0.016 0.004 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 0.696 0.018

LIMITATIONS
-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.

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

Diabetes pt tended to have lower in-hospital mortality, controlling initial blood sugar level (aOR: 0.76, 95% CI 0.62-0.94, p=0.01)
DM no DM

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

Mortality

.4

-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

.6

CURRENT CONCLUSIONS
.2

500 Blood sugar

1000

1500

-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.