Journal of Clinical and Diagnostic Research, ISSN - 0973 - 709X

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Thiruvalla, Kerala
On Sep 2018

Prof. Somashekhar Nimbalkar

"Over the last few years, we have published our research regularly in Journal of Clinical and Diagnostic Research. Having published in more than 20 high impact journals over the last five years including several high impact ones and reviewing articles for even more journals across my fields of interest, we value our published work in JCDR for their high standards in publishing scientific articles. The ease of submission, the rapid reviews in under a month, the high quality of their reviewers and keen attention to the final process of proofs and publication, ensure that there are no mistakes in the final article. We have been asked clarifications on several occasions and have been happy to provide them and it exemplifies the commitment to quality of the team at JCDR."

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Ex-Member, Governing Body, National Neonatology Forum, New Delhi
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Department of Pediatrics, Pramukhswami Medical College, Karamsad, Anand, Gujarat.
On Sep 2018

Dr. Kalyani R

"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."

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Sri Devaraj Urs Medical College
Sri Devaraj Urs Academy of Higher Education and Research , Kolar, Karnataka
On Sep 2018

Dr. Saumya Navit

"As a peer-reviewed journal, the Journal of Clinical and Diagnostic Research provides an opportunity to researchers, scientists and budding professionals to explore the developments in the field of medicine and dentistry and their varied specialities, thus extending our view on biological diversities of living species in relation to medicine.
‘Knowledge is treasure of a wise man.’ The free access of this journal provides an immense scope of learning for the both the old and the young in field of medicine and dentistry as well. The multidisciplinary nature of the journal makes it a better platform to absorb all that is being researched and developed. The publication process is systematic and professional. Online submission, publication and peer reviewing makes it a user-friendly journal.
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Dr Saumya Navit
Professor and Head
Department of Pediatric Dentistry
Saraswati Dental College
On Sep 2018

Dr. Arunava Biswas

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Their prompt and timely response to review's query and the manner in which they have set the reviewing process helps in extracting the best possible scientific writings for publication.
It's a honour and pride to be a part of the JCDR team. My very best wishes to JCDR and hope it will sparkle up above the sky as a high indexed journal in near future."

Dr. Arunava Biswas
MD, DM (Clinical Pharmacology)
Assistant Professor
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Calcutta National Medical College & Hospital , Kolkata

Dr. C.S. Ramesh Babu
" Journal of Clinical and Diagnostic Research (JCDR) is a multi-specialty medical and dental journal publishing high quality research articles in almost all branches of medicine. The quality of printing of figures and tables is excellent and comparable to any International journal. An added advantage is nominal publication charges and monthly issue of the journal and more chances of an article being accepted for publication. Moreover being a multi-specialty journal an article concerning a particular specialty has a wider reach of readers of other related specialties also. As an author and reviewer for several years I find this Journal most suitable and highly recommend this Journal."
Best regards,
C.S. Ramesh Babu,
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Muzaffarnagar Medical College,
On Aug 2018

Dr. Arundhathi. S
"Journal of Clinical and Diagnostic Research (JCDR) is a reputed peer reviewed journal and is constantly involved in publishing high quality research articles related to medicine. Its been a great pleasure to be associated with this esteemed journal as a reviewer and as an author for a couple of years. The editorial board consists of many dedicated and reputed experts as its members and they are doing an appreciable work in guiding budding researchers. JCDR is doing a commendable job in scientific research by promoting excellent quality research & review articles and case reports & series. The reviewers provide appropriate suggestions that improve the quality of articles. I strongly recommend my fraternity to encourage JCDR by contributing their valuable research work in this widely accepted, user friendly journal. I hope my collaboration with JCDR will continue for a long time".

Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
On Aug 2018

Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
The journal has a monthly publication and the articles are published quite fast. In time compared to other journals. The on-line first publication is also a great advantage and facility to review one's own articles before going to print. The response to any query and permission if required, is quite fast; this is quite commendable. I have a very good experience about seeking quick permission for quoting a photograph (Fig.) from a JCDR article for my chapter authored in an E book. I never thought it would be so easy. No hassles.
Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
My best wishes to Dr. Hemant Jain and all the editorial staff of JCDR for their untiring efforts to bring out this journal. I strongly recommend medical fraternity to publish their valuable research work in this esteemed journal, JCDR".

Dr. Mamta Gupta
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018

Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.

Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."

Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
On May 11,2011

Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."

Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
On April 2011

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.

Dr. Anuradha
On Jan 2020

Important Notice

Original article / research
Year : 2023 | Month : November | Volume : 17 | Issue : 11 | Page : OC13 - OC17 Full Version

Analysis of Glycaemic Changes and their Outcome in Critically Ill Non-diabetic Patients Admitted to the ICU: A Cohort Study

Published: November 1, 2023 | DOI:
Bharat Yadav, Vinod Kumar, Amit Nachankar

1. Physician, Department of Medicine, Military Hospital, Jabalpur, Madhya Pradesh, India. 2. Physician, Department of Medicine, ITBP Base Hospital Tigri, Delhi, India. 3. Endocrinologist, Department of Endocrinology, Army Hospital (R&R) Delhi Cantt, Delhi, India.

Correspondence Address :
Amit Nachankar,
Department of Endocrinology, Army Hospital (R&R), Delhi Cantt, Delhi, India.


Introduction: Critical illness results in physiological and metabolic changes that lead to dysglycaemia, which is associated with morbidity and mortality. There exists a J- or U-shaped relationship between average glucose levels and mortality, emphasising the importance of evaluating glycaemic variability in critical illness.

Aim: To assess glycaemic changes in critically ill patients and their association with Intensive Care Unit (ICU) outcomes.

Materials and Methods: The prospective cohort study was conducted from August 2018 to August 2019. A total of 100 non-diabetic critically ill patients admitted to the ICU were observed for seven days. The severity of illness was evaluated using the Glasgow Coma Score (GCS) and Sequential Organ Failure Assessment (SOFA) scores. Plasma glucose levels were recorded every four hours in the ICU. Patients were followed for a maximum of seven days or until discharge or death. They were categorised into hypoglycaemia, normoglycaemia, or stress hyperglycaemia groups for analysis. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 24.0.

Results: The study included 64 male and 36 female patients, with an average mean age of 55.90±16.51 years (range: 18-86 years). Among the 100 patients, 21 died within the seven-day hospitalisation period. Among these, two were in the hypoglycaemic group, 13 were in the normoglycaemic group, and six were in the stress hyperglycaemic group. The patients had a mean SOFA score of 11.55±2.20, which was significantly higher compared to patients without organ failure (mean score: 2.54±2.55), with a statistically significant association (p<0.01). Similarly, patients who died during hospitalisation had a very high SOFA score (mean score: 9.76±3.36), also statistically significant (p<0.01).

Conclusion: Critically ill patients in the stress hyperglycaemia and hypoglycaemia groups during their ICU stay had a worse prognosis compared to patients with normoglycaemia. Hypoglycaemia during the ICU stay was associated with the poorest outcome. Maintaining normoglycaemia can significantly reduce morbidity and mortality in critically ill non-diabetic patients; therefore, considering Continuous Glucose Monitoring Systems (CGMS) for more frequent glycaemic monitoring and reducing glycaemic variability may lead to better outcomes in the ICU.


Stress hyperglycaemia, Hypoglycaemia, Sequential organ failure assessment score

Any critical illness is often associated with many physiological and metabolic changes in the body that alter glucose metabolism. Stress hyperglycaemia is defined as an acute sustained rise in serum glucose levels during any acute illness (1). It commonly occurs in patients who have not previously been diagnosed with diabetes mellitus and is frequently seen in critically ill patients (2). Hyperglycaemia itself is independently associated with increased mortality in the ICU (3),(4). Therefore, intensive glycaemic monitoring in critically ill patients has become a standard of care in the ICU and remains a topic of research.

Several factors contribute to stress hyperglycaemia in critical illness, including excessive counter-regulatory hormones such as glucagon, growth hormone, catecholamines, glucocorticoids, as well as inflammatory cytokines such as IL-1, IL-6, and Tumor Necrosis Factor(TNF)-alpha. Additionally, exogenous administration of catecholamines, dextrose, and other nutritional support in the presence of relative insulin deficiency plays an important role (5). Glycaemic variability is independently associated with adverse effects on vital organs and hospital mortality. Studies have shown a J- or U-shaped relationship between average plasma glucose and mortality (6),(7),(8).

Dysglycaemia in critically ill patients is associated with increased morbidity and mortality, as demonstrated in numerous studies (9). While hypoglycaemia, hyperglycaemia, and increased glycaemic variability are associated with increased mortality in a critical care setting, the diabetic status of patients also greatly influences the final outcome (10). Stress hyperglycaemia has been shown to worsen outcomes in critically ill patients (5). Although a higher plasma glucose range is associated with a mortality benefit in diabetic patients compared to non-diabetic patients, hypoglycaemia affects mortality equally regardless of the underlying diabetic status (10). Efforts to reduce glycaemic variability, thereby preventing both hypoglycaemia and hyperglycaemia, can significantly benefit the reduction of mortality in a critically ill patients (2).

There are few studies evaluating non-diabetic subjects in a critical care setting, in which the assessment of glycaemic status at presentation and severity of illness scores are used (8),(10),(11). Thus, there is a need for further studies to fill the gaps in existing

knowledge, using expensive Continuous Glucose Monitoring Systems (CGMS) available in the market. However, due to the cost of CGMS systems, they cannot be used in a cost-free government hospitals. Therefore, this present study aimed to assess glycaemic changes, including hyperglycaemic and hypoglycaemic events, in critically ill patients in a tertiary care hospital in India using point-of-care glucometers. It also aimed to study the association between glycaemic events among critically ill patients and their ICU outcomes.

Material and Methods

This was a single-center prospective cohort study conducted at Command Hospital Lucknow , India, over a period of one year, from August 2018 to August 2019. Prior approval from the institutional ethical committee was obtained (Dated: 19th August, 2018).

Sample size estimation: was based on the reported incidence of stress hyperglycaemia among critically ill patients, which varies from 20% to 80% in different studies [11-13]. The present study aimed for a similar incidence (~60%), and a sample size of 100 was estimated using the formula suggested by Charan and Biswas (14): n = C^2 * p * (1-p) / e^2. Here, ‘p’ represents the targeted incidence (60%), i.e., 0.60, ‘C’ is a constant at a certain confidence level (at 95% confidence limit and 80% power, its value is 1.96), and ‘e’ is the allowed error (taken as 10% or 0.10). Substituting these values in the equation, the authors get 92.1984, which rounds to 92. Therefore, the calculated sample size was 92. After accounting for a contingency of 10% and rounding off, the target sample size of 100 was chosen.

Inclusion criteria: All critically ill non-diabetic patients above 18 years of age, regardless of sex who presented during the study time period were included in the study. Non-diabetic patients were determined at admission by HbA1c<5.7%. The study also included patients with hypertension, Chronic Obstructive Pulmonary Disease (COPD), and other major illnesses such as bronchial asthma or thyroid disorders.

Exclusion criteria: Patients with baseline HbA1c levels >5.6% were excluded as they were considered to have prediabetes or overt diabetes mellitus. Additionally, patients with known diabetes mellitus on treatment, known hemoglobinopathies, postoperative patients, and those receiving glucocorticoids or immunosuppressive agents were excluded. Other exclusion criteria included patients with severe underlying co-morbidities like malignancy, connective tissue diseases, chronic renal failure, and cirrhosis. Finally, patients who died within 3 days of ICU admission were also excluded.


A total of 117 patients were screened. Consent was refused by relatives of seven patients, and 10 patients did not meet the inclusion criteria. The demographic details and clinical profile of all the patients included in the study were recorded at the time of admission. Plasma glucose and HbA1c levels were measured upon admission. The severity of illness was determined using the GCS and SOFA scores (15). Critical illness was assessed using the SOFA score, and patients with a SOFA score ≥4 at admission were admitted to the ICU. If not all parameters of the SOFA score were available, critical illness warranting ICU admission was considered in the presence of acute respiratory distress syndrome, refractory hypotension, a comatose state (GCS<9), or severe metabolic acidosis.

Random Plasma Glucose (RPG) levels were recorded once every four hours during the patients’ stay in the ICU, and the average RPG for the day was calculated as the mean of all available RPG levels for that day. Patients were divided into three groups based on their RPG at admission: hypoglycaemia group (RPG<55 mg/dL), normoglycaemia group (RPG 55-180 mg/dL), and hyperglycaemia group (RPG>180 mg/dL) [16,17]. After initial detection of hypoglycaemia, the patients were given 100 mL of intravenous 50% dextrose and then received continuous 5% dextrose infusion or oral feeding to maintain their RPG in the range of 140-180 mg/dL. They underwent RPG monitoring every 1-2 hours to prevent recurrent hypoglycaemia until stable glycaemic control was achieved, at which point RPG monitoring continued every six hours. Similarly, patients with persistent hyperglycaemia >180 mg/dL on two occasions were managed with insulin infusion using a correction insulin protocol to maintain their RPG in the range of 140-180 mg/dL and prevent recurrent hyperglycaemia. They also underwent RPG monitoring every two hours to prevent subsequent hyperglycaemia until stable glycaemic control was achieved, at which point RPG monitoring resumed every six hours. The patients were classified into their respective subgroups based on RPG before the intervention was started.

All cases were followed for a maximum of seven days or until death or discharge within seven days of hospitalisation. Their final outcome, including organ failure, death, or discharge from the hospital, was recorded. There was no specific follow-up of the studied patients to analyse their recovery and satisfaction levels after the pre-defined seven-day study period or after discharge from the hospital, whichever came earlier.

Statistical Analysis

The statistical analysis was conducted using IBM SPSS Statistics for Windows, version 24.0 (IBM Corp., Armonk, N.Y., USA). The values were presented as numbers (%) and mean±SD. Chi-square test, independent samples t-test, and Analysis of Variance were utilised to compare the data. A p-value less than 0.05 was deemed statistically significant.


Total 100 critically ill patients were recruited for the study, and their baseline demographic and laboratory parameters are shown in (Table/Fig 1),(Table/Fig 2).

The patients were divided into three glycaemic groups based on RPG at admission as follows: the hypoglycaemia group (2), the normoglycaemia group (83), and the hyperglycaemia group (15). A total of 21 patients (21%) died during the study. The first mortality was seen on day 4 of hospitalisation. By day 5, a total of thirteen patients had died, and by day 6, another seven patients had succumbed. One patient died on day 7 of hospitalisation. Among the patients who died, 11 (52.38%) had organ failure.

The mean age of the study population was 55.9 years (range 18-86 years). Among them, the majority (64%) were males, and females accounted for 36%. No significant co-morbidity was found in 73.0% of the patients, whereas 12% had a previous history of hypertension, 10% had COPD, and 5% had other major illnesses. Among these, 45 (45.0%) were smokers, 35 (35.0%) were tobacco consumers, and 19 (19.0%) had a history of significant alcohol consumption. On admission, the mean RPG was found to be 110.64±26.6 mg/dL (range: 36-182 mg/dL). The mean SOFA score was found to be 3.53±3.8 (range: 0-16). Glucose levels were measured every four hours daily, and the mean glucose levels, as shown in (Table/Fig 2), were then compared with the baseline plasma glucose. The association between them was found to be statistically non-significant (p>0.05) (Table/Fig 3).

The association between glucose levels in all three groups on all days compared to the baseline, as shown in (Table/Fig 4), was found to be statistically significant (p<0.01). The association between the hypoglycaemic and hyperglycaemic groups was found to be statistically significant on day 1, day 3, day 4, and day 5 (p<0.05). No significant association between the hypoglycaemic and hyperglycaemic groups was found on day 6 and day 7. No statistically significant association was found with different socio-demographic factors. Day-to-day changes in glucose levels at all days were compared with the severity of illness according to various variables, including the SOFA score.

This study observed that the patients who recorded any form of organ failure during hospitalisation had a mean SOFA score of 11.55±2.20, which was much higher than patients who did not have any organ failure (mean score 2.54±2.55), and the association between them was found to be statistically significant (p<0.01) (Table/Fig 5).

Similarly, patients who died during hospitalisation had a very high SOFA score (mean score: 9.76±3.36), suggesting a statistically significant association with the final outcome (p<0.01).

In the studied groups, two ICU outcomes were noticed: organ failure and the final outcome (discharge/death). The association of these outcomes with glycaemic events (hyperglycaemia, hypoglycaemia, and normoglycaemia) was also observed (Table/Fig 6), and both outcomes were found to be statistically significant (p<0.05). The association of the final outcome and organ failure after day 7 of hospitalisation was also statistically significant (Table/Fig 7).


This was a prospective cohort study conducted in a tertiary care teaching hospital for a period of one year. Similar observational studies have been previously conducted by Goldberg PA et al., Finney SJ et al., Holzinger U et al., Singh V et al., and Zochios V et al., (18),(19),(20),(21),(22). The advantage of an observational study is that it is inexpensive, captures multiple variables at the time of data collection, and can prove or disprove assumptions.

In this study, a total of 100 non-diabetic critically ill adult patients were observed for a period of seven days, with a similar sample size as the studies conducted by Holzinger U et al., and Singh V et al., (20),(21). However, the study by Finney SJ et al., had a larger sample size of 531 patients due to variations in the inclusion and exclusion criteria of the studied population (19).

In this study, all adult patients were included, with an age range of 18-86 years (mean age 55.90 years), and 64% of them were male. This is consistent with the findings of Finney SJ et al., where 72.8% of the patients were male, and the median age was 64 years (19). Wernly B et al., also reported a mean age of 69 years in their study, with an age range of 58-77 years, and 61% of the patients were male (23). Singh V et al., reported a mean age of 70.02 years in their study, but they had a majority (57.2%) of female participants (21).

In this study, 73% of the patients had no significant co-morbidities, while 12% had hypertension, 10% had COPD, and 5% had other systemic illnesses. Smoking history was documented in 45% of the patients, and a total of 19% were alcohol consumers. Singh V et al., also reported hypertension (56.02%), CAD (47.80%), and smoking (22.16%) among their patients (21).

In this study, the RPG at admission was 110.64±26.6 mg/dL, with an HbA1c level of 4.85±0.53%. Umpierrez GE et al., reported a mean blood glucose level at admission for their study patients as 227±65 mg/dL, which was higher than the levels observed in this study because they included diabetic patients (24). However, this study excluded diabetic patients, which is why a non-significant association was observed between the glucose concentration on the first day and the last day of hospitalisation (p>0.05) (24).

While it is generally accepted that stress hyperglycaemia is associated with increased morbidity and mortality, it remains uncertain whether tight glycaemic control is beneficial or even harmful for critically ill patients (17),(25). Regardless of the selected blood glucose target range, the randomised clinical studies conducted by Finfer S et al., and Brunkhorst FM et al., did not achieve the predefined target range in the majority of patients, resulting in an increased rate of severe hypoglycaemia (17),(25). Earlier studies by Krinsley JS and Grover A, and Vriesendorp TM et al., investigated the consequences of hypoglycaemia under tight glycaemic control in critically ill patients, revealing conflicting results (26),(27). However, these studies primarily focused on mortality and morbidity. The present study, which focused on ICU survivors, is the first to explore the effects of hypoglycaemia and hyperglycaemia during ICU treatment.

Finney SJ et al., reported a mean SOFA score of 5 on day 1, which is very close to our finding of a mean SOFA score of 3.53±3.8 (19). In the present study, a total of 21 patients died during the seven days of hospitalisation. By day 5, thirteen patients had died, seven more succumbed by day 6, and one patient died on day 7. Organ failure was observed in 11 patients who died within these seven days of observation. The association between organ failure and death in the reported patients was found to be statistically significant (p<0.01). This demonstrated that mortality was difficult to control in patients with organ failure, and glucose levels were also inherently difficult to control. Thus, patients spent considerable periods of time with glucose levels outside the target range. This is likely due, at least in part, to the multitude of variables that impact blood glucose levels, including feeding regimen, catecholamine administration, stress response, insulin administration, inherent bioavailability, and possibly a lack of concern about a variable that may be considered relatively minor by clinical staff (1).

In this study, the association between glucose levels in all three groups on all days was found to be statistically significant (p < 0.01). The association between hypoglycaemia and hyperglycaemia was found to be significant on day 1, day 4, and day 5 (p < 0.05). However, on day 6 and day 7, the correlation between the hypoglycaemia and hyperglycaemia groups could not be found as there were no patients in the hypoglycaemic range, and only mortality was observed in the normal glucose range on day 7. The association between organ failure and the final outcome, along with their respective SOFA scores, was found to be statistically significant (p<0.01). This data suggests that hyperglycaemia is the relevant variable determining the outcome. These findings are in agreement with other investigators’ results and other observational data indicating that the level of RPG at admission represents an independent risk factor for long-term prognosis, especially after myocardial infarction and in women following coronary artery bypass graft surgery, even in those without diabetes (28),(29),(30).

In this study, two ICU outcomes were observed: organ failure and the final outcome (discharged/death). The correlation of these outcomes with initial glycaemic levels (hyperglycaemia, hypoglycaemia, and normoglycaemia) was also found to be statistically significant (p < 0.05). While it is generally agreed that adequate glycaemic control is an essential part of critical care, there are still differences among experts. There is no standard definition of normoglycaemia during ICU stay for optimal outcomes, and the only recommendation, as per the NICE-SUGAR trial, is to maintain plasma glucose between 140 to 180 mg/dL (17). Therefore, it is very difficult to determine the best protocol in terms of results and clinical effort.

Various studies conducted since 2001 by Bryer-Ash M and Garber AJ, as well as Inzucchi SE and Rosenstock J, have suggested that although proper management of hyperglycaemia improves outcomes, the precise target blood glucose level, optimal mode of administration, type of insulin used, and the subset of patients most likely to benefit remain uncertain (31),(32). The response of optimal glycaemic control immediately after acute myocardial infarction and in septicaemia is highly erratic (23). Critically ill patients tolerate hypoglycaemia poorly and may remain asymptomatic during periods of severe hypoglycaemia (26).

In recent years, one of the most controversial topics in intensive care medicine has been how to treat critically ill patients with hyperglycaemia (33). Several protocols are available for insulin therapy in the ICU, although there is great variability regarding the initiation and titration of insulin (12),(28),(34). Some recommendations apply to hospitalised patients with newly diagnosed hyperglycaemia, although some patients may no longer require glucose-lowering therapy after they have recovered from acute illness. This study has not taken into consideration the use of insulin, even at suboptimal doses, and other treatment modalities in hyperglycaemic-range patients. Hence, the correlation between the influence of insulin and other modalities with outcomes cannot be commented upon and is outside the purview of the present study.

Hyperglycaemia is common in critically ill patients, even those without diabetes mellitus (35). However, if both hyperglycaemia and increased administration of insulin are associated with an increased risk of death, can manipulation of blood glucose to lower levels with infusions of soluble insulin reduce mortality? Published evidence suggests that such a strategy is effective in certain groups of patients (28). The apparent contradiction between the adverse effects of hyperglycaemia and increased administration of insulin provokes debate about the most appropriate target for glucose control.


The limitations of this study include being a single-centre study, which means it represents an analysis of manually acquired data that is susceptible to inherent inaccuracies. It cannot be certain that bias did not occur as plasma glucose results deviated from the required range and more observations were made. Another limitation is the absence of using CGMS, which could have provided better accuracy for assessing glycaemic status. Nonetheless, the study attempted to mitigate this possibility by time-weighing its observations. Additionally, it did not consider the impact of insulin usage, even at sub-optimal doses, on the final outcome of the study group.


Critically ill patients with stress hyperglycaemia during their ICU stay have a worse prognosis compared to patients with normoglycaemia. Hypoglycaemia during the ICU stay has an even worse outcome than stress hyperglycaemia. Stress hyperglycaemia and hypoglycaemia in critical care have a significant impact on patient mortality and outcomes. Normoglycaemia can significantly reduce these negative outcomes, but consistently achieving it as an expected outcome of critical care remains clinically elusive.

This overview has examined the current performance of clinical glycaemic control studies in critical care, focusing on the differences in emerging model-based approaches that utilise a variety of computational and emerging sensor technologies, as well as current ad-hoc clinical methods. With limited published studies, it is still an emerging field rather than a mature area of research. Hence, it is recommended that in the future, clinical research should be able to determine the true impact of glycaemic variability in critically ill patients, as well as consider new technologies like CGMS to optimise plasma glucose monitoring in the ICU.


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DOI and Others

DOI: 10.7860/JCDR/2023/64957.18669

Date of Submission: Apr 27, 2023
Date of Peer Review: Jul 27, 2023
Date of Acceptance: Aug 28, 2023
Date of Publishing: Nov 01, 2023

• Financial or Other Competing Interests: None
• Was Ethics Committee Approval obtained for this study? Yes
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. NA

• Plagiarism X-checker: May 01, 2023
• Manual Googling: Aug 04, 2023
• iThenticate Software: Aug 18, 2023 (17%)

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