In-hospital glycaemic control: A bittersweet symphony

The presence of three domains of dysglycaemia—hyperglycaemia, hypoglycaemia and increased glucose variability—in acute illness has received quite some attention in the medical literature, especially with regard to their relationship to patient outcomes in different patient populations. However, controlling blood glucose levels in hospitalized patients has yielded both favourable and detrimental effects. Glycaemic control appears to be a complex interplay of various elements, or, metaphorically, ‘a bittersweet symphony’. This thesis focuses on epidemiology, monitoring and treatment of in-hospital dysglycaemia in order to optimize in-hospital glycaemic control. In the critically ill, we found that the presence of diabetes affects the relationship between three out of four measures of glycaemic control and intensive care mortality. Furthermore, we show that subcutaneous continuous glucose monitoring (CGM) is as safe and effective compared to intermittent point-of-care measurements and it reduces nursing workload and costs for glucose control using CGM. A newly developed intra-arterial CGM showed similar (and less promising) accuracy results compared to the subcutaneous CGM. The last part of this thesis focus on the consequences of stress-induced hyperglycaemia on coagulation activation. We examined the effect of the human GLP-1 analogue liraglutide in patients undergoing hip surgery and its influence on coagulation activation. The results show a significant albeit moderate reduction in glucose level (0.3 mmol/L) in patients treated with liraglutide. However, this decrease in glucose level did not convincingly influence coagulation activation. Thus, a causal relation between glucose lowering and altered coagulation activation could not be confirmed.