[ ] Hyperglycemia.pps

Hyperglycemia & Critical Illness

Definition

Normal fasting glucose 70-110 mg/dl

Diabetic fasting glucose > 126 mg/dl or random glucose > 200 mg/dl

Pathophysiology

Metabolic changes in response to stress of illness

insulin secretion stress hormones (cortisol,

catecholamines, GH, glucagon) cytokines (TNFα , IL-1) Results in gluconeogenesis,

glycogenolysis, lipolysis, proteolysis

Factors Promoting Gluconeogenesis

Causes of…INSULINRESISTANCE Pressors Corticosteroids Sepsis Uremia Cirrhosis Obesity Bed rest

INSULINDEFICIENCY Advanced age Hypothermia Hypoxemia DM Pancreatitis

Other Causes

TPN – 50% pts. receiving dextrose > 4mg/kg/min develop hyperglycemia

Meds in fat emulsions (i.e. Propofol) Dextrose containing dialysis solutions Immunosuppressants (i.e. Tacrolimus)

Symptoms of Hyperglycemia Osmotic diuresis Dehydration Ketonemia/-uria Pseudohyponatremia AMS GI symptoms Respiratory abnormalities Metabolic acidosis Difficulty weaning from ventilator

Hyperglycemia & Infection

Granulocyte chemotaxis, complement activity, and phagocytic function are decreased by hyperglycemia

Hyperglycemia > 220 on POD #1 threefold increase in infections

Risk of sternal wound infections s/p CABG decreased by 58% in pts whose BG = 150-200 with insulin gtt

Hyperglycemia & Stroke

Associated with worse prognosis May reflect the intensity of the

stress hormone response 3x mortality in pts with BG>144 Independent predictor of

hemorrhagic transformation of ischemic stroke s/p TPA (overall rate 9%, BG > 200 rate 25%)

Prevention

Hypocaloric TPN (1000 kcal and 1g/kg protein) + lipid infusion (provide 30% daily kcal) lowers incidence of hyperglycemia

Insulin in TPN + ISS Hyperglycemia itself compounds

insulin resistance and production so prevention is key

Treatment

MDA target range 100-150 mg/dl Insulin sliding scale protocol If >150/24 hours advance to

insulin drip protocol Hold treatment if nutritional

support is stopped or held

Intensive v. Conventional Insulin Therapy 1548 SICU ventilated pts. CIT: drip started at BG > 215, target

range 180-200 IIT: drip started at BG > 110, target

range 80-110 Mortality in long stay (>5d in ICU) pts

CIT 20.2% v. IIT 10.6% Parenterally fed pts required 26%

higher insulin doses to maintain target BG than those fed enterally

Hypoglycemia

BG < 40 CIT 0.8% v. 5.2% IIT 90% of all episodes occurred after

target BG reached 62% due to interrupted enteral

feeds Episodes were brief with no serious

or permanent consequences

IIT Reductions in Morbidity

Survival CIT v. IIT

Kudos to Insulin?

Repletes intracellular calcium and prevents arryhthmias

Limits myocardial damage by enhancing energy delivery to ischemic areas

Anabolic effects promote tissue repair

References Finney, SJ, et al. Glucose control & mortality

in critically ill patients. JAMA 290:15, 2003. McGowen, KC, et al. Stress induced

hyperglycemia. Critical Care Clinics 17:1, 2001.

Montori, VM, et al. Hyperglycemia in acutely ill patients. JAMA 288:17, 2002.

Van den Berghe, G. Insulin therapy for the critically ill patient. Clinical Cornerstone 5:2, 2003.

Van den Berghe, G, et al. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose vs. glycemic control. Critical Care Medicine 31:2, 2003.