Hyperglycemia and its control in the critically ill patient


Authors: Tomáš Kotulák 1;  Hynek Říha 1;  Martin Haluzík 2
Authors‘ workplace: Institut klinické a experimentální medicíny Praha, Klinika anesteziologie a resuscitace, Kardiocentrum 1;  III. interní klinika 1. LF UK a VFN, Praha 2
Published in: Čas. Lék. čes. 2011; 150: 20-23
Category: Review Article

Overview

In the critically ill patient, hyperglycemia was believed to be a response by the body to a stressful situation. Stress-induced hyperglycemia is the consequence of increased levels of cortisol, cytokines, growth hormones, catecholamines, and glucagon resulting in the stimulation of endogenous glucose production through glycogenolysis and gluconeogenesis as well as other mechanisms including central and peripheral insulin resistance. Among other things, hyperglycemia has an effect on inflammation and function of the myocardium, kidney, central nervous system, and the immune system. The protective role of intensified insulin therapy (glycemia of 4.4–6.1 mmol/l) in the critically ill patient, as suggested by the Leuven trial, resulted in the quick and widespread adoption of this approach in practice. However, later studies did not support the Leuven trial results while pointing to the possibility of developing severe hyperglycemia. The large multicenter NICE-SUGAR study in 6,022 patients showed higher 90-day mortality in the group with tight glycemic control. The results of NICE-SUGAR led to revision of the guidelines for glycemic control in the critically, recommending to control glycemia below 10 mmol/l. The aim of this overview is to summarize available data on glycemic control in the critically ill patient.

Key words:
insulin resistance, hyperglycemia, critically ill patients, tight glycemic control.


Sources

1. McCowen KC, Malhotra A, Bistrian BR. Stress-induced hyperglycemia. Crit Care Clin 2001; 17: 107–124.

2. Gustavson SM, Chu CA, Nishizawa M. Interaction of glucagon and epinephrine in the control of hepatic glucose production in the conscious dog. Am J Physiol Endocrinol Metab 2003; 284: 695–707.

3. Watt MJ, Howlett KF, Febraio MA. Adrenaline increases skeletal muscle glycogeolysis, pyruvate dehydrogenase activation and carbohydrate oxidation during moderate exercise in humans. J Physiol 2001; 534: 269–278.

4. Dresner A, Laurent D, Marcucci M. Effects of free fatty acids on glucose transport and IRS-1-associated phosphatidylinositol 3‑kinase activity. J Clin Invest 1999; 103: 253–259.

5. Lang CH, Dobrescu C, Mészáros K. Insulin mediated glucose uptake by individual tissues during sepsis. Metabolism 1990; 39: 1096–1107.

6. Esposito K, Nappo F, Marfella R. Inflammatory cytokine concentrations are increased by hyperglycemia in humans: Role of oxidative stress. Circulation 2002; 106: 2067–2072.

7. Verma S, Maitland A, Weisel RD. Hyperglycemia exaggerates ischemia-reperfusioninducedcardiomyocyte injury: reversal with endothelin antagonism. J Thorac Cardiovasc Surg 2002; 123: 1120–1124.

8. Kehl F, Krolikowski JG, Mraovic B. Hyperglycemia prevents isoflurane-induced preconditioning against myocardial infarction. Anesthesiology 2002; 96: 183–188.

9. Krogh-Madsen R, Moller K, Dela F. Effect of hyperglycemia and hyperinsulinemia on the response of IL-6, TNF-alpha, and FFAs to low-dose endotoxemia in humans. Am J Physiol Endocrinol Metab 2004; 286: 766–772.

10. Rassias AJ, Givan AL, Marrin CA. Insulin increases neutrophil count and phagocytic capacity after cardiac surgery. Anesth Analg 2002; 94(5): 1113–1119.

11. Ellger B, Debaveye Y, Vanhorebeek I. Survival benefits of intensive insulin therapy in critical illness: Impact of maintaining normoglycemia versus glycemia-independent actions of insulin. Diabetes 2006; 55: 1096–1105.

12. Marfella R, Quagliaro L, Nappo F. Acute hyperglycemia induces an oxidative stress in healthy subjects. J Clin Invest 2001; 108: 635–636.

13. Van Den Berghe G, Wouters P, Weekers F. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345: 1359–1367.

14. Butler SO, Btaiche IF, Alaniz C. Relationship between hyper­glycemia and infection in critically ill patients. Pharmacotherapy 2005, 25: 963–976.

15. Van Den Berghe G, Wilmer A, Hermans G. Intensive insulin therapy in the medical ICU. N Engl J Med 2006; 354(5): 449–461.

16. Schetz M, Vanhorebeek I, Wouters PJ. Tight blood glucose control is renoprotective in critically ill patients. J Am Soc Nephrol 2008; 19: 571–578.

17. Stead LG, Gilmore RM, Bellolio MF. Hyperglycemia as an independent predictor of worse outcome in nondiabetic patients presenting with acute ischemic stroke. Neurocritic Care 2009; 10(2): 181–186.

18. Rovlias A, Kotsou S. The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery 2000; 46: 335–342.

19. Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet 2009; 373: 1798–1807.

20. Van Den Berghe G, Wouters PJ, Bouillon R. Outcome benefit of intensive insulin therapy in the critically ill: Insulin dose versus glycemic control. Crit Care Med 2003; 31: 359–366.

21. Brunkhorst FM, Engel C, Bloos F. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008; 358: 125–139.

22. Preiser JC, Devos P, Ruiz-Santana S. A prospective randomised multi–centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med 2009; 35: 1738–1748.

23. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360: 1283–1297.

24. Vriesendorp TM, Van Santen S, Devries JH. Predisposing factors for hypoglycemia in the intensive care unit. Crit Care Med 2006; 34: 96–101.

25. Hermanides J, Bosman RJ, Vriesendorp TM. Hypoglycemia is associated with intensive care unit mortality. Crit Care Med 2010; 38: 1430–1434.

26. Suh SW, Gum ET, Hamby AM. Hypoglycemic neuronal death is triggered by glucose reperfusion and activation of neuronal NADPH oxidase. J Clin Invest 2007, 117: 910–918.

27. Egi M, Bellomo R, Stachowski, E. Variability of blood glucose concentration and shortterm mortality in critically ill patients. Anesthesiology 2006; 105: 244–252.

28. Hermanides J, Vriesendorp TM, Bosman RJ. Glucose variability is associated with intensive care unit mortality. Crit Care Med 2010; 38: 838–842.

29. Egi M, Bellomo R, Stachowski E. Blood glucose concentration and outcome of critical illness: The impact of diabetes. Crit Care Med 2008; 36: 2249–2255.

30. Blaha J, Kopecky P, Matias M. Comparison of three protocols for tight glycemic control in cardiac surgery patients. Diabetes Care 2009; 32: 757–761.

31. Ichai C, Preiser JC, Sfar SF. International recommendations for glucose control in adult non diabetic critically ill patients. Crit Care 2010; 14(5): R166.

Labels
Addictology Allergology and clinical immunology Angiology Audiology Clinical biochemistry Dermatology & STDs Paediatric gastroenterology Paediatric surgery Paediatric cardiology Paediatric neurology Paediatric ENT Paediatric psychiatry Paediatric rheumatology Diabetology Pharmacy Vascular surgery Pain management fenix.admin.empty

Article was published in

Journal of Czech Physicians


Most read in this issue

This topic is also in:


Login
Forgotten password

Don‘t have an account?  Create new account

Forgotten password

Enter the email address that you registered with. We will send you instructions on how to set a new password.

Login

Don‘t have an account?  Create new account