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Hyperglycemia & Critical Illness

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

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Hyperglycemia & Critical Illness

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  1. Hyperglycemia & Critical Illness

  2. Definition • Normal fasting glucose 70-110 mg/dl • Diabetic fasting glucose > 126 mg/dl or random glucose > 200 mg/dl

  3. 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

  4. Factors Promoting Gluconeogenesis

  5. INSULIN RESISTANCE Pressors Corticosteroids Sepsis Uremia Cirrhosis Obesity Bed rest INSULIN DEFICIENCY Advanced age Hypothermia Hypoxemia DM Pancreatitis Causes of…

  6. 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)

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

  8. 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

  9. 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%)

  10. 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

  11. 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

  12. 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

  13. 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

  14. IIT Reductions in Morbidity

  15. Survival CIT v. IIT

  16. Kudos to Insulin? • Repletes intracellular calcium and prevents arryhthmias • Limits myocardial damage by enhancing energy delivery to ischemic areas • Anabolic effects promote tissue repair

  17. 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.

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