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Transcript

  • 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. Causes of…
    • INSULIN
    • RESISTANCE
    • Pressors
    • Corticosteroids
    • Sepsis
    • Uremia
    • Cirrhosis
    • Obesity
    • Bed rest
    • INSULIN
    • DEFICIENCY
    • Advanced age
    • Hypothermia
    • Hypoxemia
    • DM
    • Pancreatitis
  • 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.  
  • 11. 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
  • 12. 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
  • 13. 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
  • 14. 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
  • 15. IIT Reductions in Morbidity
  • 16. Survival CIT v. IIT
  • 17. Kudos to Insulin?
    • Repletes intracellular calcium and prevents arryhthmias
    • Limits myocardial damage by enhancing energy delivery to ischemic areas
    • Anabolic effects promote tissue repair
  • 18. 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.