Symptoms of Hyperglycemia
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%)
Hypocaloric TPN (1000 kcal and 1g/kg
protein) + lipid infusion (provide 30%
daily kcal) lowers incidence of
Insulin in TPN + ISS
Hyperglycemia itself compounds
insulin resistance and production so
prevention is key
MDA target range 100-150 mg/dl
Insulin sliding scale protocol
If >150/24 hours advance to insulin
Hold treatment if nutritional support
is stopped or held
Intensive v. Conventional
1548 SICU ventilated pts.
CIT: drip started at BG > 215, target range
IIT: drip started at BG > 110, target range
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
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
Kudos to Insulin?
Repletes intracellular calcium and
Limits myocardial damage by
enhancing energy delivery to ischemic
Anabolic effects promote tissue
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,
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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