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,
...
Factors Promoting
Gluconeogenesis
Causes of…
INSULIN
RESISTANCE
 Pressors
 Corticosteroids
 Sepsis
 Uremia
 Cirrhosis
 Obesity
 Bed rest
INSULIN
DEFI...
Other Causes
 TPN – 50% pts. receiving dextrose >
4mg/kg/min develop hyperglycemia
 Meds in fat emulsions (i.e. Propofol...
Symptoms of Hyperglycemia
 Osmotic diuresis
 Dehydration
 Ketonemia/-uria
 Pseudohyponatremia
 AMS
 GI symptoms
 Re...
Hyperglycemia & Infection
 Granulocyte chemotaxis, complement
activity, and phagocytic function are
decreased by hypergly...
Hyperglycemia & Stroke
 Associated with worse prognosis
 May reflect the intensity of the
stress hormone response
 3x m...
Prevention
 Hypocaloric TPN (1000 kcal and 1g/kg
protein) + lipid infusion (provide 30%
daily kcal) lowers incidence of
h...
Treatment
 MDA target range 100-150 mg/dl
 Insulin sliding scale protocol
 If >150/24 hours advance to insulin
drip pro...
Intensive v. Conventional
Insulin Therapy
 1548 SICU ventilated pts.
 CIT: drip started at BG > 215, target range
180-20...
Hypoglycemia
 BG < 40 CIT 0.8% v. 5.2% IIT
 90% of all episodes occurred after
target BG reached
 62% due to interrupte...
IIT Reductions in Morbidity
Survival CIT v. IIT
Kudos to Insulin?
 Repletes intracellular calcium and
prevents arryhthmias
 Limits myocardial damage by
enhancing energy...
References
 Finney, SJ, et al. Glucose control & mortality in
critically ill patients. JAMA 290:15, 2003.
 McGowen, KC, ...
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Transcript of "[ ] Hyperglycemia.pps"

  1. 1. Hyperglycemia & Critical Illness
  2. 2. Definition  Normal fasting glucose 70-110 mg/dl  Diabetic fasting glucose > 126 mg/dl or random glucose > 200 mg/dl
  3. 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. 4. Factors Promoting Gluconeogenesis
  5. 5. Causes of… INSULIN RESISTANCE  Pressors  Corticosteroids  Sepsis  Uremia  Cirrhosis  Obesity  Bed rest INSULIN DEFICIENCY  Advanced age  Hypothermia  Hypoxemia  DM  Pancreatitis
  6. 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. 7. Symptoms of Hyperglycemia  Osmotic diuresis  Dehydration  Ketonemia/-uria  Pseudohyponatremia  AMS  GI symptoms  Respiratory abnormalities  Metabolic acidosis  Difficulty weaning from ventilator
  8. 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. 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. 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. 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. 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. 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. 14. IIT Reductions in Morbidity
  15. 15. Survival CIT v. IIT
  16. 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. 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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