Glycemic control and intensive insulin therapy in critical illness
- Renee D Stapleton, MD, PhD
Renee D Stapleton, MD, PhD
- Associate Professor of Medicine
- University of Vermont College of Medicine
- Daren K Heyland, MD, FRCPC, MSc
Daren K Heyland, MD, FRCPC, MSc
- Professor of Medicine
- Queen's University, Ontario, Canada
- Section Editors
- Polly E Parsons, MD
Polly E Parsons, MD
- Editor-in-Chief — Pulmonary and Critical Care Medicine
- Section Editor — Critical Care
- Professor of Medicine
- University of Vermont College of Medicine
- Adrienne G Randolph, MD, MSc
Adrienne G Randolph, MD, MSc
- Section Editor — Pediatric Critical Care Medicine
- Professor of Anaesthesia and Pediatrics
- Harvard Medical School
Hyperglycemia associated with critical illness (also called stress hyperglycemia or stress diabetes) is a consequence of many factors, including increased cortisol, catecholamines, glucagon, growth hormone, gluconeogenesis, and glycogenolysis . Insulin resistance may also be a contributing factor, since it has been demonstrated in more than 80 percent of critically ill patients .
Hyperglycemia was previously considered an adaptive response essential for survival and was not routinely controlled in intensive care units (ICU) [3,4]. However, more recent evidence indicating that uncontrolled hyperglycemia is associated with poor outcomes has prompted efforts to routinely correct and prevent hyperglycemia in critically ill patients.
The association between hyperglycemia and worse clinical outcomes in critically ill patients is reviewed here. Outcomes related to glycemic control are also discussed. Nutritional support in critically ill patients is described separately. (See "Nutrition support in critically ill patients: An overview".)
EFFECTS OF HYPERGLYCEMIA
There is a wealth of observational evidence from different patient populations demonstrating that hyperglycemia is associated with poor clinical outcomes in critically ill patients. However, this evidence does not prove that hyperglycemia causes poor clinical outcomes, since hyperglycemia may merely be a marker of severe illness.
Trauma — Patients who are hyperglycemic following trauma have an increased mortality rate, hospital length of stay, ICU length of stay, and incidence of nosocomial infection [5-8]. This was illustrated by a prospective cohort study of 1003 patients who were admitted to an ICU following trauma . Hyperglycemia (blood glucose ≥200 mg/dL [12.2 mmol/L]) was present in 255 patients (25 percent) at the time of ICU admission. Compared to normoglycemic patients, hyperglycemic patients had a significantly increased mortality rate (26 versus 12 percent) and incidence of nosocomial infection (52 versus 32 percent).
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