Stress hyperglycemia

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Stress hyperglycemia (also called stress diabetes or diabetes of injury) is a medical term referring to transient elevation of the blood glucose due to the stress of illness. It usually resolves spontaneously, but must be distinguished from various forms of diabetes mellitus.

Contents

It is often discovered when routine blood chemistry measurements in an ill patient reveal an elevated blood glucose. Blood glucose can be assessed either by a bedside ‘fingerstick’ glucose meter or plasma glucose as performed in a laboratory (the latter being more efficacious). A retrospective cohort study by the Mayo Clinic held that bedside glucometry was a reliable estimate of plasma glucose with a mean difference of 7.9 mg/dL, but still may not coincide with every individual. [1] The glucose is typically in the range of 140–300 mg/dl (7.8-16.7 mM) but occasionally can exceed 500 mg/dl (28 mM), especially if amplified by drugs or intravenous glucose. The blood glucose usually returns to normal within hours unless predisposing drugs and intravenous glucose are continued.[ citation needed ]

Cause

Stress hyperglycemia is especially common in patients with hypertonic dehydration and those with elevated catecholamine levels (e.g., after emergency department treatment of acute asthma with epinephrine). Steroid diabetes is a specific and prolonged form of stress hyperglycemia.[ citation needed ]

People who have experienced stress hyperglycemia during severe illness have a threefold risk of developing diabetes in subsequent years, and it may be appropriate to screen for diabetes in survivors of critical illness. [2]

Diagnosis

Diagnosing patient can be complex, as there are no guidelines that specifically define stress hyperglycemia. [3]

Treatment

One of the most sweeping changes in intensive care unit (ICU) and post-surgical care in recent years is the trend toward more aggressive treatment of stress-induced hyperglycemia. [4] The 2008 guidelines from the Surviving Sepsis Campaign recommend insulin therapy in critically ill patients. [5]

A number of research studies have demonstrated that even mildly elevated blood glucose levels (110 mg/dL or 6.1 mmol/L) in a hospital intensive care unit (ICU) can measurably increase the morbidity and mortality of such patients. According to a randomized control trial of over 1500 surgical ICU patients, controlling patients’ blood glucose below 110 mg/dL or 6.1 mmol/L significantly decreased mortality from 8% with conventional treatment to 4.6%, and also decreased morbidity from bloodstream infections by 46%, acute renal failure requiring dialysis or hemofiltration and critical illness polyneuropathy (Van den Berghe, 2001). [6] A subsequent randomized control trial of 1200 medical ICU patients found that intensive insulin therapy significantly reduced morbidity but not mortality among all patients in the medical ICU. [7] On the other hand, several studies failed to show benefit or demonstrated harmful effects (mainly from hypoglycemia) of intensive insulin therapy in critically ill patients. [8] A meta-analysis of studies on this topic could not demonstrate an advantage of tight glycemic control, while there was an increase in hypoglycemia. [9] This questions the validity of current guidelines.

Most recently, the largest randomized control trial to date (with 6104 enrolled patients) comparing the effects of intensive glucose control vs. conventional glucose control in ICU patients found that tight glucose control significantly increased mortality at 90 days after admission to the ICU as compared to conventional glucose control (2.6% increase in the absolute risk of death). [10] In this trial (the NICE-SUGAR Study), patients randomised to the intensive glucose control group had a target blood sugar range of 4.5 to 6.0 mmol/L while those placed in the conventional glucose control group had a blood glucose target range of 8.0 to 10.0 mmol/L (as compared to 10.0 to 11.1 mmol/L in Van den Berghe, 2001). Patients were enrolled from mixed ICU wards (as compared to a surgical ICU in Van den Berghe, 2001). The NICE-SUGAR trial may very well change our approach to the management of stress-induced hyperglycemia in the ICU.[ citation needed ]

Related Research Articles

<span class="mw-page-title-main">Hypoglycemia</span> Health condition

Hypoglycemia, also called low blood sugar, is a fall in blood sugar to levels below normal, typically below 70 mg/dL (3.9 mmol/L). Whipple's triad is used to properly identify hypoglycemic episodes. It is defined as blood glucose below 70 mg/dL (3.9 mmol/L), symptoms associated with hypoglycemia, and resolution of symptoms when blood sugar returns to normal. Hypoglycemia may result in headache, tiredness, clumsiness, trouble talking, confusion, fast heart rate, sweating, shakiness, nervousness, hunger, loss of consciousness, seizures, or death. Symptoms typically come on quickly.

<span class="mw-page-title-main">Diabetic ketoacidosis</span> Medical condition

Diabetic ketoacidosis (DKA) is a potentially life-threatening complication of diabetes mellitus. Signs and symptoms may include vomiting, abdominal pain, deep gasping breathing, increased urination, weakness, confusion and occasionally loss of consciousness. A person's breath may develop a specific "fruity" smell. The onset of symptoms is usually rapid. People without a previous diagnosis of diabetes may develop DKA as the first obvious symptom.

<span class="mw-page-title-main">Glucose tolerance test</span> Medical test of how quickly glucose is cleared from the blood

The glucose tolerance test is a medical test in which glucose is given and blood samples taken afterward to determine how quickly it is cleared from the blood. The test is usually used to test for diabetes, insulin resistance, impaired beta cell function, and sometimes reactive hypoglycemia and acromegaly, or rarer disorders of carbohydrate metabolism. In the most commonly performed version of the test, an oral glucose tolerance test (OGTT), a standard dose of glucose is ingested by mouth and blood levels are checked two hours later. Many variations of the GTT have been devised over the years for various purposes, with different standard doses of glucose, different routes of administration, different intervals and durations of sampling, and various substances measured in addition to blood glucose.

<span class="mw-page-title-main">Hyperglycemia</span> Too much blood sugar, usually because of diabetes

Hyperglycemia is a condition in which an excessive amount of glucose circulates in the blood plasma. This is generally a blood sugar level higher than 11.1 mmol/L (200 mg/dL), but symptoms may not start to become noticeable until even higher values such as 13.9–16.7 mmol/L (~250–300 mg/dL). A subject with a consistent range between ~5.6 and ~7 mmol/L is considered slightly hyperglycemic, and above 7 mmol/L is generally held to have diabetes. For diabetics, glucose levels that are considered to be too hyperglycemic can vary from person to person, mainly due to the person's renal threshold of glucose and overall glucose tolerance. On average, however, chronic levels above 10–12 mmol/L (180–216 mg/dL) can produce noticeable organ damage over time.

<span class="mw-page-title-main">Sepsis</span> Life-threatening organ dysfunction triggered by infection

Sepsis is a potentially life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs.

<span class="mw-page-title-main">Blood sugar level</span> Concentration of glucose present in the blood (Glycaemia)

The blood sugar level, blood sugar concentration, blood glucose level, or glycemia, is the measure of glucose concentrated in the blood. The body tightly regulates blood glucose levels as a part of metabolic homeostasis.

<span class="mw-page-title-main">Gestational diabetes</span> Medical condition

Gestational diabetes is a condition in which a woman without diabetes develops high blood sugar levels during pregnancy. Gestational diabetes generally results in few symptoms; however, it increases the risk of pre-eclampsia, depression, and of needing a Caesarean section. Babies born to mothers with poorly treated gestational diabetes are at increased risk of macrosomia, of having hypoglycemia after birth, and of jaundice. If untreated, diabetes can also result in stillbirth. Long term, children are at higher risk of being overweight and of developing type 2 diabetes.

Glycated hemoglobin is a form of hemoglobin (Hb) that is chemically linked to a sugar. Most monosaccharides, including glucose, galactose and fructose, spontaneously bond with hemoglobin when present in the bloodstream. However, glucose is less likely to do so than galactose and fructose, which may explain why glucose is used as the primary metabolic fuel in humans.

The term diabetes includes several different metabolic disorders that all, if left untreated, result in abnormally high concentrations of a sugar called glucose in the blood. Diabetes mellitus type 1 results when the pancreas no longer produces significant amounts of the hormone insulin, usually owing to the autoimmune destruction of the insulin-producing beta cells of the pancreas. Diabetes mellitus type 2, in contrast, is now thought to result from autoimmune attacks on the pancreas and/or insulin resistance. The pancreas of a person with type 2 diabetes may be producing normal or even abnormally large amounts of insulin. Other forms of diabetes mellitus, such as the various forms of maturity-onset diabetes of the young, may represent some combination of insufficient insulin production and insulin resistance. Some degree of insulin resistance may also be present in a person with type 1 diabetes.

Many types of glucose tests exist and they can be used to estimate blood sugar levels at a given time or, over a longer period of time, to obtain average levels or to see how fast body is able to normalize changed glucose levels. Eating food for example leads to elevated blood sugar levels. In healthy people these levels quickly return to normal via increased cellular glucose uptake which is primarily mediated by increase in blood insulin levels.

Hyperosmolar hyperglycemic state (HHS), also known as hyperosmolar non-ketotic state (HONK), is a complication of diabetes mellitus in which high blood sugar results in high osmolarity without significant ketoacidosis. Symptoms include signs of dehydration, weakness, leg cramps, vision problems, and an altered level of consciousness. Onset is typically over days to weeks. Complications may include seizures, disseminated intravascular coagulopathy, mesenteric artery occlusion, or rhabdomyolysis.

An insulin tolerance test (ITT) is a medical diagnostic procedure during which insulin is injected into a patient's vein, after which blood glucose is measured at regular intervals. This procedure is performed to assess pituitary function, adrenal function, insulin sensitivity, and sometimes for other purposes. An ITT is usually ordered and interpreted by an endocrinologist.

The Surviving Sepsis Campaign (SSC) is a global initiative to bring together professional organizations in reducing mortality from sepsis. The purpose of the SSC is to create an international collaborative effort to improve the treatment of sepsis and reduce the high mortality rate associated with the condition. The Surviving Sepsis Campaign and the Institute for Healthcare Improvement have teamed up to achieve a 25 percent reduction in sepsis mortality by 2009. The guidelines were updated in 2016 and again in 2021.

A stress ulcer is a single or multiple mucosal defect usually caused by physiological stress which can become complicated by upper gastrointestinal bleeding. These ulcers can be caused by shock, sepsis, trauma or other conditions and are found in patients with chronic illnesses. These ulcers are a significant issue in patients in critical and intensive care.

<span class="mw-page-title-main">Prediabetes</span> Predisease state of hyperglycemia with high risk for diabetes

Prediabetes is a component of the metabolic syndrome and is characterized by elevated blood sugar levels that fall below the threshold to diagnose diabetes mellitus. It usually does not cause symptoms but people with prediabetes often have obesity, dyslipidemia with high triglycerides and/or low HDL cholesterol, and hypertension. It is also associated with increased risk for cardiovascular disease (CVD). Prediabetes is more accurately considered an early stage of diabetes as health complications associated with type 2 diabetes often occur before the diagnosis of diabetes.

Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are overlapping syndromes of diffuse, symmetric, flaccid muscle weakness occurring in critically ill patients and involving all extremities and the diaphragm with relative sparing of the cranial nerves. CIP and CIM have similar symptoms and presentations and are often distinguished largely on the basis of specialized electrophysiologic testing or muscle and nerve biopsy. The causes of CIP and CIM are unknown, though they are thought to be a possible neurological manifestation of systemic inflammatory response syndrome. Corticosteroids and neuromuscular blocking agents, which are widely used in intensive care, may contribute to the development of CIP and CIM, as may elevations in blood sugar, which frequently occur in critically ill patients.

The dawn phenomenon, sometimes called the dawn effect, is an observed increase in blood sugar (glucose) levels that takes place in the early-morning, often between 2 a.m. and 8 a.m. First described by Schmidt in 1981 as an increase of blood glucose or insulin demand occurring at dawn, this naturally occurring phenomenon is frequently seen among the general population and is clinically relevant for patients with diabetes as it can affect their medical management. In contrast to Chronic Somogyi rebound, the dawn phenomenon is not associated with nocturnal hypoglycemia.

Critical illness–related corticosteroid insufficiency is a form of adrenal insufficiency in critically ill patients who have blood corticosteroid levels which are inadequate for the severe stress response they experience. Combined with decreased glucocorticoid receptor sensitivity and tissue response to corticosteroids, this adrenal insufficiency constitutes a negative prognostic factor for intensive care patients.

Complications of diabetes are secondary diseases that are a result of elevated blood glucose levels that occur in diabetic patients. These complications can be divided into two types: acute and chronic. Acute complications are complications that develop rapidly and can be exemplified as diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), lactic acidosis (LA), and hypoglycemia. Chronic complications develop over time and are generally classified in two categories: microvascular and macrovascular. Microvascular complications include neuropathy, nephropathy, and retinopathy; while cardiovascular disease, stroke, and peripheral vascular disease are included in the macrovascular complications.

<span class="mw-page-title-main">Diabetes</span> Group of endocrine diseases characterized by high blood sugar levels

Diabetes mellitus, often known simply as diabetes, is a group of common endocrine diseases characterized by sustained high blood sugar levels. Diabetes is due to either the pancreas not producing enough insulin, or the cells of the body becoming unresponsive to the hormone's effects. Classic symptoms include thirst, polyuria, weight loss, and blurred vision. If left untreated, the disease can lead to various health complications, including disorders of the cardiovascular system, eye, kidney, and nerves. Untreated or poorly treated diabetes accounts for approximately 1.5 million deaths every year.

References

  1. ↑ Finkielman J, Oyen L, Afessa B (2005). "Agreement between bedside blood and plasma glucose measurement in the ICU setting". Chest. 127 (5): 1749–51. doi:10.1378/chest.127.5.1749. PMID   15888855.
  2. ↑ Ali Abdelhamid, Yasmine; Kar, Palash; Finnis, Mark E.; Phillips, Liza K.; Plummer, Mark P.; Shaw, Jonathan E.; Horowitz, Michael; Deane, Adam M. (27 September 2016). "Stress hyperglycaemia in critically ill patients and the subsequent risk of diabetes: a systematic review and meta-analysis". Critical Care. 20 (1): 301. doi: 10.1186/s13054-016-1471-6 . PMC   5039881 . PMID   27677709.
  3. ↑ Dungan KM, Braithwaite SS, Preiser JC (July 2011). "Stress hyperglycaemia". The Lancet. 373 (9677): 1798–1807. doi:10.1016/S0140-6736(09)60553-5. PMC   3144755 . PMID   19465235.
  4. ↑ Dellinger RP, Carlet JM, Masur H, et al. (2004). "Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock". Crit Care Med. 32 (3): 858–873. doi:10.1097/01.ccm.0000117317.18092.e4. PMID   15090974. S2CID   27441271.
  5. ↑ Dellinger RP, Levy MM, Carlet JM, et al. (January 2008). "Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008". Crit. Care Med. 36 (1): 296–327. doi:10.1097/01.CCM.0000298158.12101.41. PMC   4969965 . PMID   18158437.
  6. ↑ Van den Berghe G, Wouters P, Weekers F, et al. (2001). "Intensive insulin therapy in the critically ill patients". N Engl J Med. 345 (19): 1359–67. doi: 10.1056/NEJMoa011300 . PMID   11794168.
  7. ↑ Van den Berghe G, Wilmer A, Hermans G, et al. (2006). "Intensive insulin therapy in the medical ICU". N Engl J Med. 354 (5): 449–61. doi: 10.1056/NEJMoa052521 . PMID   16452557.
  8. ↑ Brunkhorst FM, Engel C, Bloos F, et al. (2008). "Intensive insulin therapy and pentastarch resuscitation in severe sepsis". N Engl J Med. 358 (2): 125–39. doi: 10.1056/NEJMoa070716 . PMID   18184958.
  9. ↑ Soylemez Wiener R, Wiener DC, Larson RJ (August 2008). "Benefits and risks of tight glucose control in critically ill adults: a meta-analysis". JAMA. 300 (8): 933–44. doi:10.1001/jama.300.8.933. PMID   18728267.
  10. ↑ The NICE-SUGAR Study Investigators (2009). "Intensive versus conventional glucose control in critically ill patients". N Engl J Med. 360 (13): 1283–97. doi: 10.1056/nejmoa0810625 . PMID   19318384.
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