Hostname: page-component-78c5997874-t5tsf Total loading time: 0 Render date: 2024-11-13T09:16:33.420Z Has data issue: false hasContentIssue false
  • English
  • Français

Hyperglycemia in acutely ill emergency patients — Cause or effect?

Published online by Cambridge University Press:  21 May 2015

William R. Henderson ,
Dean R. Chittock ,
Vinay K. Dhingra  and
Juan J. Ronco
William R. Henderson*
Affiliation:
Departments of Emergency Medicine and Critical Care Medicine, Royal Columbian Hospital, New Westminster, BC UBC Program of Critical Care Medicine, University of British Columbia, Vancouver, BC Vancouver Coastal Health Research Institute, Vancouver, BC
Dean R. Chittock
Affiliation:
UBC Program of Critical Care Medicine, University of British Columbia, Vancouver, BC Centre for Clinical Epidemiology and Evaluation, Vancouver, BC
Vinay K. Dhingra
Affiliation:
UBC Program of Critical Care Medicine, University of British Columbia, Vancouver, BC
Juan J. Ronco
Affiliation:
UBC Program of Critical Care Medicine, University of British Columbia, Vancouver, BC
*
Departments of Emergency Medicine & Critical Care, Royal Columbian Hospital, 330 E Columbia St., New Westminster BC V3L 3W7

Abstract

Core share and HTML view are not available for this content. However, as you have access to this content, a full PDF is available via the ‘Save PDF’ action button.
Objectives:

To clarify the benefits, risks and timing of glucose control and intensive insulin therapy in several groups, specifically the neurologic, cardiac and septic populations of patients, commonly seen in the emergency department.

Methods:

Electronic search of MEDLINE (1966–2005; once with PubMed and once with Ovid) and Embase (1980–2005) using the terms insulin and glucose combined with emergency medicine, intensive care, cardiology and emergency department.

Results:

There is considerable controversy in the literature surrounding the use of strict glucose control in cardiac, neurologic and septic patients. Much of this literature is non-randomized, and the timing of therapy is poorly investigated.

Conclusions:

Hyperglycemia is associated with adverse outcomes in acutely ill neurologic, cardiac and septic patients, but it remains unclear whether this is a causative association. Glucose control and intensive insulin therapy may be useful in some patient subgroups; however, controlled trials of aggressive glycemic control have provided insufficient evidence to justify subjecting patients to the real risks of iatrogenic hypoglycemia. We recommend a cautious approach to the control of glucose levels in acutely ill emergency department patients, with a target glucose of below 8 to 9 mmol/L.

Keywords

glucoseinsulinmortalitystrokesepsismyocardial infarction
Type
Education • Éducation
Information
Canadian Journal of Emergency Medicine , Volume 8 , Issue 5 , September 2006 , pp. 339 - 343
Copyright
Copyright © Canadian Association of Emergency Physicians 2006

References

1.Mizock, BA. Alterations in carbohydrate metabolism during stress: a review of the literature. Am J Med 1995;98:75–84.Google Scholar
2.Rovlias, A, Kotsou, S. The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery 2000;46:335–42.Google Scholar
3.Young, B, Ott, L, Dempsey, R, et al. Relationship between admission hyperglycemia and neurologic outcome of severely brain-injured patients. Ann Surg 1989;210:466–72.Google Scholar
4.Yang, S, Zhang, S, Wang, M. Clinical significance of admission hyperglycemia and factors related to it in patients with acute severe head injury. Surg Neurol 1995;44:373–7.Google Scholar
5.Weir, CJ, Murray, GD, Dyker, AG, et al. Is hyperglycaemia an independent predictor of poor outcome after acute stroke? Results of a long-term follow up study. BMJ 1997;314:1303–6.CrossRefGoogle ScholarPubMed
6.Capes, SE, Hunt, D, Malmberg, K, et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001;32:2426–32.Google Scholar
7.Demchuk, AM, Morgenstern, LB, Krieger, DW, et al. Serum glucose level and diabetes predict tissue plasminogen activator-related intracerebral hemorrhage in acute ischemic stroke. Stroke 1999;30:34–9.Google Scholar
8.Wahab, NN, Cowden, EA, Pearce, NJ, et al. Is blood glucose an independent predictor of mortality in acute myocardial infarction in the thrombolytic era? J Am Coll Cardiol 2002;40:1748–54.CrossRefGoogle ScholarPubMed
9.Norhammar, AM, Ryden, L, Malmberg, K. Admission plasma glucose. Independent risk factor for long-term prognosis after myocardial infarction even in nondiabetic patients. Diabetes Care 1999;22:1827–31.Google Scholar
10.Mehta, SR, Yusuf, S, Diaz, R, et al. Effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction: the CREATE-ECLA randomized controlled trial. JAMA 2005;293:437–46.Google Scholar
11.Malmberg, K, Ryden, L, Efendic, S, et al. Randomized trial of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI study): effects on mortality at 1 year. J Am Coll Cardiol 1995;26:57–65.Google Scholar
12.Malmberg, K. Prospective randomised study of intensive insulin treatment on long term survival after acute myocardial infarction in patients with diabetes mellitus. DIGAMI (Diabetes Mellitus, Insulin Glucose Infusion in Acute Myocardial Infarction) Study Group. BMJ 1997;314:1512–5.Google Scholar
13.van den Berghe, G, Wouters, P, Weekers, F, et al. Intensive insulin therapy in the surgical intensive care unit. N Engl J Med 2001;345:1359–67.Google Scholar
14.Van den Berghe, G, Wilmer, A, Hermans, G, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449–61.Google Scholar
15.Brunkhorst, F, Kuhnt, E, Engel, C, et al. Intensive insulin therapy in patient with severe sepsis and septic shock is associated with an increased rate of hypoglycemia — results from a randomized multicenter study (VISEP). Infection 2005;33:19.Google Scholar
16.Regel, G, Grotz, M, Weltner, T, et al. Pattern of organ failure following severe trauma. World J Surg 1996;20:422–9.Google Scholar
17.Bilevicius, E, Dragosavac, D, Dragosavac, S, et al. Multiple organ failure in septic patients. Braz J Infect Dis 2001;5:103–10.Google Scholar
18.Oswald, GA, Smith, CC, Betteridge, DJ, et al. Determinants and importance of stress hyperglycaemia in non-diabetic patients with myocardial infarction. Br Med J (Clin Res Ed) 1986;293:917–22.Google Scholar
19.Andersson, U, Wang, H, Palmblad, K, et al. High mobility group 1 protein (HMG-1) stimulates proinflammatory cytokine synthesis in human monocytes. J Exp Med 2000;192:565–70.Google Scholar
20.Dofferhoff, AS, Bom, VJ, de Vries-Hospers, HG, et al. Patterns of cytokines, plasma endotoxin, plasminogen activator inhibitor, and acute-phase proteins during the treatment of severe sepsis in humans. Crit Care Med 1992;20:185–92.CrossRefGoogle ScholarPubMed
21.Michelson, D, Gold, PW, Sternberg, EM. The stress response in critical illness. New Horizons 1994;2:426–31.Google ScholarPubMed
22.Lin, Y, Rajala, MW, Berger, JP, et al. Hyperglycemia-induced production of acute phase reactants in adipose tissue. J Biol Chem 2001;276:42077–83.Google Scholar
23.Perner, A, Nielsen, SE, Rask-Madsen, J. High glucose impairs superoxide production from isolated blood neutrophils. Intensive Care Med 2003;29:642–5.CrossRefGoogle ScholarPubMed
24.Rassias, AJ, Marrin, CA, Arruda, J, et al. Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Anaesth Analg. 1999;88:1011–6.Google Scholar
25.Nielson, CP, Hindson, DA. Inhibition of polymorphonuclear leukocyte respiratory burst by elevated glucose concentrations in vitro. Diabetes 1031; 38:1031–5.Google Scholar
26.Weekers, F, Van Herck, E, Coopmans, W, et al. A novel in vivo rabbit model of hypercatabolic critical illness reveals a biphasic neuroendocrine stress response. Endocrinology 2002;143:764–74.Google Scholar
27.Weekers, F, Giulietti, AP, Michalaki, M, et al. Metabolic, endocrine, and immune effects of stress hyperglycemia in a rabbit model of prolonged critical illness. Endocrinology 2003;144:5329–38.Google Scholar
28.Krinsley, JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 2004;79:992–1000.CrossRefGoogle ScholarPubMed
29.Thomas, DJ, Platt, HS, Alberti, KG. Insulin-dependent diabetes during the peri-operative period. An assessment of continuous glucose-insulin-potassium infusion, and traditional treatment. Anaesthesia 1984;39:629–37.Google Scholar
30.Mackenzie, I, Ingle, S, Zaidi, S, et al. Tight glycaemic control:a survey of intensive care practice in large English hospitals. Intensive Care Med 2005;31:1136.CrossRefGoogle ScholarPubMed
31.Gale, EA, Bennett, T, Macdonald, IA, et al. The physiological effects of insulin-induced hypoglycaemia in man: responses at differing levels of blood glucose. Clin Sci 1983;65:263–71.Google Scholar
32.Schultes, B, Oltmanns, KM, Kern, W, et al. Acute and prolonged effects of insulin-induced hypoglycemia on the pituitary-thyroid axis in humans. Metab Clin Exp. 2002;51:1370–4.Google Scholar
33.Pomposelli, JJ, Baxter, JK III, Babineau, TJ, et al. Early postoperative glucose control predicts nosocomial infection rate in diabetic patients. JPEN J Parenter Enteral Nutr 1998;22:77–81.Google Scholar