Stress induced hyperglycaemia (S.I.H) is common in critically ill patients.
- a) Define S.I.H
- b) Outline the mechanisms thought important in the pathogenesis of S.I.H.
- c) Outline clinical implications and treatment of S.I.H.
Answer and interpretation
a) Define S.I.H
Transient hyperglycaemia during acute illness –usually restricted to patients without prior evidence of diabetes with reversion to normal after discharge.
b) Outline the mechanisms thought important in the pathogenesis of S.I.H.
- S.I.H is thought to develop due to complex interplay between counter regulatory hormones such as catecholamines, GH, cortisol and cytokines.
- The underlying illness and treatments (TPN, enteral feed, steroids, and vasopressors) might affect the scale of these derangements.
- The key contributor would appear to be high hepatic glucose output via gluconeogenesis driven by glucagon, adrenaline and cortisol. Cytokines such as TNFα interact to enhance this response.
Insulin resistance plays a role.
- Underlying abnormalities in glucose regulation may be present.
c) Outline clinical implications and treatment of S.I.H.
- Recent data suggests that S.I.H and diabetic hyperglycaemia are two different phenomena with differing clinical outcomes.
- Patients with S.I.H have been shown in several studies to have increased risk of mortality, adverse events, and greater organ failure scores compared to those with diabetes.
- Whether S.I.H per se causes harm or instead is a marker of severity of counter regulatory response and degree of illness is unknown.
- Management of S.I.H cannot be distinguished from hyperglycaemia due to other causes. In most cases it is not generally predictable or preventable. Early recognition and interception might prevent persistence and exacerbation. Recommendations include insulin therapy with more conservative glucose targets.
- Candidates mentioning recent data from RCTs were given credit.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.