Stress Induced Hyperglycaemia

OVERVIEW

  • Stress Induced Hyperglycaemia (SIH) is transient hyperglycaemia associated with acute illness
  • resolves with resolution of the underlying critical illness
  • a marker of disease severity, but does not imply causation (e.g. hyperglycemia is not predictive when corrected for hyperlactemia, another marker of physiological stress)
  • strictly speaking the diagnosis is reserved for patient without prior evidence of diabetes

MECHANISMS

Complex interaction between HPA axis, sympathoadrenal system and cytokines:

  • catecholamines:
  • cortisol: increased hepatic gluconeogenesis, decreased peripheral uptake in skeletal muscle

Mechanisms

  • high hepatic glucose output via gluconeogenesis driven by glucagon, adrenaline and cortisol, TNF alpha
  • insulin resistance (less important than increased glucose output)
  • effects of therapies: TPN, enteral feed, steroids, vasopressors
  • underlying abnormalities in glucose regulation may be present
  • underlying illness

CLINICAL IMPLICATIONS

  • recent data suggests that SIH and diabetic hyperglycaemia are two different phenomena with different clinical outcomes
  • SIH: increased mortality, mortality, LOS, infections more overall complications
  • both admission glucose and mean glucose during ICU stay are associated with patient outcomes
  • whether SIH per se causes harm or instead is a marker of severity of regulatory response of illness is unknown
  • difficult to distinguish from other causes of hyperglycaemia

MANAGEMENT

  • early recognition and interception may (or may not) prevent persistence and exacerbation
  • insulin therapy with conservative glucose targets (see  Glucose control in the critically ill)
  • control precipitant if possible
  • depending on severity: re-start oral agents or insulin (always some insulin!)
  • measure BSL frequently
  • expect sudden changes
  • avoid hypoglycaemia

References and Links

LITFL

Journal articles

  • Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet. 2009 May 23;373(9677):1798-807. PMC3144755.
  • Marik PE, Bellomo R. Stress hyperglycemia: an essential survival response! Crit Care. 2013 Mar 6;17(2):305. PMID: 23470218.

CCC 700 6

Critical Care

Compendium

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and 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 two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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