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.
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
| INTENSIVE | RAGE | Resuscitology | SMACC
