Skip to main content Accessibility help
×
Home

Hyperglycemia in acutely ill emergency patients — Cause or effect?

  • William R. Henderson (a1) (a2) (a3), Dean R. Chittock (a2) (a4), Vinay K. Dhingra (a2) and Juan J. Ronco (a2)

Abstract

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.

    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Hyperglycemia in acutely ill emergency patients — Cause or effect?
      Available formats
      ×

      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Hyperglycemia in acutely ill emergency patients — Cause or effect?
      Available formats
      ×

      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Hyperglycemia in acutely ill emergency patients — Cause or effect?
      Available formats
      ×

Copyright

Corresponding author

Departments of Emergency Medicine & Critical Care, Royal Columbian Hospital, 330 E Columbia St., New Westminster BC V3L 3W7

References

Hide All
1.Mizock, BA. Alterations in carbohydrate metabolism during stress: a review of the literature. Am J Med 1995;98:7584.
2.Rovlias, A, Kotsou, S. The influence of hyperglycemia on neurological outcome in patients with severe head injury. Neurosurgery 2000;46:335–42.
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.
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.
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.
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.
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.
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.
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.
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.
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;26:5765.
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.
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.
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.
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.
16.Regel, G, Grotz, M, Weltner, T, et al. Pattern of organ failure following severe trauma. World J Surg 1996;20:422–9.
17.Bilevicius, E, Dragosavac, D, Dragosavac, S, et al. Multiple organ failure in septic patients. Braz J Infect Dis 2001;5:103–10.
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.
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.
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.
21.Michelson, D, Gold, PW, Sternberg, EM. The stress response in critical illness. New Horizons 1994;2:426–31.
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.
23.Perner, A, Nielsen, SE, Rask-Madsen, J. High glucose impairs superoxide production from isolated blood neutrophils. Intensive Care Med 2003;29:642–5.
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.
25.Nielson, CP, Hindson, DA. Inhibition of polymorphonuclear leukocyte respiratory burst by elevated glucose concentrations in vitro. Diabetes 1031; 38:1031–5.
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.
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.
28.Krinsley, JS. Effect of an intensive glucose management protocol on the mortality of critically ill adult patients. Mayo Clin Proc 2004;79:9921000.
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.
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.
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.
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.
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;22:7781.

Keywords

Metrics

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed