Hyperglycemia in the Surgical Intensive Care Unit

  • Gary W. Cushing
  • Gary W. Cushing


Hyperglycemia is the most common metabolic disturbance seen in the postoperative, intensive care patient. It can occur in patients with previously diagnosed diabetes mellitus, with undiagnosed diabetes,1 and in patients without diabetes under the acute stress of trauma, surgery, or myocardial infarction.2 Critical illness induces insulin resistance at the cellular level, which coupled with relative insulin inadequacy and unabated hepatic glucose release, leads to persistent elevation in blood glucose. A number of factors released during acute illness and stress act as mediators for this response, including cytokines, growth hormone, glucagon, catecholamines, and cortisol.3 Impairment of insulin action leads to lipolysis and protein catabolism that produce substrates for additional glucose production by the liver. Glycogenolysis is promoted by release or administration of catecholamines. Insulin-mediated glucose uptake by heart and skeletal muscle is impaired and further worsens glucose homeostasis. To some extent, the resultant increase in blood glucose can be adaptive to provide increased substrate to organs that do not require insulin for glucose uptake such as brain and blood cells. Not surprisingly, when pushed to the extreme by critical illness these accommodations can lead to untoward consequences requiring interventions in order to reverse this metabolic derangement.


Insulin Glargine Insulin Infusion Basal Insulin Diabetic Ketoacidosis Intensive Insulin Therapy 


  1. 1.
    Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87:978–982.PubMedCrossRefGoogle Scholar
  2. 2.
    Norhammer A, Tenerz A, Nillson G, et al. Glucose metabolism in patients with acute myocardial infarction and no previous diagnosis of diabetes mellitus: a prospective study. Lancet. 2002;359:2140–2144.CrossRefGoogle Scholar
  3. 3.
    Vanhorebeek I, Langouche L, Van den Berghe G. Intensive insulin therapy in the intensive care unit: update on clinical impact and mechanisms of action. Endocr Pract. 2006;12:14–21.PubMedCrossRefGoogle Scholar
  4. 4.
    Krinsley J. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78:1471–1478.PubMedCrossRefGoogle Scholar
  5. 5.
    Jeremitsky E, Omert LA, Dubham CM, et al. The impact of hyperglycemia on patients with severe brain injury. J Trauma. 2005;58:47–50.PubMedCrossRefGoogle Scholar
  6. 6.
    Gore DC, Chinkes D, Heggers J, et al. Association of hyperglycemia with increased mortality after severe burn injury. J Trauma. 2001;51:540–544.PubMedCrossRefGoogle Scholar
  7. 7.
    Yendamuri S, Fulda GJ, Tinkoff GH. Admission hyperglycemia as a prognostic indicator in trauma. J Trauma. 2003;55:33–38.PubMedCrossRefGoogle Scholar
  8. 8.
    Gandhi G, Nutall GA, Abel MD. Intraoperative hyperglycemia and outcomes in cardiac patients. Mayo Clin Proc. 2005;80:862–866.PubMedCrossRefGoogle Scholar
  9. 9.
    Gaglia JL, Wyckoff J, Abrahamson MJ. Acute hyperglycemic crisis in the elderly. Med Clin North Am. 2004;88(4):1063–1084.PubMedCrossRefGoogle Scholar
  10. 10.
    Omrani GR, Shams M, Afkhamizadeh M, et al. Hyperglycemic crises in diabetic patients. Int J Endocrinol Metab. 2005;1:52–61.Google Scholar
  11. 11.
    Nesto RW. Correlation between cardiovascular disease and diabetes mellitus: current concepts. Am J Med. 2004;116(Suppl 5A):11S–22S.PubMedCrossRefGoogle Scholar
  12. 12.
    Duncan AI, Koch CG, Xu M, et al. Recent metformin ingestion does not increase in-hospital morbidity or mortality after cardiac surgery. Anesth Analg. 2007;104:4–6.CrossRefGoogle Scholar
  13. 13.
    Home PD, Pocock SJ, Beck-Nielsen H, et al. Rosiglitazone evaluated for cardiovascular outcomes – an interim analysis. N Engl J Med. 2007;357(1):28–38.PubMedCrossRefGoogle Scholar
  14. 14.
    Putz D, Kabadi UM. Insulin glargine in continuous enteric tube feeding. Diabetes Care. 2002;10:1889–1890.CrossRefGoogle Scholar
  15. 15.
    The DCCT Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329:977–986.CrossRefGoogle Scholar
  16. 16.
    Nathan DM, Cleary PA, Backlund JY. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;353:2643–2653.PubMedCrossRefGoogle Scholar
  17. 17.
    UKPDS Study Group. Intensive blood glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. Lancet. 1998;352:837–853.CrossRefGoogle Scholar
  18. 18.
    Blondel JJ, Beilman GJ. Glycemic control and prevention of perioperative infection. Curr Opin Crit Care. 2007;13:421–427.CrossRefGoogle Scholar
  19. 19.
    Lipsett P. The importance of insulin administration in the critical care unit. Adv Surg. 2006;40:47–57.PubMedCrossRefGoogle Scholar
  20. 20.
    Furnary AP, Zerr KJ, Grunkemeier GL, et al. Continuous insulin infusion reduces the incidence of deep sternal wound infection in diabetic patients after cardiac surgical procedures. Ann Thorac Surg. 1999;67:352–362.PubMedCrossRefGoogle Scholar
  21. 21.
    Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2003;125:1007–1021.PubMedCrossRefGoogle Scholar
  22. 22.
    Van den Bergh G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345:1359–1367.CrossRefGoogle Scholar
  23. 23.
    Capes SE, Hunt D, Malberg K, et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients. Stroke. 2001;32:2426–2432.PubMedCrossRefGoogle Scholar
  24. 24.
    Malberg K, Ryden L, Efendic S, et al. Randomized trail of insulin-glucose infusion followed by subcutaneous insulin treatment in diabetic patients with acute myocardial infarction (DIGAMI); effects on mortality at one year. J Am Coll Cardiol. 1995;26:57–65.CrossRefGoogle Scholar
  25. 25.
    Malberg K, Ryden L, Wedel H, et al. Intense metabolic control y means of insulin in patients with diabetes mellitus and acute myocardial infarction (DIGAMI 2): effects on mortality and morbidity. Eur Heart J. 2005;26:650–661.CrossRefGoogle Scholar
  26. 26.
    The CREATE-EVAL Trial Group Investigators. The effect of glucose-insulin-potassium infusion on mortality in patients with acute ST-segment elevation myocardial infarction. JAMA. 2005;293:437–446.CrossRefGoogle Scholar
  27. 27.
    Scott JF, Robinson GM, French JM, et al. Glucose- potassium-insulin infusions in the treatment of acute stroke patients with mild to moderate hyperglycemia: the Glucose Insulin in Stroke Trial (GIST). Stroke. 1999;30:793–799.PubMedCrossRefGoogle Scholar
  28. 28.
    Pittas AG, Siegel RD, Lau J. Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials. Arch Int Med. 2006;164:2005–2011.CrossRefGoogle Scholar
  29. 29.
    Krinsley JS, Jones RL. Cost analysis of intensive glycemic control in critically ill patients. Chest. 2006;129:644–650.PubMedCrossRefGoogle Scholar
  30. 30.
    Quattara A, Lecomte P, LeManach Y, et al. Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. Anaesthesiol. 2001;18:277–294.Google Scholar
  31. 31.
    Gandhi GY, Nuthall GA, Abel MD, et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc. 2005;80:862–866.PubMedCrossRefGoogle Scholar
  32. 32.
    Gandhi GY, Nuthall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery. Ann Int Med. 2007;146:233–243.PubMedCrossRefGoogle Scholar
  33. 33.
    Bode BW, Braithwaite SS, Steed RD, et al. Intravenous insulin infusion therapy: indications, methods, and transition to subcutaneous insulin therapy. Endocr Pract. 2004;10:71–80.PubMedCrossRefGoogle Scholar
  34. 34.
    Furnary AP, Wu Y, Bookin SO. Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgery procedures: the Portland Diabetic Project. Endocr Pract. 2004;10:21–33.PubMedCrossRefGoogle Scholar
  35. 35.
    Goldberg PA, Siegel MD, Sherman RS, et al. Implementation of a safe and effective insulin infusion protocol in a medical intensive care unit. Diabetes Care. 2004;27:461–467.PubMedCrossRefGoogle Scholar
  36. 36.
    Davidson PC, Steed RD, Bode BW. Glucommander: a computer-directed intravenous insulin system shown to be safe, simple, and effective in 120, 618 hr of operation. Diabetes Care. 2005;28:2418–2423.PubMedCrossRefGoogle Scholar
  37. 37.
    Leahy JL. Insulin management of diabetic patients on general medical and surgical floors. Endocr Pract. 2006;12:86–90.PubMedCrossRefGoogle Scholar
  38. 38.
    Kitabachi AE, Umpierrez GE, Murphy MB, et al. Management of hyperglycemic crises in patients with diabetes. Diab Care. 2001;24:131–153.CrossRefGoogle Scholar
  39. 39.
    Magee MF, Bhatt BA. Management of decompensated diabetes. Diabetic ketoacidosis and hyperglycemic hyperosmolar syndrome. Crit Care Clin. 2001;17:75–106.PubMedCrossRefGoogle Scholar
  40. 40.
    Carlotti AP, Bohn D, Kamel KS, et al. Minimizing the risk of developing cerebral edema during therapy for diabetic ketoacidosis. Crit Care Med. 2007;35:1450.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2010

Authors and Affiliations

  • Gary W. Cushing
    • 1
  • Gary W. Cushing
    • 2
  1. 1.Tufts University School of MedicineBurlingtonUSA
  2. 2.Department of Endocrinology, Lahey Clinic Medical CenterTufts University School of MedicineBurlingtonUSA

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