Abstract
Stress-induced hyperglycemia has been considered an adaptive mechanism to stress up to the first intensive insulin therapy trial, which showed a 34% reduction in relative risk of in-hospital mortality when normalizing blood glucose levels. Further trials had conflicting results and, at present, stress-induced hyperglycemia management remains non-consensual. These findings could be explained by discrepancies in trials, notably regarding the approach to treat hyperglycemia: high versus restrictive caloric intake. Stress-induced hyperglycemia is a frequent complication during intensive care unit stay and is associated with a higher mortality. It results from an imbalance between insulin and counter-regulatory hormones, increased neoglucogenesis, and the cytokine-induced insulin-resistant state of tissues. In this review, we summarize detrimental effects of hyperglycemia on organs in the critically ill (peripheric and central nervous, liver, immune system, kidney, and cardiovascular system). Finally, we show clinical and experimental evidence of potential benefits from glucose and insulin administration, notably on metabolism, immunity, and the cardiovascular system.
Highlights
In an ICU, stress induces insulin resistance and overproduction of glucose, resulting in a syndrome called stressinduced hyperglycemia (SIH) [1]
SIH is common during critical illness and is associated with high mortality [1,2,3]
Glucose metabolism during critical illness has been the focus of an increasing number of experimental and clinical studies
Summary
In an ICU, stress induces insulin resistance and overproduction of glucose, resulting in a syndrome called stressinduced hyperglycemia (SIH) [1]. In the two ‘positive’ trials from Leuven, mean non-protein daily caloric intake was approximately 20 kcal/kg per day, essentially via glucose administration initially given intravenously: up to 200 to 300 g/day in the 2001 trial, with a median total daily insulin administration of 71 units (confidence interval of 48 to 100). In NICE-SUGAR (Normoglycemia in Intensive Care Evaluation and Surviving Using Glucose Algorithm Regulation), which suggested increased mortality with intensive insulin therapy, caloric intake was 11.04 ± 6.08 kcal/kg per day, with 19.5% given intravenously, and cumulative mean daily dose of insulin was 50.2 ± 38.1 units per day [5]. The aim of this review is to discuss experimental evidence of organ injury and insulin sensitivity during SIH and expose differences in strategies for its control that include a liberal or a rather restrictive glucose intake
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