Stress-Induced Hyperglycemia (SIH)

Stress-Induced Hyperglycemia (SIH)

David Ray Velez, MD

Table of Contents

Definition
Pathophysiology
Effects/Complications
Treatment

Definition

Definition: Abnormal Rise in Blood Sugar Caused by Illness, Physical Stress, or Psychological Stress

Causes

  • Surgery
  • Critical Illness
  • Trauma
  • Burns
  • Any Other Cause of Significant Stress

Pathophysiology

Pathophysiology

  • Primary Factors:
    • Increased Gluconeogenesis
    • Hepatic Insulin Resistance
  • Release of Excessive Counterregulatory Hormones
  • Relative Overall State of Insulin Resistance
  • Impaired Glucose Transporter (GLUT)-4 Receptor Translocation
  • Impaired Skeletal Muscle Uptake of Glucose

Counterregulatory Hormones

  • Glucagon
  • Cortisol – Increased Gluconeogenesis and Protein Catabolism
  • Growth Hormone – Inhibits Insulin Receptors
  • Catecholamines – Promote Hepatic Glucose Production
  • Cytokines (IL-1, IL-6, TNF-Alpha) – Promote Hepatic Glucose Production

Effects/Complications

Effects of Hyperglycemia in Critical Illness

  • Increased Oxidative Injury
  • Increased Proinflammatory Response
  • Increased Hypercoagulability
  • Immunosuppression
  • Abnormal Vascular Reactivity
  • Potential Osmotic Diuresis
  • Increased Morbidity and Mortality
    • High Glucose Variability is Also Associated with Increased Mortality

Complications

  • Myocardial Infarction (MI)
  • Stroke
  • Confusion
  • Infections/Sepsis
  • Impaired Wound Healing
  • Renal Failure
  • Increased Mortality

Increased Risk for Developing Type 2 Diabetes After Recovery

Treatment

Correct Any Underlying Causes

Primary Treatment: Insulin

  • Generally Start with a Sliding-Scale Regimen
  • May Require Insulin Infusion

General Glucose Target

  • Goal Blood Glucose ≤ 140-180 mg/dL
  • Levels > 180 mg/dL Increase the Risk for Postoperative Complications, SSI, LOS, and Mortality
    • Effect is More Pronounced in Non-Diabetic Patients than in Diabetic Patients
  • Overly Strict Glucose Control Increases the Risk of Hypoglycemia without Improved Outcomes
    • *NICE SUGAR Trial – Found Increased Mortality with Intensive Insulin Therapy (Goals 81-108 mg/dL)