Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Surg Proced. Nov 28, 2016; 6(3): 30-39
Published online Nov 28, 2016. doi: 10.5412/wjsp.v6.i3.30
Glycemic management in critically ill patients
Eden A Nohra, Jarot J Guerra, Grant V Bochicchio
Eden A Nohra, Jarot J Guerra, Grant V Bochicchio, Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis, St. Louis, MO 63110, United States
Author contributions: Nohra EA and Guerra JJ conducted the literature search and wrote the paper; Guerra JJ designed the figure; Bochicchio GV provided mentorship and edited the manuscript.
Conflict-of-interest statement: Authors declare no conflict of interest for this article.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Eden A Nohra, MD, Section of Acute and Critical Care Surgery, Department of Surgery, Washington University in St. Louis, 660 S. Euclid, St. Louis, MO 63110, United States.
Telephone: +1-314-4439727 Fax: +1-314-3625743
Received: May 27, 2016
Peer-review started: May 30, 2016
First decision: June 30, 2016
Revised: August 6, 2016
Accepted: August 27, 2016
Article in press: August 29, 2015
Published online: November 28, 2016

Hyperglycemia associated with critical illness, also called “stress hyperglycemia” or “stress diabetes”, is a consequence of many pathophysiologic hormonal responses including increased catecholamines, cortisol, glucagon, and growth hormone. Alterations in multiple biochemical pathways result in increased hepatic and peripheral insulin resistance with an uncontrolled activation of gluconeogenesis and glycogenolysis. Hyperglycemia has a negative impact on the function of the immune system, on the host response to illness or injury, and on infectious and overall outcomes. The degree of glucose elevation is associated with increased disease severity. Large randomized controlled trials including the Van den Berghe study, the NICE-SUGAR trial, VISEP and GLUCONTROL have shown that the control of glucose levels in critically ill patients has implications on outcome and that both hyperglycemia and hypoglycemia are detrimental and should be avoided. Glucose variability has also been shown to be detrimental. Aggressive glucose control strategies have changed due to the concerns of hypoglycemia and therefore intermediate target glucose control strategies are most often adopted. Different patient populations may vary with regards to optimal glucose targets, timing and approach for glucose control, and with regards to the prognostic significance of glucose excursions and variability. Medical, surgical, and trauma patients may benefit at different rates from glucose control and the approach may need to be adapted to various medical settings and to correspond to the workflow of health providers. Effect modifiers for the success of insulin therapy for hyperglycemia include the methods of nutritional supplementation and exogenous glucose administration. Further research is required to improve insulin protocols for glucose control, to further define glucose targets, and to enhance the accuracy of glucose measuring technologies.

Keywords: Hyperglycemia, Hypoglycemia, Critically ill, Intensive care unit, Glucose control

Core tip: Hyperglycemia is not innocuous, especially in the critically ill; and glucose control has been shown to significantly impact morbidity and mortality. In this review, we describe the pathophysiology of the “diabetes of stress”; we summarize the major investigations that constitute the body of evidence and the reasons behind current practices. Further, we emphasize glucose considerations in special populations, especially trauma and postoperative populations. Finally, we provide insight on the relative importance of avoiding hyperglycemia, hypoglycemia, and glucose variability.