List the causes of hyperglycaemia in the intensive care patient population, and outline your management of hyperglycaemia.

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College Answer

Causes:  consider  diabetes  mellitus  (previously  known  or not known,  type I or II, on diet, oral agents, insulin or combination), secondary causes of diabetes (e.g. pancreatitis, haemochromatosis, Cushing’s syndrome, acromegaly), insulin resistance (e.g. sepsis, systemic inflammatory response/stress response [including multiple trauma], beta-agonists [endogenous or exogenous], exogenous corticosteroids), carbohydrate load (e.g. feeding enteral/parenteral, peritoneal dialysis).

Management:  consider  control  of  factors  worsening  response  to  insulin  (sepsis,  drugs,  stress response), control glucose within acceptable range (minimise metabolic and immune effects), recommence oral agents or use insulin (dependent on severity).  Principle of glucose control in diabetics include always some insulin, administer some glucose, measure glucose frequently, expect sudden  changes,  and avoid  hypoglycaemia.    Recent  studies  suggest  tight glucose  control  using insulin  infusions  if necessary  may dramatically  reduce  mortality  after myocardial  infarction  (in diabetic patients: DIGAMI), and in the surgical intensive care (Van den Berghe et al).

Discussion

This question is identical to Question 24 from the first paper of 2006