List the causes of hyperglycaemia in the intensive care patient population, and outline your management of hyperglycaemia.
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).
This question is identical to Question 24 from the first paper of 2006