Relationship Between Hyperglycemia and Infection in Critically Ill Patients

Simona O. Butler, PharmD; Imad F. Btaiche, PharmD; Cesar Alaniz, PharmD

Disclosures

Pharmacotherapy. 2005;25(7):963-976. 

In This Article

Abstract and Introduction

Abstract

Hyperglycemia is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Studies have demonstrated impairment of host defenses, including decreased polymorphonuclear leukocyte mobilization, chemotaxis, and phagocytic activity related to hyperglycemia. Until 2001, hyperglycemia (blood glucose concentrations up to 220 mg/dl) had been tolerated in critically ill patients not only because high blood glucose concentrations were believed to be a normal physiologic reaction in stressed patients and excess glucose is necessary to support the energy needs of glucose-dependent organs, but also because the true significance of short-term hyperglycemia was not known. Recent clinical data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. Intensive insulin therapy minimizes derangements in normal host defense mechanisms and modulates release of inflammatory mediators. The principal benefit of intensive insulin therapy is a decrease in infection-related complications and mortality. Further research will define which patient populations will benefit most from intensive insulin therapy and firmly establish the blood glucose concentration at which benefits will be realized.

Introduction

Hyperglycemia is a common problem encountered in hospitalized patients, especially in critically ill patients and those with diabetes mellitus. Risk of hyperglycemia is increased in patients receiving concentrated dextrose infusions such as parenteral nutrition. Uncontrolled hyperglycemia may be associated with complications such as fluid and electrolyte disturbances and increased infection risk. Controlling hyperglycemia reduces microvascular and macrovascular complications in patients with diabetes[1,2,3,4,5,6] and reduces nosocomial and wound infections in perioperative hyperglycemic and diabetic patients.[7,8,9,10,11,12,13,14,15,16] However, a cause and effect relationship between sepsis and hyperglycemia has long been debated. Although it has been clearly documented that sepsis induces hyperglycemia, the effects of hyperglycemia on increasing infection risk had not been fully elucidated.[17] Until 2001, blood glucose concentrations up to 220 mg/dl had been tolerated in critically ill patients.[18,19] This was essentially based on the belief that high blood glucose concentrations were a normal physiologic reaction in stressed patients, and excess glucose was necessary to support the energy needs of glucose-dependent organs such as the brain, adrenal medulla, and red blood cells. However, recent data show that the use of intensive insulin therapy to maintain tight blood glucose concentrations between 80 and 110 mg/dl decreases morbidity and mortality in critically ill surgical patients. The benefits of tight glucose control also extend to significant reductions in several morbidity factors including infection rate.[20]

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