Stress hyperglycemia: an essential survival response!

Abstract

Stress hyperglycemia is common in critically ill patients and appears to be a marker of disease severity. Furthermore, both the admission as well as the mean glucose level during the hospital stay is strongly associated with patient outcomes. Clinicians, researchers and policy makers have assumed this association to be causal with the widespread adoption of protocols and programs for tight in-hospital glycemic control. However, a critical appraisal of the literature has demonstrated that attempts at tight glycemic control in both ICU and non-ICU patients do not improve health care outcomes. We suggest that hyperglycemia and insulin resistance in the setting of acute illness is an evolutionarily preserved adaptive responsive that increases the host's chances of survival. Furthermore, attempts to interfere with this exceedingly complex multi-system adaptive response may be harmful. This paper reviews the pathophysiology of stress hyperglycemia and insulin resistance and the protective role of stress hyperglycemia during acute illness.

The Central Role of Glucose in Metabolism and Nutrition of Critically Ill Patients

“…To, co se zdá, jako negativní účinek na funkci jednoho orgánu, může být z pohledu celého organismu prospěšně. Marik a Bellomo poukazují na možnost, že akutní hyperglykémie je mechanismem, jakým organismus také zvyšuje svoji šanci na přežití (97).…”

Treatment thresholds for hyperglycemia in critically ill patients with and without diabetes

“…However, the blood glucose threshold above which stress hyperglycemia becomes harmful is unknown. Furthermore, we suggest that both the duration and the degree of hyperglycemia are important in determining whether hyperglycemia is protective or harmful [5]. It seems most unlikely that a few days of hyperglycemia would be harmful; indeed attempts at rapid correction of blood glucose in these patients may be harmful.…”

“…Subsequent studies, the most important being the NICE-SUGAR study, demonstrated that intensive glucose control (81-108 mg/dl, 4.5-6.0 mol/l) increased mortality when compared to conventional glucose control (144-180 mg/ dl, 8.0-10.0 mmol/l) [4]. We have previously argued that hyperglycemia is a marker of illness severity rather than a cause of poor outcome [5]. Indeed, the degree of hyperglycemia is related to the degree of activation of the stress response.…”

“…Indeed, the degree of hyperglycemia is related to the degree of activation of the stress response. Stress hyperglycemia is regarded as an evolutionary adaptive response which allows the host to survive during periods of severe stress [5]. The neuroendocrine response to stress is characterized by excessive gluconeogenesis, glycogenolysis, and insulin resistance, with increased hepatic output of glucose (gluconeogenesis) being the major cause of stress hyperglycemia.…”

“…The neuroendocrine response to stress is characterized by excessive gluconeogenesis, glycogenolysis, and insulin resistance, with increased hepatic output of glucose (gluconeogenesis) being the major cause of stress hyperglycemia. Insects, worms, and all verterbrates including fish develop stress hyperglycemia when exposed to stress [5]. Stress hyperglycemia provides a source of fuel for the immune system and brain at a time of stress.…”