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Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications

  • Hospital Management of Diabetes (GE Umpierrez, Section Editor)
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Abstract

Numerous studies have demonstrated an association between hyperglycemia in the perioperative period and adverse clinical outcomes. Many patients who experience hyperglycemia while hospitalized do not have a known history of diabetes and experience a transient phenomenon often described as “stress hyperglycemia” (SH). We discuss the epidemiology and pathogenesis of SH as well as evidence to date regarding predisposing factors and outcomes. Further research is needed to identify the long-term sequelae of SH as well as perioperative measures that may modulate glucose elevations and optimal treatment strategies.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–82. This study demonstrates hyperglycemia during hospitalization and was associated with poor clinical outcomes in patients with and without a known history of diabetes.

    Article  CAS  PubMed  Google Scholar 

  2. Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001;32(10):2426–32.

    Article  CAS  PubMed  Google Scholar 

  3. Krinsley JS. Glycemic control, diabetic status, and mortality in a heterogeneous population of critically ill patients before and during the era of intensive glycemic management: six and one-half years experience at a university-affiliated community hospital. Semin Thorac Cardiovasc Surg. 2006;18(4):317–25.

    Article  PubMed  Google Scholar 

  4. Egi M, Bellomo R, Stachowski E, French CJ, Hart GK, Hegarty C, et al. Blood glucose concentration and outcome of critical illness: the impact of diabetes. Crit Care Med. 2008;36(8):2249–55.

    Article  CAS  PubMed  Google Scholar 

  5. Bláha J, Mráz M, Kopecký P, Stříteský M, Lipš M, Matias M, et al. Perioperative tight glucose control reduces postoperative adverse events in nondiabetic cardiac surgery patients. J Clin Endocrinol Metab. 2015;100(8):3081–9. This study demonstrated benefits of intensive insulin therapy in patients with stress hyperglycemia undergoing cardiac surgery.

    Article  PubMed  Google Scholar 

  6. Kotagal M, Symons RG, Hirsch IB, Umpierrez GE, Dellinger EP, Farrokhi ET, et al. SCOAP-CERTAIN collaborative perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97–103. This study demonstrates the correlation with stress hyperglycemia and poor clinical outcomes.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Dungan KM, Braithwaite SS, Preiser JC. Stress hyperglycaemia. Lancet. 2009;373(9677):1798–807. This paper is a thorough review of the factors contributing to stress hyperglycemia and underlying pathophysiology.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  8. Srinivas-Shankar U, Somauroo JD, Delduca AM, Jordan TS, Bowles SA, Rutter MK. Temporal change in glucose tolerance in non-ST-elevation myocardial infarction. Diabetes Res Clin Pract. 2008;82(3):310–6.

    Article  CAS  PubMed  Google Scholar 

  9. Dave JA, Engel ME, Freercks R, Peter J, May W, Badri M, et al. Abnormal glucose metabolism in non-diabetic patients presenting with an acute stroke: prospective study and systematic review. QJM. 2010;103(7):495–503.

    Article  CAS  PubMed  Google Scholar 

  10. Ishihara M, Inoue I, Kawagoe T, Shimatani Y, Kurisu S, Hata T, et al. Is admission hyperglycaemia in non-diabetic patients with acute myocardial infarction a surrogate for previously undiagnosed abnormal glucose tolerance? Eur Heart J. 2006;27(20):2413–9.

    Article  PubMed  Google Scholar 

  11. Gray CS, Scott JF, French JM, Alberti KG, O'Connell JE. Prevalence and prediction of unrecognised diabetes mellitus and impaired glucose tolerance following acute stroke. Age Ageing. 2004;33(1):71–7.

    Article  PubMed  Google Scholar 

  12. Barth E, Albuszies G, Baumgart K, Matejovic M, Wachter U, Vogt J, et al. Glucose metabolism and catecholamines. Crit Care Med. 2007;35(9 Suppl):S508–18.

    Article  CAS  PubMed  Google Scholar 

  13. McGuinness OP, Shau V, Benson EM, Lewis M, Snowden RT, Greene JE, et al. Role of epinephrine and norepinephrine in the metabolic response to stress hormone infusion in the conscious dog. Am J Physiol. 1997;273(4 Pt 1):E674–81.

    CAS  PubMed  Google Scholar 

  14. Cely CM, Arora P, Quartin AA, Kett DH, Schein RM. Relationship of baseline glucose homeostasis to hyperglycemia during medical critical illness. Chest. 2004;126(3):879–87.

    Article  CAS  PubMed  Google Scholar 

  15. Lang CH, Dobrescu C, Mészáros K. Insulin-mediated glucose uptake by individual tissues during sepsis. Metabolism. 1990;39(10):1096–107.

    Article  CAS  PubMed  Google Scholar 

  16. Zauner A, Nimmerrichter P, Anderwald C, Bischof M, Schiefermeier M, Ratheiser K, et al. Severity of insulin resistance in critically ill medical patients. Metabolism. 2007;56(1):1–5.

    Article  CAS  PubMed  Google Scholar 

  17. Yu WK, Li WQ, Li N, Li JS. Influence of acute hyperglycemia in human sepsis on inflammatory cytokine and counterregulatory hormone concentrations. World J Gastroenterol. 2003;9(8):1824–7.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  18. Losser MR, Damoisel C, Payen D. Bench-to-bedside review: glucose and stress conditions in the intensive care unit. Crit Care. 2010;14(4):231.

    Article  PubMed  PubMed Central  Google Scholar 

  19. McDonnell ME, Umpierrez GE. Insulin therapy for the management of hyperglycemia in hospitalized patients. Endocrinol Metab Clin North Am. 2012;41(1):175–201. This paper is a thorough review of the pathophysiology of inpatient hyperglycemia as well as strategies for management.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  20. Thorell A, Efendic S, Gutniak M, Häggmark T, Ljungqvist O. Insulin resistance after abdominal surgery. Br J Surg. 1994;81(1):59–63.

    Article  CAS  PubMed  Google Scholar 

  21. Clarke RS. The hyperglycaemic response to different types of surgery and anaesthesia. Br J Anaesth. 1970;42(1):45–53.

    Article  CAS  PubMed  Google Scholar 

  22. Thorell A, Nygren J, Essén P, Gutniak M, Loftenius A, Andersson B, et al. The metabolic response to cholecystectomy: insulin resistance after open compared with laparoscopic operation. Eur J Surg. 1996;162(3):187–91.

    CAS  PubMed  Google Scholar 

  23. Donatelli F, Vavassori A, Bonfanti S, Parrella P, Lorini L, Fumagalli R, et al. Epidural anesthesia and analgesia decrease the postoperative incidence of insulin resistance in preoperative insulin-resistant subjects only. Anesth Analg. 2007;104(6):1587–93.

    Article  CAS  PubMed  Google Scholar 

  24. Lattermann R, Carli F, Wykes L, Schricker T. Epidural blockade modifies perioperative glucose production without affecting protein catabolism. Anesthesiology. 2002;97(2):374–81.

    Article  CAS  PubMed  Google Scholar 

  25. Fragen RJ, Shanks CA, Molteni A, Avram MJ. Effects of etomidate on hormonal responses to surgical stress. Anesthesiology. 1984;61(6):652–6.

    Article  CAS  PubMed  Google Scholar 

  26. Desborough JP, Hall GM, Hart GR, Burrin JM. Midazolam modifies pancreatic and anterior pituitary hormone secretion during upper abdominal surgery. Br J Anaesth. 1991;67(4):390–6.

    Article  CAS  PubMed  Google Scholar 

  27. Belhoula M, Ciébiéra JP, De La Chapelle A, Boisseau N, Coeurveille D, Raucoules-Aimé M. Clonidine premedication improves metabolic control in type 2 diabetic patients during ophthalmic surgery. Br J Anaesth. 2003;90(4):434–9.

    Article  CAS  PubMed  Google Scholar 

  28. Gaumann DM, Tassonyi E, Rivest RW, Fathi M, Reverdin AF. Cardiovascular and endocrine effects of clonidine premedication in neurosurgical patients. Can J Anaesth. 1991;38(7):837–43.

    Article  CAS  PubMed  Google Scholar 

  29. Metz SA, Halter JB, Robertson RP. Induction of defective insulin secretion and impaired glucose tolerance by clonidine. Selective stimulation of metabolic alpha-adrenergic pathways. Diabetes. 1978;27(5):554–62.

    Article  CAS  PubMed  Google Scholar 

  30. Lyons FM, Bew S, Sheeran P, Hall GM. Effects of clonidine on the pituitary hormonal response to pelvic surgery. Br J Anaesth. 1997;78(2):134–7.

    Article  CAS  PubMed  Google Scholar 

  31. Naguib AN, Tobias JD, Hall MW, Cismowski MJ, Miao Y, Barry N, et al. The role of different anesthetic techniques in altering the stress response during cardiac surgery in children: a prospective, double-blinded, and randomized study. Pediatr Crit Care Med. 2013;14(5):481–90.

    Article  PubMed  Google Scholar 

  32. Gupta K, Maggo A, Jain M, Gupta PK, Rastogi B, Singhal AB. Blood glucose estimation as an indirect assessment of modulation of neuroendocrine stress response by dexmedetomidine versus fentanyl premedication during laparoscopic cholecystectomy: a clinical study. Anesth Essays Res. 2013;7(1):34–8.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Anand KJ, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. N Engl J Med. 1992;326(1):1–9.

    Article  CAS  PubMed  Google Scholar 

  34. Diltoer M, Camu F. Glucose homeostasis and insulin secretion during isoflurane anesthesia in humans. Anesthesiology. 1988;68(6):880–6.

    Article  CAS  PubMed  Google Scholar 

  35. Tanaka K, Kawano T, Tomino T, Kawano H, Okada T, Oshita S, et al. Mechanisms of impaired glucose tolerance and insulin secretion during isoflurane anesthesia. Anesthesiology. 2009;111(5):1044–51.

    Article  CAS  PubMed  Google Scholar 

  36. Jung SM, Cho CK. The effects of deep and light propofol anesthesia on stress response in patients undergoing open lung surgery: a randomized controlled trial. Korean J Anesthesiol. 2015;68(3):224–31.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Yamasaki K, Inagaki Y, Mochida S, Funaki K, Takahashi S, Sakamoto S. Effect of intraoperative acetated Ringer’s solution with 1% glucose on glucose and protein metabolism. J Anesth. 2010;24(3):426–31.

    Article  PubMed  Google Scholar 

  38. Ljungqvist O, Thorell A, Gutniak M, Haggmark T, Efendic S. Glucose infusion instead of preoperative fasting reduces postoperative insulin resistance. J Am Coll Surg. 1994;178(4):329–36.

    CAS  PubMed  Google Scholar 

  39. Moghissi ES, Korytkowski MT, DiNardo M, Einhorn D, Hellman R, Hirsch IB, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353–69. This paper summarizes the current guidelines for inpatient management of hyperglycemia including etiologies and treatment strategies.

    Article  PubMed  Google Scholar 

  40. Monnier L, Mas E, Ginet C, Michel F, Villon L, Cristol JP, et al. Activation of oxidative stress by acute glucose fluctuations compared with sustained chronic hyperglycemia in patients with type 2 diabetes. JAMA. 2006;295(14):1681–7.

    Article  CAS  PubMed  Google Scholar 

  41. Gresele P, Guglielmini G, De Angelis M, Ciferri S, Ciofetta M, Falcinelli E, et al. Acute, short-term hyperglycemia enhances shear stress-induced platelet activation in patients with type II diabetes mellitus. J Am Coll Cardiol. 2003;41(6):1013–20.

    Article  CAS  PubMed  Google Scholar 

  42. Malmstedt J, Wahlberg E, Jörneskog G, Swedenborg J. Influence of perioperative blood glucose levels on outcome after infrainguinal bypass surgery in patients with diabetes. Br J Surg. 2006;93(11):1360–7.

    Article  CAS  PubMed  Google Scholar 

  43. Olsen MA, Nepple JJ, Riew KD, Lenke LG, Bridwell KH, Mayfield J, et al. Risk factors for surgical site infection following orthopaedic spinal operations. J Bone Joint Surg Am. 2008;90(1):62–9.

    Article  PubMed  Google Scholar 

  44. Ambiru S, Kato A, Kimura F, Shimizu H, Yoshidome H, Otsuka M, et al. Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan. J Hosp Infect. 2008;68(3):230–3.

    Article  CAS  PubMed  Google Scholar 

  45. Mohan S, Kaoutzanis C, Welch KB, Vandewarker JF, Winter S, Krapohl G, et al. Postoperative hyperglycemia and adverse outcomes in patients undergoing colorectal surgery: results from the Michigan surgical quality collaborative database. Int J Colorectal Dis. 2015;23.

  46. Vilar-Compte D, Alvarez de Iturbe I, Martín-Onraet A, Pérez-Amador M, Sánchez-Hernández C, Volkow P. Hyperglycemia as a risk factor for surgical site infections in patients undergoing mastectomy. Am J Infect Control. 2008;36(3):192–8.

    Article  PubMed  Google Scholar 

  47. Sato H, Carvalho G, Sato T, Lattermann R, Matsukawa T, Schricker T. The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. J Clin Endocrinol Metab. 2010;95(9):4338–44.

    Article  CAS  PubMed  Google Scholar 

  48. Cammu G, Lecomte P, Casselman F, Demeyer I, Coddens J, Morias K, et al. Preinduction glycemia and body mass index are important predictors of perioperative insulin management in patients undergoing cardiac surgery. J Clin Anesth. 2007;19(1):37–43.

    Article  CAS  PubMed  Google Scholar 

  49. Gianchandani R, Saberi S, Patil P, Prager R, Pop busui R. Prevalence and determinants of glycemic abnormalities in cardiac surgery patients without a history of diabetes: a prospective study. Endocrinol. 2015;11(6):125. This study evaluated the prevalence and persistence 3 months postoperatively of dysglycemia in patients without established diabetes undergoing cardiac surgery.

    Google Scholar 

  50. Shah B, Burdowski J, Lobach I, Gianos E, Sedlis SP. A risk score for prediction of hyperglycemia at coronary angiography. JACC Cardiovasc Interv. 2014;7(10):1199–201.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Jämsen E, Nevalainen PI, Eskelinen A, Kalliovalkama J, Moilanen T. Risk factors for perioperative hyperglycemia in primary hip and knee replacements. Acta Orthop. 2015;86(2):175–82.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Kotagal M, Symons RG, Hirsch IB, Umpierrez GE, Dellinger EP, Farrokhi ET, et al. SCOAP-CERTAIN collaborative perioperative hyperglycemia and risk of adverse events among patients with and without diabetes. Ann Surg. 2015;261(1):97–103. This paper examined sequelae of hyperglycemia during the perioperative period in patients with and without diabetes.

    Article  PubMed  PubMed Central  Google Scholar 

  53. Umpierrez G, Cardona S, Pasquel F, Jacobs S, Peng L, Unigwe M, et al. Randomized controlled trial of intensive versus conservative glucose control in patients undergoing coronary artery bypass graft surgery: GLUCO-CABG trial. Diabetes Care. 2015;38(9):1665–72. This study examined the role of intensive glucose control during the perioperative period in both patients with establish diabetes and SH.

    Article  PubMed  Google Scholar 

  54. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67.

    Article  PubMed  Google Scholar 

  55. Furnary AP. Intensive insulin therapy in hospitalized patients. Ann Intern Med. 2011;154(12):845–6.

    Article  PubMed  Google Scholar 

  56. Duncan AE, Abd-Elsayed A, Maheshwari A, Xu M, Soltesz E, Koch CG. Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology. 2010;112(4):860–71.

    Article  PubMed  Google Scholar 

  57. Buehler L, Fayfman M, Alexopoulos AS, Zhao L Farrokhi F Weaver J, Smiley-Byrd D, Pasquel FJ, Vellanki P, Umpierrez GE. The impact of hyperglycemia and obesity on hospitalization costs and clinical outcome in general surgery patients. J Diabetes Complicat. 2015;29(8):1177–82.

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Authors and Affiliations

  1. Department of Medicine, Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, 221 Longwood Ave, Suite 381, Boston, MA, 02115, USA

    Nadine E. Palermo & Marie E. McDonnell

  2. Department of Medicine, Division of Metabolism, Endocrinology and Diabetes, University of Michigan Health Systems, University of Michigan Medical School, 24 Frank Lloyd Wright Drive, Ann Arbor, MI, 48109, USA

    Roma Y. Gianchandani

  3. Department of Medicine, Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston University School of Medicine, 732 Harrison Ave, 5th Floor, Suite 511, Boston, MA, 02118, USA

    Sara M. Alexanian

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  1. Nadine E. Palermo
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  2. Roma Y. Gianchandani
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  3. Marie E. McDonnell
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  4. Sara M. Alexanian
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Correspondence to Nadine E. Palermo or Roma Y. Gianchandani.

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Nadine E. Palermo, Roma Y. Gianchandani, Marie E. McDonnell, and Sara M. Alexanian declare that they have no conflict of interest.

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This article is part of the Topical Collection on Hospital Management of Diabetes

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Palermo, N.E., Gianchandani, R.Y., McDonnell, M.E. et al. Stress Hyperglycemia During Surgery and Anesthesia: Pathogenesis and Clinical Implications. Curr Diab Rep 16, 33 (2016). https://doi.org/10.1007/s11892-016-0721-y

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