Can high blood sugar cause death?

Don't underestimate the reactive hyperglycemia of critically ill patients.
If you manage it well, you will end up in danger; if you don't manage it well, you will.
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serve the doctors and improve the medical treatment.

The medical profession invited Professor Zhu Lei, Director of the Department of Critical Care Medicine and Director of the Department of Respiratory Therapy of Beijing Tsinghua Chang Gung Memorial Hospital, Tsinghua University, to bring a series of courses "Balancing and Disorders of Body Fluid Metabolism in Critically Ill Patients".

Picture: Screenshot of Professor Zhu Lei's excellent class.
The content of the course is full of dry goods.
In order to give readers a more intuitive experience, the editor selects the essence of "Characteristics and Treatment of Reactive Hyperglycemia in Critically Ill Patients" in the series of courses to share with you ~ 1.
A death caused by high blood sugar First of all, Professor Zhu Lei threw out a case.

Case male, 48 years old, had pulmonary embolism, severe hypoxemia and shock.

No history of diabetes.

After anticoagulation, thrombolytic therapy, and mechanical ventilation for tracheal intubation, hypoxemia and shock were improved.

However, he developed hyperglycemia, coma after being given "regular" insulin treatment, and eventually died.

 The patient’s laboratory test results showed that: blood sugar was high; blood sodium and blood chloride were slightly high; blood potassium was slightly low; metabolic alkalosis.

Figure: The patient’s laboratory test results are as follows.
The patient’s treatment process is as follows.
Let’s discuss whether such a treatment option is reasonable? Picture: The treatment process of this patient If you already have the answer in your mind, you might as well compare with Professor Zhu Lei's opinion.

 In response to the treatment of this case, Professor Zhu Lei raised the following questions: The patient developed reactive hyperglycemia and insulin resistance, why not increase the insulin dose? The patient's blood sodium and blood chloride concentrations have increased, why not use 5% glucose solution instead of normal saline? Professor Zhu Lei emphasized that as long as the appropriate amount of insulin is increased, the blood glucose concentration will surely be lowered quickly, and that the blood glucose concentration does not decrease or increase must be the result of insufficient insulin.

Therefore, the key to treatment is to regulate the application of insulin to make the blood glucose concentration drop steadily.

 In addition, we should realize that with the correct application of insulin, the increase or decrease in blood sugar can be easily resolved quickly.

However, hypernatremia and hyperchlorine will not be significantly improved in a short period of time.

So, why use so much sodium when the concentration of blood sodium and blood chlorine has increased? This will inevitably lead to a further increase in blood sodium concentration.

2.
Why does hyperglycemia suddenly appear? After dealing with this case, looking back at the cause, are you a bit confused?
Obviously there is no history of diabetes, how can you suddenly hyperglycemia, even as high as the upper limit of the blood glucose meter (40mmol/L)? Professor Zhu Lei pointed out that stress response is the main factor of high blood sugar.

 Under stress, the hypothalamic-pituitary-cortical axis is excited, the sympathetic nerve-catecholamine system is excited, and the secretion of growth hormone and glucagon increases, leading to the decomposition of glycogen, fat and protein into glucose, while the ability of tissues to use glucose decreases , Eventually causing reactive blood sugar rise.

 In addition, excessive energy supplementation in and out of the intestine, diffusion of peritoneal dialysate and glucose produced by drugs are also factors that cause reactive hyperglycemia.

 And reactive hyperglycemia will have a series of effects on the body, including: internal environment disorders; metabolic changes-decreased body synthesis function, metabolic acidosis; multiple organ dysfunction; immune dysfunction; promote inflammatory response; impact Complement activity induces or aggravates infection.

 Among them, the basic types of internal environmental disorders are: hyperosmolar dehydration, hyperosmolaremia, hypernatremia (concentration or hypervolemia), potassium loss hypokalemia or hyperkalemia, hypophosphatemia , Hypomagnesemia or hypermagnesemia, metabolic alkalosis or acidosis.

 Professor Zhu Lei emphasized that when diagnosing the internal environment disorder, it must be classified correctly, and it is clear that there are several types coexisting.

3.
How to deal with reactive hyperglycemia correctly (1) Sufficient fluid rehydration Rehydration is the basis for improving the internal environment, the effect of insulin and the control of hyperglycemia.

The amount, speed and nature of rehydration should be combined with circulatory function and electrolyte concentration (mainly sodium and potassium) and the specific conditions of the patient.

 (2) The application of insulin must form basic cognition-the amount of insulin used for reactive hyperglycemia is much larger than that of diabetic ketoacidosis.

 Short-acting insulin is the first choice for insulin, and different dosage forms or different drugs should be avoided.
It is recommended to establish a separate rehydration channel for insulin injection, either intravenous drip or micropump infusion.

 (3) Closely monitor blood glucose and electrolyte changes once every 1 to 2 hours, not 24 hours as a cycle.

 (4) Protect the function of organs and carry out comprehensive treatment focusing on the primary disease and improving the internal environment.

 (5) Treatment of high-risk factors: Insufficient blood volume: Avoid or use nephrotoxic drugs with caution, especially in combination with diuretics.

Obvious hypoproteinemia: first supplement the colloid; control the amount and speed of the infusion to avoid pulmonary edema.

 It is worth mentioning that Professor Zhu Lei emphasized the standardized use of insulin: ① Medication route and liquid selection Micropump infusion: no special requirements.

Intravenous drip: If there is no hypernatremia, choose normal saline; if there is hypernatremia, avoid normal saline, use 5% glucose solution to increase the amount of insulin.

②The initial dosage and total amount of insulin vary greatly among individuals, and there is no special regulation.

The principle is to ensure a steady drop in blood sugar, if necessary, temporary static push.

 ③ The rate of blood sugar decrease is about 5mmol/L per hour (3.
9~5.
6mmol/L).

At the beginning, blood glucose was monitored every 1h and electrolytes every 2h.

 ④ Intensive treatment of target blood sugar: blood sugar may be higher in the early stage of the disease, and 5~10mmol/L is appropriate.

Maintenance treatment: The condition is significantly improved, and it is controlled within the normal range or close to normal.

 ⑤Adverse effects of insulin and prevention and treatment of hypokalemia: simultaneous potassium supplementation; blood potassium should be checked every 2h at the beginning and every 4h afterwards; when the blood potassium level is low or hypokalemia, avoid the blood glucose concentration drop or drop too fast.

Hypotension: Control the rate of blood sugar decline; adequate fluid replacement.

Hypomagnesemia, hypophosphatemia and insulin allergies.
Finally, Professor Zhu Lei pointed out that when the body enters a relative "decay period" from the stress period, the level of stress hormones in the body will decrease, changing from catabolism to anabolism.
A large amount of potassium, magnesium and phosphorus are transferred into the cells, and the body's sensitivity to insulin is also increased.

 Therefore, in this remission period, the treatment requirements are transformed into: increasing energy, protein, potassium, magnesium and water-soluble vitamin supplements.

Quickly reduce the amount of insulin.

Strengthen monitoring.

 All in all, the characteristics of reactive hyperglycemia in critically ill patients are: the imbalance of hormone secretion caused by stress response is the core factor of hyperglycemia.

Improper clinical intervention is a common cause of severe or intractable disorders.

Often coexists with other ion disorders.

Insulin application is significantly different from diabetes or diabetic ketoacidosis.

Strengthen the management of fluid replacement, especially the management of sodium.

Pay attention to the difference after remission.

 After reading this article, I wonder if the readers and viewers have gained a lot? Professor Zhu Lei’s series of courses "Balancing and Disorders of Body Fluid Metabolism in Critically Ill Patients", in addition to the "Characteristics and Treatment of Reactive Hyperglycemia in Critically Ill Patients", but also "Stress Response and Body Fluid Metabolism in Critically Ill Patients", Exciting content such as "Responding to Metabolic Alkalosis in Critically Ill Patients" and "Practical Combat of Electrolyte Disturbance Cases".

 After listening to the class, remember to go to the actual case to check how much you have mastered~ Course viewing 1.
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