Note: We asked Ada County Paramedic R. Steve Cole and EMS educator Buck Feris to respond to a user question about the relationship between sepsis and hyperglycemia.
Obtaining a glucose reading should be a priority on every sick patient that is receiving an ALS assessment and treatment, regardless of circumstances. EMS professionals adhere to this practice to find out if diabetes or lack of intake is the cause of the current complaint or a complicating factor.
But did you know that there are several other causes of hyperglycemia? A curious student emailed CentreLearn with the following question: "Why does sepsis cause symptoms of hyperglycemia?" The question sparked some good old shop talk between educators, and we would like to share the information with you here.
Sepsis and many other acute illnesses will often cause hepatic glucose production to be increased. This is thought to be a byproduct of the catecholamines which are released in response to severe illness as well as the heightened levels of cytokines, glucagon, and cortosol. This will often raise blood glucose levels even in the absence of diabetes. This can become so profound that insulin therapy must be temporarily employed to stabilize blood glucose levels.
The new 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation discusses the importance of maintaining adequate blood glucose levels in post-cardiac arrest patients. High blood glucose levels have been shown to increase mortality in these patients and worsen neurological outcomes. You may read about it here in Part 9 of the new guidelines.
Beyond this, sepsis and other acute illnesses can lead to dehydration through volume depletion. Dehydration reduces the plasma content of the blood stream; reducing the amount of fluid in the blood vessels. However, dehydration by itself will not change the glucose level of the blood. This creates a higher concentration of glucose in the bloodstream. Since glucometers simply measure the amount of glucose dissolved in a small sample of blood (mg/dL or mmol/L), the instrument will show a higher blood glucose reading than normal. Lower plasma levels are the cause of the hyperglycemia, not diabetes.
Another possible cause of hyperglycemia is advanced shock. Under certain conditions, advanced shock states can lead to organ damage and decreased end organ perfusion. Sometimes this can cause damage to the pancreas and one possible result would be a decrease in insulin production. The result of decreased insulin production would again be increased serum levels of glucose.
Finally, hyperglycemia can also be seen in some end stage cancer patients. Many types of cancer can cause a decrease of albumin in the bloodstream. Albumin is a large protein that creates an osmotic pull that retains plasma in the vascular space. A reduction in albumin levels will often cause blood plasma to leak into the interstitial space. As with dehydration, this does not affect serum glucose levels. This reduction in blood plasma again causes high concentrations of blood glucose levels that will be seen in glucometer readings for these patients.
The take home from all of this is that hyperglycemia may be a sign of acute illness that has nothing to do with diabetes. Prehospital providers should be watchful, and not get tunnel vision when encountering hyperglycemia in the field. You just might have a critically ill patient who needs a completely different approach.
Sepsis and many other acute illnesses will often cause hepatic glucose production to be increased. This is thought to be a byproduct of the catecholamines which are released in response to severe illness as well as the heightened levels of cytokines, glucagon, and cortosol. This will often raise blood glucose levels even in the absence of diabetes. This can become so profound that insulin therapy must be temporarily employed to stabilize blood glucose levels.
The new 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation discusses the importance of maintaining adequate blood glucose levels in post-cardiac arrest patients. High blood glucose levels have been shown to increase mortality in these patients and worsen neurological outcomes. You may read about it here in Part 9 of the new guidelines.
Beyond this, sepsis and other acute illnesses can lead to dehydration through volume depletion. Dehydration reduces the plasma content of the blood stream; reducing the amount of fluid in the blood vessels. However, dehydration by itself will not change the glucose level of the blood. This creates a higher concentration of glucose in the bloodstream. Since glucometers simply measure the amount of glucose dissolved in a small sample of blood (mg/dL or mmol/L), the instrument will show a higher blood glucose reading than normal. Lower plasma levels are the cause of the hyperglycemia, not diabetes.
Another possible cause of hyperglycemia is advanced shock. Under certain conditions, advanced shock states can lead to organ damage and decreased end organ perfusion. Sometimes this can cause damage to the pancreas and one possible result would be a decrease in insulin production. The result of decreased insulin production would again be increased serum levels of glucose.
Finally, hyperglycemia can also be seen in some end stage cancer patients. Many types of cancer can cause a decrease of albumin in the bloodstream. Albumin is a large protein that creates an osmotic pull that retains plasma in the vascular space. A reduction in albumin levels will often cause blood plasma to leak into the interstitial space. As with dehydration, this does not affect serum glucose levels. This reduction in blood plasma again causes high concentrations of blood glucose levels that will be seen in glucometer readings for these patients.
The take home from all of this is that hyperglycemia may be a sign of acute illness that has nothing to do with diabetes. Prehospital providers should be watchful, and not get tunnel vision when encountering hyperglycemia in the field. You just might have a critically ill patient who needs a completely different approach.
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