What is relative hypoglycemia?

Rinaldo Bellomo
Melbourne
Australia
• High rate of hypoglycemia and 3% excess
mortality in intensive control group

• Cardiovascular cause of death more

common in the intensive control group

• Hypo independently associated with

increased mortality

• Association strongest among patients with

distributive shock
hypoglycemia per se may be harmful
Hypoglycemia

Chemoreceptors in
carotid glomus

Cardiac baroreceptor sensitivity

Heart rate variability
Sympathetic outflow

Cardiovascular instability
Previous hypoglycaemia increases hypothalamic activation
during subsequent hypoglycaemia
The back-to-front glucagon response in diabetes
 Hypoglycemia is ”silent” in ICU
Which makes it particularly bad

10 • Activation of hormonal counterregulation

Blood Glucose Level (mmol/L)

9 – Adrenaline
– Noradrenaline
8
– Cortisol
7 – Growth hormone
6 – Glucagon invisible
• Neuroglycopenic symptoms
5
– Confusion
4 3.9 – Weakness
No – Drowsiness
3 Diabetes
– etc…
 Diabetic patients may be different
The concept of relative hypoglycemia

10 • Evidence from ’clamp studies’

Blood Glucose Level (mmol/L)

9
• 30% drop from baseline triggers
8 hormonal/neuroglucopenic
7 30% responses (relative hypoglycemia)
6 • Hypoglycemia counter-regulation
5 30% Diabetes can occur within a normal blood
4 glucose range in patients with
No chronic poor glucose control
3 Diabetes

The adverse effects of hypoglycemia may happen

at a normal glucose level in diabetics
Do we have reasons to believe this is true?
10-14 mmol/l

Conventional
range
Chronic glycemia and relative hypoglycemia
Change compared to usual baseline
Another view of relative hypoglycemia
Mortality and relative hypoglycemia in ICU patients(>30% fall b/w 2 consecutive blood gases)
After adjustment for illness severity
Frequency of relative hypoglycemia and risk of death
Insulin induced relative hypoglycemia and mortality
Rapid (<4hours) relative hypoglycemia and mortality
 Where to from here?
• Evidence that glucose control matters (NICE-SUGAR)
• Evidence that hypoglycemia is injurious
• Evidence that relative hypoglycemia exists
• Evidence that it may also be bad
• Evidence that diabetics (esp. bad ones) are different and at
particular risk of relative hypoglycemia
• Evidence we can assess chronic glycemic control on
admission by HbA1c
• Evidence we can decrease relative hypoglycemia with
liberal glycemic control in diabetics
• Evidence that relative hypoglycemia is associated with
mortality in non-diabetic patients
• Further studies underway