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Chen GD, Zhang JL, Chen YT, Zhang JX, Wang T, Zeng QY. Insulin alleviates mitochondrial oxidative stress involving upregulation of superoxide dismutase 2 and uncoupling protein 2 in septic acute kidney injury. Exp Ther Med 2018; 15:3967-3975. [PMID: 29563990 PMCID: PMC5858081 DOI: 10.3892/etm.2018.5890] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 02/19/2018] [Indexed: 12/15/2022] Open
Abstract
The aim of the present study was to explore the effects and mechanisms of insulin on mitochondrial oxidative stress in septic acute kidney injury (AKI). Male Sprague Dawley rats were divided randomly into four groups: Control group, sham surgery group, cecal ligation and puncture (CLP) group, and CLP plus insulin group. Blood specimens and kidney tissues were obtained at 12 and 24 h after surgery as separate experiments. Analyses of histology and indicators of renal injury [blood urea nitrogen (BUN) and serum creatinine (CRE) and neutrophil gelatinase-associated lipocalin (NGAL)], mitochondrial function [adenosine triphosphate (ATP) and mitochondrial membrane potential (MMP)], oxidative stress [inducible nitric oxide synthase (iNOS), reactive oxygen species (ROS) and nitric oxide (NO)], endogenous antioxidant systems [superoxide dismutase (SOD) and glutathione (GSH)] as well as the expression of uncoupling protein (UCP), PINK1 protein (a major mediator of mitophagy), PGC1α protein (a major regulator of mitochondrial biogenesis) were performed. Compared with CLP group, the CLP plus insulin group had milder histological damage, higher levels of ATP and MMP as well as lower levels of BUN, serum CRE and NGAL, intrarenal iNOS, mitochondrial ROS and total NO. Moreover, the CLP plus insulin group demonstrated increased expression of SOD2 and UCP2. In contrast, insulin administration suppressed mitophagy meanwhile did not upregulate total GSH and induce mitochondrial biogenesis following CLP. These findings indicated that the upregulation of SOD2 and UCP2 may be involved in insulin protecting against mitochondrial oxidative stress in septic AKI.
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Affiliation(s)
- Guang-Dao Chen
- Center of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China.,Department of Pediatrics, Central Hospital of Panyu District, Guangzhou, Guangdong 511400, P.R. China
| | - Jun-Liang Zhang
- Center of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China.,Department of Neonatology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Yi-Ting Chen
- Center of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
| | - Ju-Xing Zhang
- Center of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
| | - Tao Wang
- Center of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
| | - Qi-Yi Zeng
- Center of Pediatrics, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, P.R. China
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Jochum F, Krohn K, Kohl M, Loui A, Nomayo A, Koletzko B. Parenterale Ernährung von Kindern und Jugendlichen: Empfehlungen und Experten-Statements. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-014-3278-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Lex DJ, Szántó P, Breuer T, Tóth R, Gergely M, Prodán Z, Sápi E, Szatmári A, Szántó T, Gál J, Székely A. Impact of the insulin and glucose content of the postoperative fluid on the outcome after pediatric cardiac surgery. Interv Med Appl Sci 2014; 6:160-9. [PMID: 25598989 DOI: 10.1556/imas.6.2014.4.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 09/03/2014] [Accepted: 09/03/2014] [Indexed: 01/08/2023] Open
Abstract
INTRODUCTION The aim of this study was to investigate the role of the insulin and glucose content of the maintenance fluid in influencing the outcomes of pediatric patients undergoing heart surgery. METHODS A total of 2063 consecutive pediatric patients undergoing cardiac surgery were screened between 2003 and 2008. A dextrose and an insulin propensity-matched group were constructed. In the dextrose model, 5% and 10% dextrose maintenance infusions were compared below 20 kg of weight. RESULTS A total of 171 and 298 pairs of patients were matched in the insulin and glucose model, respectively. Mortality was lower in the insulin group (12.9% vs. 7%, p = 0.049). The insulin group had longer intensive care unit (ICU) stay [days, 10.9 (5.8-18.4) vs. 13.7 (8.2-21), p = 0.003], hospital stay [days, 19.8 (13.6-26.6) vs. 22.7 (17.6-29.7), p < 0.01], duration of mechanical ventilation [hours, 67 (19-140) vs. 107 (45-176), p = 0.006], and the incidence of severe infections (18.1% vs. 28.7%, p = 0.01) and dialysis (11.7% vs. 24%, p = 0.001) was higher. In the dextrose model, the incidence of pulmonary complications (13.09% vs. 22.5%, p < 0.01), low cardiac output (17.11% vs. 30.9%, p < 0.01), and severe infections (10.07% vs. 20.5%, p < 0.01) was higher, and the duration of the hospital stay [days, 16.4 (13.1-21.6) vs. 18.1 (13.8-24.6), p < 0.01] was longer in the 10% dextrose group. CONCLUSIONS Insulin treatment appeared to decrease mortality, and lower glucose content was associated with lower occurrence of adverse events.
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Barennes H, Pussard E. Improving the management of dysglycemia in children in the developing world. Am J Trop Med Hyg 2014; 92:6-8. [PMID: 25311692 DOI: 10.4269/ajtmh.14-0212] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Improving the availability of point-of-care (POC) diagnostics for glucose is crucial in resource-constrained settings (RCS). Both hypo and hyperglycemia have an appreciable frequency in the tropics and have been associated with increased risk of deaths in pediatrics units. However, causes of dysglycemia, including hyperglycemia, are numerous and insufficiently documented in RCS. Effective glycemic control with glucose infusion and/or intensive insulin therapy can improve clinical outcomes in western settings. A non-invasive way for insulin administration is not yet available for hyperglycemia. We documented a few causes and developed simple POC treatment of hypoglycemia in RCS. We showed the efficacy of sublingual sugar in two clinical trials. Dextrose gel has been recently tested for neonate mortality. This represents an interesting alternative that should be compared with sublingual sugar in RCS. New studies had to be done to document dysglycemia mechanism, frequency and morbid-mortality, and safe POC treatment in the tropics.
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Affiliation(s)
- Hubert Barennes
- INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France; Agence Nationale de Recherche sur le VIH et Hépatite, ANRS Phnom Penh, Cambodia; Epidemiology Unit, Pasteur Institute, Phnom Penh, Cambodia; Génétique Moléculaire, Pharmacogénétique et Hormonologie CHU Bicêtre, Kremlin Bicêtre, Paris, France
| | - Eric Pussard
- INSERM, ISPED, Centre INSERM U897-Epidemiologie-Biostatistique, F-33000 Bordeaux, France; Agence Nationale de Recherche sur le VIH et Hépatite, ANRS Phnom Penh, Cambodia; Epidemiology Unit, Pasteur Institute, Phnom Penh, Cambodia; Génétique Moléculaire, Pharmacogénétique et Hormonologie CHU Bicêtre, Kremlin Bicêtre, Paris, France
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Abstract
OBJECTIVES To assess the willingness of pediatric intensivists to conduct a pediatric trial of blood glucose control, and to determine if self-reported practices were influenced by adult-specific data over the past 4 yrs. This was a follow-up to our previous 2005 survey. DESIGN Electronic survey comprising a 30-item questionnaire. SETTING North American PICUs that were members of, or connected to, the Pediatric Acute Lung Injury and Sepsis Network (n = 96 targeted institutions). PARTICIPANTS North American pediatric intensivists (n = 209). INTERVENTIONS None. METHODS We conducted a survey of North American PICUs using a Web-based questionnaire. Invitations were sent to 96 institutions in 37 states/provinces. RESULTS Response rate was 68% (141/209). The median definitions of hyperglycemia (150 mg/dL) and hypoglycemia (≤60 mg/dL) were similar to our 2005 survey results. Self-reported practice patterns remain variable. Although 75% of clinician respondents denied a change in clinical practice based on the published literature, the preferred blood glucose target range increased from 80-110 mg/dL in 2005 to 90-140 mg/dL in 2009. Intensivists who preferred a blood glucose target of 80-110 mg/dL decreased from 43% to 6% (p < 0.001). Many respondents (45%) indicated that the acceptable severe hypoglycemia rate (% patients) for a protocol was ≤2.5%. The majority (93%) indicated they would be willing to enroll patients in a pediatric trial of blood glucose control. CONCLUSIONS Pediatric intensivists report that they control blood glucose with insulin in critically ill children and do not necessarily adopt adult-specific data or a single uniform blood glucose target. The published evidence does not adequately address PICU clinicians concerns. Unanswered questions and persistent variation in practice suggest a need for a multicenter clinical trial of blood glucose control in critically ill children.
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Hacıhamdioğlu B, Kendirli T, Oçal G, Sıklar Z, Savaş Erdeve S, Ince E, Berberoğlu M. Pathophysiology of critical illness hyperglycemia in children. J Pediatr Endocrinol Metab 2013; 26:715-20. [PMID: 23640956 DOI: 10.1515/jpem-2012-0313] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2012] [Accepted: 03/24/2013] [Indexed: 11/15/2022]
Abstract
Causes of hyperglycemia in critically ill non-diabetic children may differ from those in adults. The objective of this study was to investigate the pathogenesis of critical illness hyperglycemia (CIH) in terms of insulin resistance and β-cell dysfunction. Critically ill children with blood glucose (BG) levels of >150 mg/dL (8.3 mmol/L) were enrolled in the study. Insulin sensitivity and β-cell function in the hyperglycemic and euglycemic periods were analyzed with BG/insulin and BG/C-peptide ratios, and utilizing homeostasis model assessment (HOMA). A total of 40 patients were enrolled in the study. BG/insulin and BG/C-peptide ratios were significantly higher in the hyperglycemic period. The HOMA-B and S scores for the hyperglycemic period revealed that out of all the patients who survived (n=30), 20 had β-cell dysfunction, while the remaining (n=11) had insulin resistance. β-cell dysfunction was significantly higher in the hyperglycemic period (p<0.001). As in adults, β-cell dysfunction may play a major role in the pathophysiology of CIH in children.
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Bordbar MR, Taj-Aldini R, Karamizadeh Z, Haghpanah S, Karimi M, Omrani GH. Thyroid function and stress hormones in children with stress hyperglycemia. Endocrine 2012; 42:653-7. [PMID: 22653725 DOI: 10.1007/s12020-012-9707-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 05/15/2012] [Indexed: 12/26/2022]
Abstract
The purpose of the study is to determine the prevalence of stress hyperglycemia and to investigate how thyroid and stress hormones alter during stress hyperglycemia in children admitted to pediatric emergency wards. A prospective cross-sectional study was conducted in children, less than 19 years old, who were admitted to pediatric emergency wards of Nemazee and Dastgheib Hospitals, Shiraz, Southern Iran. Those patients taking steroids, beta-agonists or intravenously administered glucose before venipuncture, and patients with diabetes mellitus (DM) or thyroid diseases were excluded. Children with blood glucose ≥ 150 mg/dL during admission were regarded as cases. The controls were age- and- sex- matched, euglycemic children. Stress hormones including cortisol, insulin, growth hormone, and prolactin were measured, and thyroid function was tested with a radioimmunoassay (RIA) method in all cases and controls. The results showed that among 1,054 screened children, 39 cases (3.7 %) had stress hyperglycemia and 89 controls were included in the study. The occurrence of hyperglycemia was independent of sex, but it occurred mostly in children under 6 years old. Hyperglycemia occurred more frequently in patients with a positive family history of DM (odds ratio = 3.2, 95 % CI = 1.3-7.9, and P = 0.009). There were no significant differences between cases and controls regarding any hormones except higher cortisol, and lower total T3 and T4 in cases compared with controls. Neither of cases developed diabetes in the 24-month follow-up period. These findings led us to the conclusion that stress hyperglycemia is occasionally seen in critically ill patients. Among the stress hormones measured, only cortisol increased during hyperglycemia. It seems that hyperglycemia is not an important risk factor for future diabetes.
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de Betue CTI, Verbruggen SCAT, Schierbeek H, Chacko SK, Bogers AJJC, van Goudoever JB, Joosten KFM. Does a reduced glucose intake prevent hyperglycemia in children early after cardiac surgery? a randomized controlled crossover study. Crit Care 2012; 16:R176. [PMID: 23031354 PMCID: PMC3682276 DOI: 10.1186/cc11658] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2012] [Revised: 08/14/2012] [Accepted: 10/02/2012] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Hyperglycemia in children after cardiac surgery can be treated with intensive insulin therapy, but hypoglycemia is a potential serious side effect. The aim of this study was to investigate the effects of reducing glucose intake below standard intakes to prevent hyperglycemia, on blood glucose concentrations, glucose kinetics and protein catabolism in children after cardiac surgery with cardiopulmonary bypass (CPB). METHODS Subjects received a 4-hour low glucose (LG; 2.5 mg/kg per minute) and a 4-hour standard glucose (SG; 5.0 mg/kg per minute) infusion in a randomized blinded crossover setting. Simultaneously, an 8-hour stable isotope tracer protocol was conducted to determine glucose and leucine kinetics. Data are presented as mean ± SD or median (IQR); comparison was made by paired samples t test. RESULTS Eleven subjects (age 5.1 (20.2) months) were studied 9.5 ± 1.9 hours post-cardiac surgery. Blood glucose concentrations were lower during LG than SG (LG 7.3 ± 0.7 vs. SG 9.3 ± 1.8 mmol/L; P < 0.01), although the glycemic target (4.0-6.0 mmol/L) was not achieved. No hypoglycemic events occurred. Endogenous glucose production was higher during LG than SG (LG 2.9 ± 0.8 vs. SG 1.5 ± 1.1 mg/kg per minute; P = 0.02), due to increased glycogenolysis (LG 1.0 ± 0.6 vs. SG 0.0 ± 1.0 mg/kg per minute; P < 0.05). Leucine balance, indicating protein balance, was negative but not affected by glucose intake (LG -54.8 ± 14.6 vs. SG -58.8 ± 16.7 μmol/kg per hour; P = 0.57). CONCLUSIONS Currently recommended glucose intakes aggravated hyperglycemia in children early after cardiac surgery with CPB. Reduced glucose intake decreased blood glucose concentrations without causing hypoglycemia or affecting protein catabolism, but increased glycogenolysis. TRIAL REGISTRATION Dutch trial register NTR2079.
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Affiliation(s)
- Carlijn TI de Betue
- Intensive Care and Department of Pediatric Surgery, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - Sascha CAT Verbruggen
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
| | - Henk Schierbeek
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Meibergdreef 9. 1105 AZ, Amsterdam, The Netherlands
| | - Shaji K Chacko
- Department of Pediatrics, Baylor College of Medicine, USDA-ARS Children's Nutrition Research Center, 1100 Bates Street, Houston, TX 77030, USA
| | - Ad JJC Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, University Medical Center Rotterdam, Dr. Molewaterplein 50, 3015 GE, Rotterdam, The Netherlands
| | - Johannes B van Goudoever
- Department of Pediatrics, Emma Children's Hospital, Academic Medical Center, University of Amsterdam, Meibergdreef 9. 1105 AZ, Amsterdam, The Netherlands
- Department of Pediatrics, VU University Medical Center, De Boelelaan 1117, 1081 HV, Amsterdam, The Netherlands
| | - Koen FM Joosten
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, University Medical Center Rotterdam, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
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Li Y, Zhu R, Qian Y, Deng J. The characteristics of blood glucose and WBC counts in peripheral blood of cases of hand foot and mouth disease in China: a systematic review. PLoS One 2012; 7:e29003. [PMID: 22235257 PMCID: PMC3250408 DOI: 10.1371/journal.pone.0029003] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 11/18/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Outbreaks of Hand Foot and Mouth Disease (HFMD) have occurred in many parts of the world especially in China. We aimed to summarize the characteristics of the levels of blood glucose and white blood cell (WBC) counts in cases of HFMD in Mainland China and Taiwan, using meta-analysis based on systematic review of published articles. METHODS We systematically reviewed published studies, from the MEDLINE and WANFANG Data, about the levels of blood glucose and WBC counts in cases of HFMD until 15(th) June 2011, and quantitatively summarized the characteristics of them using meta-analysis. RESULTS In total, 37 studies were included in this review. In Mainland China and Taiwan, generally, the average level of blood glucose, the prevalence of hyperglycemia, WBC counts and the prevalence of leukocytosis increased with the severity of the illness. There was no significant difference in the prevalence of leukocytosis between ANS (autonomic nervous system dysregulation)/PE (pulmonary edema) group and CNS (central nervous system) group, and in the average level of blood glucose between healthy controls and mild cases of HFMD. WBC counts in cases infected by EV71 were less than those in cases infected by CA16. CONCLUSIONS our analyses indicated that blood glucose and WBC counts increased with the severity of HFMD disease, which would help doctors to manage patients efficiently.
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Affiliation(s)
- Yuyun Li
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
| | - Runan Zhu
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
| | - Yuan Qian
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
- * E-mail:
| | - Jie Deng
- Laboratory of Virology, Capital Institute of Pediatrics, Beijing, China
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Verbruggen SC, Landzaat LJ, Reiss IKM, van Goudoever JB, Joosten KFM. Efficacy and safety of a tight glucose control protocol in critically ill term neonates. Neonatology 2012; 101:232-8. [PMID: 22085889 DOI: 10.1159/000330846] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 07/08/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND A large single-center randomized trial showed that treating hyperglycemia in critically ill children improved outcome, despite an increased incidence of hypoglycemia, especially in infants. OBJECTIVES We evaluated the efficacy and incidence of hypoglycemia using a tight glucose protocol in critically ill term neonates. METHODS Term hyperglycemic (>8 mmol·l(-1); >144 mg·dl(-1)) neonates treated with a tight glucose protocol during a 3.5-year period in a tertiary pediatric intensive care unit were retrospectively analyzed. RESULTS Seventy-three term hyperglycemic neonates [age 0 days (0-6), weight 3.2 ± 0.8 kg, PRISM 16 (11-20)] were included for analysis. Eighteen neonates died (25%). The initial mean (range) glucose level was 11.1 mmol·l(-1) [9.6-15.2; 200 mg·dl(-1) (173-274)], and normoglycemia (<8 mmol·l(-1); <144 mg·dl(-1)) was reached within 5.3 h (1-25) with an overall treatment duration of 27 h (10-57). Seven hypoglycemic incidents (5 times ≤2.2 mmol·l(-1); 40 mg·dl(-1), and 2 times <1.7 mmol·l(-1); 31 mg·dl(-1)) occurred in 5 (6.7%) infants, without severe clinical signs. Three hypoglycemic incidents were directly explained due to a protocol violation. One hypoglycemic incident occurred with the onset of sepsis, while no apparent cause was identified for three hypoglycemic incidents. CONCLUSIONS Our glucose protocol was effective, but hypoglycemia occurred more frequently than in older children reported previously. Potential differences in glucose and insulin metabolism in term neonates appear to justify additional safety approaches, while awaiting further studies assessing the benefits of tight glucose protocols in this population. Meanwhile, we have decreased the initial insulin starting doses in our protocol.
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Affiliation(s)
- Sascha C Verbruggen
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands.
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Current recommended parenteral protein intakes do not support protein synthesis in critically ill septic, insulin-resistant adolescents with tight glucose control. Crit Care Med 2011; 39:2518-25. [PMID: 21765361 DOI: 10.1097/ccm.0b013e3182257410] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the effects of insulin infusion and increased parenteral amino acid intakes on whole body protein balance, glucose kinetics, and lipolysis in critically ill, insulin-resistant, septic adolescents. DESIGN A single-center, randomized, crossover study. SETTING A medicosurgical intensive care unit in a tertiary university hospital. PATIENTS Nine critically ill, septic adolescents (age 15.0 ± 1.2 yrs, body mass index 20 ± 4 kg m(-2)) receiving total parenteral nutrition. INTERVENTIONS Patients received total parenteral nutrition with standard (1.5 g · kg(-1) · day(-1)) and high (3.0 g · kg(-1) · day(-1)) amino acid intakes in a 2-day crossover setting, randomized to the order in which they received it. On both study days, we conducted a primed, constant, 7-hr stable isotope tracer infusion with [1-(13)C]leucine, [6,6-(2)H(2)]glucose, and [1,1,2,3,3-(2)H(5)]glycerol, in combination with a hyperinsulinemic euglycemic clamp during the last 3 hrs. MEASUREMENTS AND MAIN RESULTS Insulin decreased protein synthesis at standard amino acid and high amino acid intakes (p < .01), while protein breakdown decreased with insulin at standard amino acid intake (p < .05) but not with the high amino acid intake. High amino acid intake improved protein balance (p < .05), but insulin did not have an additive effect. There was significant insulin resistance with an M value of ~3 (mg · kg(-1) · min(-1))/(mU · mL(-1)) which was 30% of reported normal values. At high amino acid intake, endogenous glucose production was not suppressed by insulin and lipolysis rates increased. CONCLUSION The current recommended parenteral amino acid intakes are insufficient to maintain protein balance in insulin-resistant patients during tight glucose control. During sepsis, insulin decreases protein synthesis and breakdown, and while high amino acid intake improves protein balance, its beneficial effects may be offset by enhanced endogenous glucose production and lipolysis, raising concerns that insulin resistance may have been exacerbated and that gluconeogenesis may have been favored by high amino acid intakes. Dose-response studies on the effect of the level of amino acid intakes (protein) on energy metabolism are needed.
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Verhoeven JJ, Koenraads M, Hop WCJ, Brand JB, van de Polder MM, Joosten KFM. Baseline insulin/glucose ratio as a marker for the clinical course of hyperglycemic critically ill children treated with insulin. Nutrition 2011; 28:25-9. [PMID: 21820870 DOI: 10.1016/j.nut.2011.04.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2010] [Revised: 04/19/2011] [Accepted: 04/23/2011] [Indexed: 10/17/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the relations of baseline insulin/glucose ratio to the clinical course of critically ill children. Such information will provide insight into the pathophysiologic mechanisms leading to hyperglycemia and will optimize preventive and therapeutic measures for hyperglycemia in critically ill children. METHODS Sixty-four consecutively admitted critically ill children with hyperglycemia, defined as a blood glucose level higher than 8 mmol/L (>145 mg/dL) and treated with insulin according to a glucose-control protocol, were included. Demographic data and clinical and laboratory parameters were collected. Insulin sensitivity was investigated by calculating the ratio of insulin to the blood glucose level just before the start of insulin administration. Results are expressed as median (range). RESULTS Sixty-four children (24 girls) 7.0 y of age (0.3-16.9 y) with various diagnoses were included. A hyperinsulinemic response, indicated by an increased insulin/glucose ratio (>18 pmol/mmol), was seen in 55% of children. The durations of insulin therapy, mechanical ventilation, and pediatric intensive care unit length of stay in children with a hyperinsulinemic response were longer than in children with a hypoinsulinemic response. CONCLUSION Hyper- and hypoinsulinemic responses play a role in the occurrence of hyperglycemia in critically ill children. Each is associated with a particular clinical course after the initiation of insulin therapy. It would be worthwhile to further investigate if the insulinemic response to hyperglycemia, determined by the insulin/glucose ratio in combination with the type of organ dysfunction, could be used in clinical practice to determine the need for insulin therapy.
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Affiliation(s)
- Jennifer J Verhoeven
- Intensive Care, Erasmus MC-Sophia Children's Hospital, Erasmus MC, Rotterdam, The Netherlands.
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Verbruggen SCAT, de Betue CTI, Schierbeek H, Chacko S, van Adrichem LNA, Verhoeven J, van Goudoever JB, Joosten KFM. Reducing glucose infusion safely prevents hyperglycemia in post-surgical children. Clin Nutr 2011; 30:786-92. [PMID: 21719165 DOI: 10.1016/j.clnu.2011.05.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2011] [Revised: 05/24/2011] [Accepted: 05/24/2011] [Indexed: 01/16/2023]
Abstract
BACKGROUND & AIMS To investigate the effects of two different glucose infusions on glucose homeostasis and amino acid metabolism in post-surgical children. METHODS This randomized crossover study evaluated glucose and amino acid metabolism in eight children (age 9.8 ± 1.9 months, weight 9.5 ± 1.1 kg) admitted to a pediatric intensive care unit in a tertiary university hospital after surgical correction for non-syndromal craniosynostosis. Patients were randomized to receive low (LG; 2.5 mg kg(-1) min(-1)) and standard (SG; 5.0 mg kg(-1) min(-1)) glucose infusion in a crossover setting. After a bolus (4 g kg(-1)) of deuterium oxide, we conducted a primed, constant, 8 h tracer infusion with [6,6-²H₂]Glucose, [1-¹³C]Leucine, [ring-²H₅]Phenylalanine and [3,3-²H₂]Tyrosine. RESULTS SG resulted in hyperglycemia (defined as > 6.1 mmol L(-1)), while during LG plasma glucose levels were normoglycemic (5.9 ± 0.6 vs. 7.5 ± 1.7 mmol L(-1); LG vs. SG respectively, p = 0.02). Hypoglycemia did not occur during LG infusion. Endogenous glucose production was not fully suppressed during the hyperglycemic state under SG and increased with reduced glucose infusion (2.6 ± 1.5 vs. 1.1 ± 1.4 mg kg(-1) min(-1); LG vs. SG; p = 0.05). Whole body protein balance derived from leucine and phenylalanine kinetics was slightly negative but not further affected with a decrease in glucose infusion. CONCLUSIONS The current recommended glucose infusion induces hyperglycemia in post-surgical children. A reduced glucose infusion safely reduced high glucose levels, while children were capable to sustain normoglycemia with increased endogenous glucose production. The reduced glucose infusion did not exacerbate the mild catabolic state in which the patients were.
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Affiliation(s)
- Sascha C A T Verbruggen
- Department of Pediatrics, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
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Albumin synthesis rates in post-surgical infants and septic adolescents; influence of amino acids, energy, and insulin. Clin Nutr 2011; 30:469-77. [PMID: 21367495 DOI: 10.1016/j.clnu.2011.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Revised: 01/26/2011] [Accepted: 02/03/2011] [Indexed: 01/25/2023]
Abstract
BACKGROUND & AIMS To investigate the effects of glucose, parenteral amino acids, and intravenous insulin on albumin synthesis rates in critically ill children. METHODS Two studies were performed in 8 post-surgical infants (age 9.8 ± 1.9 months; weight 9.5 ± 1.1 kg) and 9 septic adolescents (age 15 ± 1 yr; BMI 23 ± 4 kg m(-2)), respectively. All received a primed, constant, tracer infusion with [1-(13)C]Leucine. The infants in study 1 were randomized to receive low (2.5 mg kg(-1) min(-1)) and standard (5.0 mg kg(-1) min(-1)) glucose intake in a cross-over setting of two periods of 4 h each. The adolescents in study 2 were randomized to receive total parenteral nutrition with standard (1.5 g kg(-1) day(-1)) and high (3.0 g kg(-1) day(-1)) amino acid intake in a two day cross-over setting. On both study days, during the last 3 h of the tracer study, they received insulin infused at 80 mU m(-2) min(-1). RESULTS The post-surgical infants and the septic adolescents were mildly hypoalbuminemic (∼2.5 g dL(-1)) with high synthesis rates, which were not affected by different intakes of glucose, amino acids, or insulin infusion. CONCLUSIONS Albumin synthesis rates in hypoalbuminemic critically ill children are high but were not upregulated through nutrient supply, and in septic adolescents are unaffected by insulin.
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Pathophysiological aspects of hyperglycemia in children with meningococcal sepsis and septic shock: a prospective, observational cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R44. [PMID: 21276273 PMCID: PMC3221973 DOI: 10.1186/cc10006] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 09/29/2010] [Accepted: 01/31/2011] [Indexed: 12/28/2022]
Abstract
INTRODUCTION The objective of this study was to investigate the occurrence of hyperglycemia and insulin response in critically ill children with meningococcal disease in the intensive care unit of an academic children's hospital. METHODS Seventy-eight children with meningococcal disease were included. The group was classified into shock non-survivors, shock survivors and sepsis survivors. There were no sepsis-only non-survivors. The course of laboratory parameters during 48 hours was assessed. Insulin sensitivity and β-cell function on admission were investigated by relating blood glucose level to insulin level and C-peptide level and by homeostasis model assessment (HOMA) [β-cell function (HOMA-%B) and insulin sensitivity (HOMA-%S)]. RESULTS On admission, hyperglycemia (glucose >8.3 mmol/l) was present in 33% of the children. Shock and sepsis survivors had higher blood glucose levels compared with shock non-survivors. Blood glucose level on admission correlated positively with plasma insulin, C-peptide, cortisol, age and glucose intake. Multiple regression analysis revealed that both age and plasma insulin on admission were significantly related to blood glucose. On admission, 62% of the hyperglycemic children had overt insulin resistance (glucose >8.3 mmol/l and HOMA-%S <50%); 17% had β-cell dysfunction (glucose >8.3 mmol/l and HOMA-%B <50%) and 21% had both insulin resistance and β-cell dysfunction. Hyperglycemia was present in 11% and 8% of the children at 24 and 48 hours after admission, respectively. CONCLUSIONS Children with meningococcal disease often show hyperglycemia on admission. Both insulin resistance and β-cell dysfunction play a role in the occurrence of hyperglycemia. Normalization of blood glucose levels occurs within 48 hours, typically with normal glucose intake and without insulin treatment.
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Verhoeven JJ, Hokken-Koelega ACS, den Brinker M, Hop WCJ, van Thiel RJ, Bogers AJJC, Helbing WA, Joosten KFM. Disturbance of glucose homeostasis after pediatric cardiac surgery. Pediatr Cardiol 2011; 32:131-8. [PMID: 21082177 PMCID: PMC3033526 DOI: 10.1007/s00246-010-9829-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 10/25/2010] [Indexed: 01/28/2023]
Abstract
This study aimed to evaluate the time course of perioperative blood glucose levels of children undergoing cardiac surgery for congenital heart disease in relation to endogenous stress hormones, inflammatory mediators, and exogenous factors such as caloric intake and glucocorticoid use. The study prospectively included 49 children undergoing cardiac surgery. Blood glucose levels, hormonal alterations, and inflammatory responses were investigated before and at the end of surgery, then 12 and 24 h afterward. In general, blood glucose levels were highest at the end of surgery. Hyperglycemia, defined as a glucose level higher than 8.3 mmol/l (>150 mg/dl) was present in 52% of the children at the end of surgery. Spontaneous normalization of blood glucose occurred in 94% of the children within 24 h. During surgery, glucocorticoids were administered to 65% of the children, and this was the main factor associated with hyperglycemia at the end of surgery (determined by univariate analysis of variance). Hyperglycemia disappeared spontaneously without insulin therapy after 12-24 h for the majority of the children. Postoperative morbidity was low in the study group, so the presumed positive effects of glucocorticoids seemed to outweigh the adverse effects of iatrogenic hyperglycemia.
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Affiliation(s)
- Jennifer J. Verhoeven
- Intensive Care, Erasmus MC-Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands ,Department of Pediatrics, Maasstad Hospital, Rotterdam, The Netherlands
| | - Anita C. S. Hokken-Koelega
- Department of Pediatrics, Division of Pediatric Endocrinology, Erasmus MC, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Marieke den Brinker
- Intensive Care, Erasmus MC-Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands ,Department of Pediatrics, Ghent University Hospital, Ghent, Belgium
| | - Wim C. J. Hop
- Department of Epidemiology and Biostatistics, Erasmus MC, Rotterdam, The Netherlands
| | - Robert J. van Thiel
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Ad J. J. C. Bogers
- Department of Cardiothoracic Surgery, Erasmus MC, Rotterdam, The Netherlands
| | - Wim A. Helbing
- Department of Pediatrics, Division of Pediatric Cardiology, Erasmus MC-Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - Koen F. M. Joosten
- Intensive Care, Erasmus MC-Sophia Children’s Hospital, P.O. Box 2060, 3000 CB Rotterdam, The Netherlands
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Tridgell DM, Tridgell AH, Hirsch IB. Inpatient management of adults and children with type 1 diabetes. Endocrinol Metab Clin North Am 2010; 39:595-608. [PMID: 20723822 DOI: 10.1016/j.ecl.2010.05.014] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Type 1 diabetes poses unique inpatient challenges because of the risks of diabetic ketoacidosis, uncontrolled hyperglycemia, and hypoglycemia. Although newer insulin analogs and insulin pumps provide means for improved glycemic control, they can be daunting for nonexperts. This article focuses on inpatient and perioperative insulin management of stable, nonketotic, nonpregnant adults and children with type 1 diabetes. These principles can also be applied to patients with steroid-induced hyperglycemia.
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Affiliation(s)
- David M Tridgell
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, 1959 NE Pacific Street, Box 356426, Seattle, WA 98195, USA.
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[Is it necessary to obtain a tight glycemic control in critically ill children?]. ACTA ACUST UNITED AC 2010; 29:570-2. [PMID: 20655168 DOI: 10.1016/j.annfar.2010.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Asencio Y, Voillet F, Paut O. Le contrôle glycémique en réanimation pédiatrique. Arch Pediatr 2010; 17:987-8. [DOI: 10.1016/s0929-693x(10)70212-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Verhoeven JJ, Brand JB, van de Polder MM, Joosten KFM. Management of hyperglycemia in the pediatric intensive care unit; implementation of a glucose control protocol. Pediatr Crit Care Med 2009; 10:648-52. [PMID: 19602994 DOI: 10.1097/pcc.0b013e3181ae787b] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate a stepwise nurse-driven glucose control protocol for the treatment of hyperglycemia in critically ill pediatric patients. SETTING Academic pediatric intensive care unit. DESIGN Prospective observational study. PATIENTS A total of 50 consecutively admitted critically ill children with hyperglycemia >8 mmol/L (>145 mg/dL) were included and treated according to the glucose control protocol. MEASUREMENTS AND MAIN RESULTS Demographic data and clinical parameters were collected and different steps in the protocol were evaluated. Data were expressed as medians with interquartile ranges. Fifty children (28 boys), aged 3.5 yrs (range, 1.2 -9.3 yrs) were treated in 18 mos. Forty-two children had multiple organ failure. Eight children died. Insulin treatment was initiated 4 hrs after the first episode of hyperglycemia was documented (median blood glucose, 11.4 mmol/L, [207 mg/dL] [9.7-14.5 mmol/L, 176-264 mg/dL]). Blood glucose was <8 mmol/L (<145 mg/dL) within 12 hrs of initiating insulin therapy in 47 (94%) of 50 children (median, 5 hrs). Duration of treatment was 34 hrs (17-72 hrs) and the maximum insulin dose ranged between 20 and 200 mIU/kg/hr (median, 70 mIU/kg/hr). Episodes of severe hypoglycemia <2.2 mmol/L (<47 mg/dL) did not occur. CONCLUSION The use of a stepwise nurse-driven glucose control protocol resulted in normoglycemia within 12 hrs for 94% of the children involved. Episodes of severe hypoglycemia did not occur. We conclude that the glucose control protocol is effective in treating hyperglycemia in critically ill children. Further studies are necessary to assess safety before the protocol could also be implemented in other pediatric intensive care units.
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Affiliation(s)
- Jennifer J Verhoeven
- Intensive Care, Erasmus MC-Sophia Children's Hospital Rotterdam, Rotterdam, The Netherlands
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Affiliation(s)
- Urban Flaring
- Department of Paediatric Anaesthesia and Intensive Care, Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden.
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Abstract
OBJECTIVES To review the epidemiology of pediatric multiple organ dysfunction syndrome (MODS) and summarize current concepts regarding the pathophysiology of shock, organ dysfunction, and nosocomial infections in this population. DATA SOURCE A MEDLINE-based literature search using the keywords MODS and child, without any restriction to the idiom. MAIN RESULTS Critically ill children may frequently develop multisystemic manifestations during the course of severe infections, multiple trauma, surgery for congenital heart defects, or transplantations. Descriptive scores to estimate the severity of pediatric MODS have been validated. Young age and chronic health conditions have also been recognized as important contributors to the development of MODS. Unbalanced inflammatory processes and activation of coagulation may lead to the development of capillary leak and acute respiratory distress syndrome. Neuroendocrine and metabolic responses may result in insufficient adaptive immune response and the development of nosocomial infections, which may further threaten host homeostasis. CONCLUSIONS Over the last 20 yrs, there has been an increasing knowledge on the epidemiology of pediatric MODS and on the physiologic mechanisms involved in the genesis of organ dysfunction. Nevertheless, further studies are needed to more clearly evaluate what is the long-term outcome of pediatric MODS.
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