1
|
Mohamed AO, El-Megied MAA, Hosni YA. Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit. Indian J Crit Care Med 2023; 27:754-758. [PMID: 37908430 PMCID: PMC10613863 DOI: 10.5005/jp-journals-10071-24546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 08/31/2023] [Indexed: 11/02/2023] Open
Abstract
Background Sepsis is one of the major causes of admission to the pediatric intensive care unit (PICU), as well as a primary cause of poor outcomes. Glycemic variation may occur because of sepsis resulting in either hypoglycemia or hyperglycemia. Measuring the random blood glucose (RBG) level of patients presenting with sepsis in PICU is an easy way to assess their prognosis. Objectives A prospective study was done from February 2023 to June 2023 to evaluate the relation between the outcome of pediatric septic patients and blood glucose level upon PICU admission. Patients and methods One hundred three children diagnosed with sepsis underwent clinical assessment upon admission to the PICU and initial labs including blood glucose levels were done. Pediatric Sequential Organ Failure Assessment (pSOFA) was calculated for every patient. The outcome of sepsis including length of stay, review of body systems, and mortality was documented. Results Hypoglycemic patients had the highest percentage of non-survivors (20.4%). They had a higher pSOFA score with a median of 11 (interquartile range-IQR 7-15), shorter PICU stay with a median of 2 (IQR 1-6) days, lower RBG with a median of 95 (45-120), a higher percentage of ventilation (55.1%), and a higher percentage of inotropic support (87.8%) with statistical significance with p-value (< 0.001, < 0.001, 0.001, < 0.001, 0.002), respectively. Conclusion Critically ill patients with abnormal random blood sugar (RBS) had a higher possibility of non-survival particularly those with hypoglycemia. Accordingly, RBS measurement is a rapid and cheap method that could be used in any emergency and as an early indicator to detect outcome. How to cite this article Mohamed AO, Abd El-Megied MA, Hosni YA. Prognostic Value of Serum Glucose Level in Critically Ill Septic Patients on Admission to Pediatric Intensive Care Unit. Indian J Crit Care Med 2023;27(10):754-758.
Collapse
Affiliation(s)
- Aya Osama Mohamed
- Department of Pediatrics, Faculty of Medicine, Cairo University, Maadi, Giza, Egypt
| | | | - Yomna Ahmed Hosni
- Department of Pediatrics, Faculty of Medicine, Cairo University, Maadi, Giza, Egypt
| |
Collapse
|
2
|
Tsotridou E, Kotzapanagiotou E, Violaki A, Dimitriadou M, Svirkos M, Mantzafleri PE, Papadopoulou V, Sdougka M, Christoforidis A. The Effect of Various, Everyday Practices on Glucose Levels in Critically Ill Children. J Diabetes Sci Technol 2022; 16:81-87. [PMID: 33025823 PMCID: PMC8875055 DOI: 10.1177/1932296820959315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND To evaluate the effect of various, everyday intensive care unit (ICU) practices on glucose levels in critically ill pediatric patients with the use of a continuous glucose monitoring system. METHODS Seventeen sensors were placed in 16 pediatric patients (8 male). All therapeutic and diagnostic interventions were recorded and 15 minutes later, a flash glucose measurement was obtained by swiping the sensor with a reader. Glucose difference was calculated as the glucose value 15 minutes after the intervention minus the mean daily glucose value for each individual patient. Additionally, the consciousness status of the patient (awake or sedated) was recorded. RESULTS Two hundred and five painful skin interventions were recorded. The mean difference of glucose values was higher by 1.84 ± 14.76 mg/dL (95% CI: -0.19 to 3.87 mg/dL, P = .076). However, when patients were categorized regarding their consciousness level, mean glucose difference was significantly higher in awake state than in sedated patients (4.76 ± 28.07 vs -2.21 ± 15.77 mg/dL, P < .001). Six hundred forty-nine interventions involving the respiratory system were recorded. Glucose difference during washings proved to be significantly higher than the ones during simple suctions (4.74 ± 14.18 mg/dL vs 0.32 ± 18.22 mg/dL, P = .016). Finally, glucose difference in awake patients was higher by 3.66 ± 13.91 mg/dL compared to glucose difference of -2.25 ± 21.07 mg/dL obtained during respiratory intervention in sedated patients. CONCLUSIONS Diagnostic and therapeutic procedures in the ICU, especially when performed in an awake state, exacerbate the stress and lead to a significant rise in glucose levels.
Collapse
Affiliation(s)
- Eleni Tsotridou
- 1st Department of Pediatrics, Aristotle University, Ippokratio General Hospital, Thessaloniki, Greece
| | | | - Asimina Violaki
- Pediatric Intensive Care Unit, Ippokratio General Hospital, Thessaloniki, Greece
| | - Meropi Dimitriadou
- 1st Department of Pediatrics, Aristotle University, Ippokratio General Hospital, Thessaloniki, Greece
| | - Menelaos Svirkos
- Pediatric Intensive Care Unit, Ippokratio General Hospital, Thessaloniki, Greece
| | | | | | - Maria Sdougka
- Pediatric Intensive Care Unit, Ippokratio General Hospital, Thessaloniki, Greece
| | - Athanasios Christoforidis
- 1st Department of Pediatrics, Aristotle University, Ippokratio General Hospital, Thessaloniki, Greece
- Athanasios Christoforidis, MD, PhD, 1st Department of Pediatrics, Aristotle University of Thessaloniki, 49 Konstantinoupoleos Str, Thessaloniki 54642, Greece.
| |
Collapse
|
3
|
Wen F, Zhang Y, Lin C, Deng M, Zhang J, Zhang J. Insulin therapy is not associated with improved clinical outcomes in critically ill infants with stress hyperglycemia. Exp Ther Med 2019; 18:397-403. [PMID: 31258678 DOI: 10.3892/etm.2019.7537] [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: 07/25/2018] [Accepted: 04/16/2019] [Indexed: 12/15/2022] Open
Abstract
The aim of the present study was to examine the benefits of insulin use and non-use in critically ill infants with stress-induced hyperglycemia. The present retrospective study used clinical data from 302 critically ill infants with stress hyperglycemia admitted to pediatric intensive care units (PICUs). The patients were recruited randomly and divided into three groups: The tight glycemic control, conventional insulin therapy and control groups. Correlations between insulin therapy and improved clinical outcomes were assessed according to key parameters (length of PICU stay, total length of stay, occurrence of organ dysfunction and mortality). Correlations between blood glucose level and these parameters in the three groups were also examined. Blood glucose levels following insulin therapy were not correlated with the length of PICU stay, total length of stay, mortality, secondary coma, or secondary hepatic or renal dysfunction in the three groups. At 96 h following PICU admission, blood glucose levels were statistically similar (5.0±1.2, 4.9±1.3 and 5.1±0.9 mmol/l, respectively; P>0.05). Insulin therapy was revealed to have no benefit on the length of hospitalization, the occurrence of organ dysfunction or mortality in critically ill pediatric patients with stress hyperglycemia. Even with no insulin use, the blood glucose level could spontaneously return to normal, with no associated risk of organ dysfunction or fatality.
Collapse
Affiliation(s)
- Fang Wen
- Pediatric Intensive Care Unit, The Shunde Women's and Children's Healthcare Hospital, Foshan, Guangdong 528300, P.R. China
| | - Yi Zhang
- Pediatric Intensive Care Unit, The Yuexiu District Children's Hospital of Guangzhou, Guangzhou, Guangdong 510462, P.R. China
| | - Chunwang Lin
- Pediatric Intensive Care Unit, The Shunde Women's and Children's Healthcare Hospital, Foshan, Guangdong 528300, P.R. China
| | - Minghong Deng
- Pediatric Intensive Care Unit, The Shunde Women's and Children's Healthcare Hospital, Foshan, Guangdong 528300, P.R. China
| | - Jinfeng Zhang
- Pediatric Intensive Care Unit, The Shunde Women's and Children's Healthcare Hospital, Foshan, Guangdong 528300, P.R. China
| | - Jianping Zhang
- Pediatric Intensive Care Unit, The Shunde Women's and Children's Healthcare Hospital, Foshan, Guangdong 528300, P.R. China
| |
Collapse
|
4
|
El-Sherbini SA, Marzouk H, El-Sayed R, Hosam-ElDin S. Etiology of hyperglycemia in critically ill children and the impact of organ dysfunction. Rev Bras Ter Intensiva 2018; 30:286-293. [PMID: 30328985 PMCID: PMC6180474 DOI: 10.5935/0103-507x.20180051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Accepted: 01/25/2018] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE This study aimed to study the incidence of stress hyperglycemia in critically ill children and to investigate the etiological basis of the hyperglycemia based on homeostasis model assessment. METHODS This was a prospective cohort study in one of the pediatric intensive care units of Cairo University, including 60 critically ill children and 21 healthy controls. Serum blood glucose, insulin, and C-peptide levels were measured within 24 hours of admission. Homeostasis model assessment was used to assess β-cell function and insulin sensitivity. RESULTS Hyperglycemia was estimated in 70% of patients. Blood glucose values ≥ 180mg/dL were associated with a poor outcome. Blood glucose levels were positively correlated with Pediatric Risk for Mortality (PRISM III) score and number of organ dysfunctions (p = 0.019 and p = 0.022, respectively), while insulin levels were negatively correlated with number of organ dysfunctions (r = -0.33, p = 0.01). Homeostasis model assessment revealed that 26 (43.3%) of the critically ill patients had low β-cell function, and 18 (30%) had low insulin sensitivity. Combined pathology was detected in 2 (3.3%) patients only. Low β-cell function was significantly associated with the presence of multi-organ dysfunction; respiratory, cardiovascular, and hematological dysfunctions; and the presence of sepsis. CONCLUSIONS β-Cell dysfunction appeared to be prevalent in our cohort and was associated with multi-organ dysfunction.
Collapse
Affiliation(s)
| | - Huda Marzouk
- Department of Pediatrics, Cairo University - Cairo, Egypt
| | - Riham El-Sayed
- Department of Clinical and Chemical Pathology, Cairo University - Cairo; Egypt
| | | |
Collapse
|
5
|
Fattorusso V, Nugnes R, Casertano A, Valerio G, Mozzillo E, Franzese A. Non-Diabetic Hyperglycemia in the Pediatric Age: Why, How, and When to Treat? Curr Diab Rep 2018; 18:140. [PMID: 30370431 DOI: 10.1007/s11892-018-1115-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Non-diabetic hyperglycemia (NDHY) is a pathological condition that is not yet well known. The aim of this review is to examine approaches for management of this condition. RECENT FINDINGS While it is well known that persistent hyperglycemia in diabetes affects immune response and risk for diabetes-related micro- and macrovascular complications, little is known about the biological effects of transient NDHY, particularly in the pediatric age group. Stress HY (SHY) is typically defined as blood glucose > 8.33 mmol/L (150 mg/dL) during physical stress, resolving spontaneously after dissipation of acute illness in patients without known diabetes. Based on the literature and clinical practice, two situations can be classified: (1) SHY1, which occurs during severe and prolonged illness and under serious life-threatening conditions, mainly in emergency situations and in resuscitation areas; and (2) SHY2, which occurs during acute illness, mainly in non-life-threatening conditions. Furthermore, (NDHY) among pediatric patients can be induced by drugs; the most frequent conditions are secondary to (1) steroid therapy and (2) antineoplastic/immunosuppressive therapy.
Collapse
Affiliation(s)
- Valentina Fattorusso
- Department of Translational Medical Science (DISMET), Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Rosa Nugnes
- Department of Translational Medical Science (DISMET), Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Alberto Casertano
- Department of Translational Medical Science (DISMET), Section of Pediatrics, University of Naples Federico II, Naples, Italy
| | - Giuliana Valerio
- Department of Movement Sciences and Wellbeing, Parthenope University, Naples, Italy
| | - Enza Mozzillo
- Department of Translational Medical Science (DISMET), Section of Pediatrics, University of Naples Federico II, Naples, Italy.
| | - Adriana Franzese
- Department of Translational Medical Science (DISMET), Section of Pediatrics, University of Naples Federico II, Naples, Italy
| |
Collapse
|
6
|
Srinivasan V. Nutrition Support and Tight Glucose Control in Critically Ill Children: Food for Thought! Front Pediatr 2018; 6:340. [PMID: 30460219 PMCID: PMC6232306 DOI: 10.3389/fped.2018.00340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 10/22/2018] [Indexed: 11/13/2022] Open
Abstract
Numerous studies have examined the strategy of tight glucose control (TGC) with intensive insulin therapy (IIT) to improve clinical outcomes in critically ill adults and children. Although early studies of TGC with IIT demonstrated improved outcomes at the cost of elevated hypoglycemia rates, subsequent studies in both adults and children have not demonstrated any benefit from such a strategy. Differences in patient populations, variable glycemic targets, and glucose control protocols, inconsistency in attaining these targets, heterogeneous intermittent sampling, and measurement techniques, and variable expertise in protocol implementation are possible reasons for the contrasting results from these studies. Notably, differences in modes of nutrition support may have also contributed to these disparate results. In particular, combined use of early parenteral nutrition (PN) and a strategy of TGC with IIT may be associated with improved outcomes, while combined use of enteral nutrition (EN) and a strategy of TGC with IIT may be associated with equivocal or worse outcomes. This article critically examines published clinical trials that have employed a strategy of TGC with IIT in critically ill children to highlight the role of EN vs. PN in influencing clinical outcomes including efficacy of TGC, and adverse effects such as occurrence of hypoglycemia and hospital acquired infections. The perspective afforded by this article should help practitioners consider the potential importance of mode of nutrition support in impacting key clinical outcomes if they should choose to employ a strategy of TGC with IIT in critically ill children with hyperglycemia.
Collapse
Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.,Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| |
Collapse
|
7
|
The Metabolic Response to Stress and Infection in Critically Ill Children: The Opportunity of an Individualized Approach. Nutrients 2017; 9:nu9091032. [PMID: 28926994 PMCID: PMC5622792 DOI: 10.3390/nu9091032] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Revised: 09/06/2017] [Accepted: 09/14/2017] [Indexed: 01/04/2023] Open
Abstract
The metabolic response to stress and infection is closely related to the corresponding requirements of energy and nutrients. On a general level, the response is driven by a complex endocrine network and related to the nature and severity of the insult. On an individual level, the effects of nutritional interventions are highly variable and a possible source of complications. This narrative review aims to discuss the metabolic changes in critically-ill children and the potential of developing personalized nutritional interventions. Through a literature search strategy, we have investigated the importance of blood glucose levels, the nutritional aspects of the different phases of acute stress response, and the reliability of the available tools to assess the energy expenditure. The dynamics of metabolism during stressful events reveal the difficult balance between risk of hypo- or hyperglycemia and under- or overfeeding. Within this context, individualized and accurate measurement of energy expenditure may help in defining the metabolic needs of patients. Given the variability of the metabolic response in critical conditions, randomized clinical studies in ill children are needed to evaluate the effect of individualized nutritional intervention on health outcomes.
Collapse
|
8
|
American College of Critical Care Medicine Clinical Practice Parameters for Hemodynamic Support of Pediatric and Neonatal Septic Shock. Crit Care Med 2017; 45:1061-1093. [PMID: 28509730 DOI: 10.1097/ccm.0000000000002425] [Citation(s) in RCA: 381] [Impact Index Per Article: 54.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES The American College of Critical Care Medicine provided 2002 and 2007 guidelines for hemodynamic support of newborn and pediatric septic shock. Provide the 2014 update of the 2007 American College of Critical Care Medicine "Clinical Guidelines for Hemodynamic Support of Neonates and Children with Septic Shock." DESIGN Society of Critical Care Medicine members were identified from general solicitation at Society of Critical Care Medicine Educational and Scientific Symposia (2006-2014). The PubMed/Medline/Embase literature (2006-14) was searched by the Society of Critical Care Medicine librarian using the keywords: sepsis, septicemia, septic shock, endotoxemia, persistent pulmonary hypertension, nitric oxide, extracorporeal membrane oxygenation, and American College of Critical Care Medicine guidelines in the newborn and pediatric age groups. MEASUREMENTS AND MAIN RESULTS The 2002 and 2007 guidelines were widely disseminated, translated into Spanish and Portuguese, and incorporated into Society of Critical Care Medicine and American Heart Association/Pediatric Advanced Life Support sanctioned recommendations. The review of new literature highlights two tertiary pediatric centers that implemented quality improvement initiatives to improve early septic shock recognition and first-hour compliance to these guidelines. Improved compliance reduced hospital mortality from 4% to 2%. Analysis of Global Sepsis Initiative data in resource rich developed and developing nations further showed improved hospital mortality with compliance to first-hour and stabilization guideline recommendations. CONCLUSIONS The major new recommendation in the 2014 update is consideration of institution-specific use of 1) a "recognition bundle" containing a trigger tool for rapid identification of patients with septic shock, 2) a "resuscitation and stabilization bundle" to help adherence to best practice principles, and 3) a "performance bundle" to identify and overcome perceived barriers to the pursuit of best practice principles.
Collapse
|
9
|
Shirzadeh L, Nasrfard S, Abdollahpour N, Khademi G, Sezavar M. Investigation of the Relation Between Hyperglycemia and Morbidity and Mortality Rates in Critically Ill Children in March 2013 to February 2014. RAZAVI INTERNATIONAL JOURNAL OF MEDICINE 2016. [DOI: 10.17795/rijm40340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
|
10
|
Predictive score for early diagnosis of acute encephalopathy with biphasic seizures and late reduced diffusion (AESD). J Neurol Sci 2015; 358:62-5. [DOI: 10.1016/j.jns.2015.08.016] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 08/03/2015] [Accepted: 08/11/2015] [Indexed: 11/20/2022]
|
11
|
Hyperglycemia at the Time of Acquiring Central Catheter-Associated Bloodstream Infections Is Associated With Mortality in Critically Ill Children. Pediatr Crit Care Med 2015; 16:621-8. [PMID: 25901541 DOI: 10.1097/pcc.0000000000000445] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Hyperglycemia is common and may be a risk factor for nosocomial infections, including central catheter-associated bloodstream infections in critically ill children. It is unknown whether hyperglycemia at the time of acquiring central catheter-associated bloodstream infections in pediatric critical illness is associated with worse outcomes. We hypothesized that hyperglycemia (blood glucose concentration > 126 mg/dL [> 7 mmol/L]) at the time of acquiring central catheter-associated bloodstream infections (from 4 d prior to the day of first positive blood culture, i.e., central catheter-associated bloodstream infections) in critically ill children is common and associated with ICU mortality. DESIGN Retrospective observational cohort study. SETTING Fifty-five-bed PICU and 26-bed cardiac ICU at an academic freestanding children's hospital. PATIENTS One hundred sixteen consecutively admitted critically ill children from January 1, 2008, to June 30, 2012, who were 0-21 years with central catheter-associated bloodstream infections were included. We excluded children with diabetes mellitus, metabolic disorders, and those with a "do not attempt resuscitation" order. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The study cohort had an overall ICU mortality of 23%, with 48% of subjects developing hyperglycemia at the time of acquiring central catheter-associated bloodstream infections. Compared with survivors, nonsurvivors experienced more hyperglycemia both at the time of acquiring central catheter-associated bloodstream infections and subsequently. Median blood glucose at the time of acquiring central catheter-associated bloodstream infections was higher in nonsurvivors compared with survivors (139.5 mg/dL [7.7 mmol/L] vs 111 mg/dL [6.2 mmol/L]; p < 0.001) with 70% of nonsurvivors experiencing blood glucose greater than 126 mg/dL (> 7 mmol/L) during the 7 days following central catheter-associated bloodstream infections (in comparison to 45% of survivors; p = 0.03). After controlling for severity of illness and interventions, hyperglycemia at the time of acquiring central catheter-associated bloodstream infections was independently associated with ICU mortality (adjusted odds ratio, 1.9; 95% CI, 1.1-6.4; p = 0.03), in addition to other risk factors for ICU mortality (vasopressor use and severity of organ dysfunction). CONCLUSIONS Hyperglycemia at the time of acquiring central catheter-associated bloodstream infections is common and associated with ICU mortality in critically ill children. Strategies to monitor and control blood glucose to avoid hyperglycemia may improve outcomes in critically ill children experiencing central catheter-associated bloodstream infections.
Collapse
|
12
|
Askegard-Giesmann JR, Kenney BD. Controversies in nutritional support for critically ill children. Semin Pediatr Surg 2015; 24:20-4. [PMID: 25639806 DOI: 10.1053/j.sempedsurg.2014.11.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nutritional support for critically ill infants and children is of paramount importance and can greatly affect the outcome of these patients. The energy requirement of children is unique to their size, gestational age, and physiologic stress, and the treatment algorithms developed in adult intensive care units cannot easily be applied to pediatric patients. This article reviews some of the ongoing controversial topics of fluid, electrolyte, and nutritional support for critically ill pediatric patients focusing on glycemic control and dysnatremia. The use of enteral and parenteral nutrition as well as parenteral nutritional-associated cholestasis will also be discussed.
Collapse
Affiliation(s)
- Johanna R Askegard-Giesmann
- Division of Pediatric Surgery, Riley Hospital for Children, Indiana University, 705 Riley Hospital Dr, Room 2500, Indianapolis, Indiana 46202.
| | - Brian D Kenney
- Division of Pediatric Surgery, The Ohio State University, Nationwide Children's Hospital, Columbus, Ohio
| |
Collapse
|
13
|
Srinivasan V, Agus MS. Tight glucose control in critically ill children--a systematic review and meta-analysis. Pediatr Diabetes 2014; 15:75-83. [PMID: 24783254 DOI: 10.1111/pedi.12134] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND It is unclear if tight glucose control (TGC) with intensive insulin therapy (IIT) can improve outcomes in critically ill children admitted to the intensive care unit (ICU). The objective of this systematic review and meta-analysis is to describe the benefits and risks of TGC with IIT in critically ill children and explore differences between published studies. METHODS Prospective randomized controlled trials (RCTs) of TGC with IIT in critically ill children admitted to the ICU were identified through a search of MEDLINE, PubMed, EMBASE, Scopus, ISI Web of Science and Cochrane Database of Systematic Reviews as well as detailed citation review of relevant primary and review articles. RCTs of TGC with IIT in critically ill adults and preterm neonates were excluded. Data on study design and setting, sample size, incidence of hypoglycemia, incidence of acquired infection, and 30-day mortality were abstracted. Meta-analytic techniques were used for analysis of outcomes including 30-day mortality, acquired infection, and incidence of hypoglycemia. RESULTS We identified four RCTs of TGC with IIT in critically ill children that included 3288 subjects. Overall, TGC with IIT did not result in a decrease in 30-day mortality [odds ratio (OR): 0.79; 95% confidence interval (CI): 0.55-1.15, p = 0.22]. TGC with IIT was associated with decrease in acquired infection (OR: 0.76; 95% CI: 0.59-0.99, p = 0.04). TGC with IIT was also associated with significant increase in hypoglycemia (OR: 6.14; 95% CI: 2.74-13.78, p < 0.001). CONCLUSIONS TGC with IIT does not result in decrease in 30-day mortality, but appears to reduce acquired infection in critically ill children. However, TGC with IIT is associated with higher incidence of hypoglycemia. Large multi-center studies of TGC with IIT using continuous glucose monitoring in critically ill children are needed to determine if this strategy can definitively improve clinical outcomes in this population without increasing hypoglycemia.
Collapse
Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - Michael S.D. Agus
- Division of Medicine Critical Care, Department of Medicine; Boston Children's Hospital and Harvard Medical School; Boston MA USA
| |
Collapse
|
14
|
Abstract
OBJECTIVES To determine the incidence and study association of hyperglycemia with outcome of critically ill children. SETTING AND DESIGN This was a prospective observational study conducted in eight bedded pediatric intensive care unit (PICU) of a tertiary care hospital. MATERIALS AND METHODS One hundred and one critically ill non-diabetic children between ages of 1 month to 16 years were studied from the day of admission till discharge or death. Serial blood sugars were determined first at admission, thereafter every 12 hourly in all children. Blood glucose level above 126 mg/dl (>7 mmol/dl) was considered as hyperglycemia. Children with hyperglycemia were followed 6 hourly till blood glucose fell below 126 mg/dl. Hyper and non-hyperglycemic children were compared with respect to length of stay, mechanical ventilation, use of inotrops and final outcome. Survivors and non-survivors were compared in relation to admission blood glucose, peak blood glucose level and duration of hyperglycemia. RESULTS Seventy (69.3%) children had hyperglycemia. Requirement of ventilation [(23) 32.9% vs.(3) 9.7%], requirement of inotropic support [(27) 38.6% vs.(5) 16.1%], Mean length of stay in PICU (7.91 ± 5.01 vs. 5.58 ± 1.95 days) and mortality (28.6% vs. 3.2%) among hyperglycemic children was significantly higher (P < 0.05) than that of non-hyperglycemic. Logistic regression analysis showed Peak blood glucose level and duration of hyperglycemia has independent association with increased risk of death. CONCLUSION Incidence of hyperglycemia is high in critically ill children and it is associated with high morbidity and mortality.
Collapse
Affiliation(s)
| | - Swati Balasaheb Chougule
- Department of Pediatrics, Bharati Vidyapeeth University Medical College, Sangli, Maharashtra, India
| |
Collapse
|
15
|
|
16
|
Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41:580-637. [PMID: 23353941 DOI: 10.1097/ccm.0b013e31827e83af] [Citation(s) in RCA: 3896] [Impact Index Per Article: 354.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Some recommendations were ungraded (UG). Recommendations were classified into three groups: 1) those directly targeting severe sepsis; 2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and 3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 hrs after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 hr of recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 hrs of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1C); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients) (1C); fluid challenge technique continued as long as hemodynamic improvement, as based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥ 65 mm Hg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO2/FIO2 ratio of ≤ 100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 hrs) for patients with early ARDS and a Pao2/Fio2 < 150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are > 180 mg/dL, targeting an upper blood glucose ≤ 180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 hrs after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 hrs of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5 to 10 mins (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Collapse
|
17
|
Dellinger RP, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 2013; 39:165-228. [PMID: 23361625 PMCID: PMC7095153 DOI: 10.1007/s00134-012-2769-8] [Citation(s) in RCA: 3079] [Impact Index Per Article: 279.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2012] [Accepted: 11/12/2012] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To provide an update to the "Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock," last published in 2008. DESIGN A consensus committee of 68 international experts representing 30 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict of interest policy was developed at the onset of the process and enforced throughout. The entire guidelines process was conducted independent of any industry funding. A stand-alone meeting was held for all subgroup heads, co- and vice-chairs, and selected individuals. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development. METHODS The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide assessment of quality of evidence from high (A) to very low (D) and to determine the strength of recommendations as strong (1) or weak (2). The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized. Recommendations were classified into three groups: (1) those directly targeting severe sepsis; (2) those targeting general care of the critically ill patient and considered high priority in severe sepsis; and (3) pediatric considerations. RESULTS Key recommendations and suggestions, listed by category, include: early quantitative resuscitation of the septic patient during the first 6 h after recognition (1C); blood cultures before antibiotic therapy (1C); imaging studies performed promptly to confirm a potential source of infection (UG); administration of broad-spectrum antimicrobials therapy within 1 h of the recognition of septic shock (1B) and severe sepsis without septic shock (1C) as the goal of therapy; reassessment of antimicrobial therapy daily for de-escalation, when appropriate (1B); infection source control with attention to the balance of risks and benefits of the chosen method within 12 h of diagnosis (1C); initial fluid resuscitation with crystalloid (1B) and consideration of the addition of albumin in patients who continue to require substantial amounts of crystalloid to maintain adequate mean arterial pressure (2C) and the avoidance of hetastarch formulations (1B); initial fluid challenge in patients with sepsis-induced tissue hypoperfusion and suspicion of hypovolemia to achieve a minimum of 30 mL/kg of crystalloids (more rapid administration and greater amounts of fluid may be needed in some patients (1C); fluid challenge technique continued as long as hemodynamic improvement is based on either dynamic or static variables (UG); norepinephrine as the first-choice vasopressor to maintain mean arterial pressure ≥65 mmHg (1B); epinephrine when an additional agent is needed to maintain adequate blood pressure (2B); vasopressin (0.03 U/min) can be added to norepinephrine to either raise mean arterial pressure to target or to decrease norepinephrine dose but should not be used as the initial vasopressor (UG); dopamine is not recommended except in highly selected circumstances (2C); dobutamine infusion administered or added to vasopressor in the presence of (a) myocardial dysfunction as suggested by elevated cardiac filling pressures and low cardiac output, or (b) ongoing signs of hypoperfusion despite achieving adequate intravascular volume and adequate mean arterial pressure (1C); avoiding use of intravenous hydrocortisone in adult septic shock patients if adequate fluid resuscitation and vasopressor therapy are able to restore hemodynamic stability (2C); hemoglobin target of 7-9 g/dL in the absence of tissue hypoperfusion, ischemic coronary artery disease, or acute hemorrhage (1B); low tidal volume (1A) and limitation of inspiratory plateau pressure (1B) for acute respiratory distress syndrome (ARDS); application of at least a minimal amount of positive end-expiratory pressure (PEEP) in ARDS (1B); higher rather than lower level of PEEP for patients with sepsis-induced moderate or severe ARDS (2C); recruitment maneuvers in sepsis patients with severe refractory hypoxemia due to ARDS (2C); prone positioning in sepsis-induced ARDS patients with a PaO (2)/FiO (2) ratio of ≤100 mm Hg in facilities that have experience with such practices (2C); head-of-bed elevation in mechanically ventilated patients unless contraindicated (1B); a conservative fluid strategy for patients with established ARDS who do not have evidence of tissue hypoperfusion (1C); protocols for weaning and sedation (1A); minimizing use of either intermittent bolus sedation or continuous infusion sedation targeting specific titration endpoints (1B); avoidance of neuromuscular blockers if possible in the septic patient without ARDS (1C); a short course of neuromuscular blocker (no longer than 48 h) for patients with early ARDS and a PaO (2)/FI O (2) <150 mm Hg (2C); a protocolized approach to blood glucose management commencing insulin dosing when two consecutive blood glucose levels are >180 mg/dL, targeting an upper blood glucose ≤180 mg/dL (1A); equivalency of continuous veno-venous hemofiltration or intermittent hemodialysis (2B); prophylaxis for deep vein thrombosis (1B); use of stress ulcer prophylaxis to prevent upper gastrointestinal bleeding in patients with bleeding risk factors (1B); oral or enteral (if necessary) feedings, as tolerated, rather than either complete fasting or provision of only intravenous glucose within the first 48 h after a diagnosis of severe sepsis/septic shock (2C); and addressing goals of care, including treatment plans and end-of-life planning (as appropriate) (1B), as early as feasible, but within 72 h of intensive care unit admission (2C). Recommendations specific to pediatric severe sepsis include: therapy with face mask oxygen, high flow nasal cannula oxygen, or nasopharyngeal continuous PEEP in the presence of respiratory distress and hypoxemia (2C), use of physical examination therapeutic endpoints such as capillary refill (2C); for septic shock associated with hypovolemia, the use of crystalloids or albumin to deliver a bolus of 20 mL/kg of crystalloids (or albumin equivalent) over 5-10 min (2C); more common use of inotropes and vasodilators for low cardiac output septic shock associated with elevated systemic vascular resistance (2C); and use of hydrocortisone only in children with suspected or proven "absolute"' adrenal insufficiency (2C). CONCLUSIONS Strong agreement existed among a large cohort of international experts regarding many level 1 recommendations for the best care of patients with severe sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for this important group of critically ill patients.
Collapse
|
18
|
Abstract
UNLABELLED NEED AND PURPOSE OF REVIEW: Hyperglycemia is prevalent among critically ill pediatric patients. Previously thought to be an adaptive response to stress, hyperglycemia is now recognized to be associated with an adverse outcome. Correction of such hyperglycemia with insulin infusion has been shown to improve outcome but carries risk of hypoglycemia. This review addresses these issues related to treatment of hyperglycemia. METHODS A Pubmed search was performed using the search strategy: (hyperglycemia OR blood glucose OR insulin therapy) AND (critical illness OR critical care OR intensive care unit). Randomized controlled trials, clinical trials, meta-analysis and observational studies (adult and pediatric) published in the last 10 years were included. CONCLUSION Blood sugar monitoring and correction of hyperglycemia while caring for critically ill children is crucial. A modest blood glucose target of <150 mg/dL is appropriate. Providing adequate nutrition along with training of the nursing personnel would prevent any adverse effect such as hypoglycemia.
Collapse
|
19
|
Wintergerst KA, Foster MB, Sullivan JE, Woods CR. Association of hyperglycemia, glucocorticoids, and insulin use with morbidity and mortality in the pediatric intensive care unit. J Diabetes Sci Technol 2012; 6:5-14. [PMID: 22401317 PMCID: PMC3320816 DOI: 10.1177/193229681200600102] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Studies of pediatric intensive care unit (PICU) patients have shown a significant association of morbidity and mortality with hyperglycemia. We retrospectively evaluated the degree of hyperglycemia as well as its correlation with glucocorticoid and insulin use and assessed its association with hospital length of stay (LOS) and mortality. This study preceded the initiation of a standard glycemic control protocol. METHODS We examined medical records at Kosair Children's Hospital for all PICU admissions from 2008 of patients without diabetes mellitus. Critical illness hyperglycemia (CIH) was defined by having three or more peak glucose values greater than thresholds of 110, 140, 180, and 200 mg/dl. These patients were evaluated for glucocorticoid, insulin use, and outcome measures. RESULTS We evaluated the eligible 1173 admissions, where 10.5% of these patients reached the highest threshold (200 mg/dl) of CIH. Glucocorticoids were used in 43% of these patients, with dexamethasone being the most common (58%). There was a significant correlation between glucocorticoids and higher peak glucose values, where 81% of the patients who were above the 200 mg/dl cutoff level were treated with glucocorticoids. Only 36.8% in that group were also treated with insulin. Patients at the 200 mg/dl cutoff had the highest median PICU and total hospital length of stays (4 and 10 days, respectfully). Mortality was associated with increasing glucose levels, reaching 18.7% among patients above the 200 mg/dl cutoff. CONCLUSION Hyperglycemia was prevalent in the PICU and was associated with increased morbidity, as characterized by increased LOS and increased mortality. Glucocorticoid use was prevalent among patients exhibiting hyperglycemia. Insulin use was uncommon.
Collapse
Affiliation(s)
- Kupper A Wintergerst
- Department of Pediatrics, Division of Endocrinology, University of Louisville School of Medicine, Louisville, Kentucky 40202, USA.
| | | | | | | |
Collapse
|
20
|
Abstract
Stress hyperglycemia (SH) commonly occurs during critical illness in children. The historical view that SH is beneficial has been questioned in light of evidence that demonstrates the association of SH with worse outcomes. In addition to intrinsic changes in glucose metabolism and development of insulin resistance, specific intensive care unit (ICU) practices may influence the development of SH during critical illness. Mechanical ventilation, vasoactive infusions, renal replacement therapies, cardiopulmonary bypass and extracorporeal life support, therapeutic hypothermia, prolonged immobility, nutrition support practices, and the use of medications are all known to mediate development of SH in critical illness. Tight glucose control (TGC) to manage SH has emerged as a promising therapy to improve outcomes in critically ill adults, but results have been inconclusive. Large variations in ICU practices across studies likely resulted in inconsistent results. Future studies of TGC need to take into account the impact of commonly used ICU practices and, ideally, standardize protocols in an attempt to improve the accuracy of conclusions from such studies.
Collapse
Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
| |
Collapse
|
21
|
Mormile R, De Michele M. Meningococcal septic shock: is insulin lifesaving in children? Int J Infect Dis 2011; 15:e504. [DOI: 10.1016/j.ijid.2011.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 03/14/2011] [Accepted: 03/21/2011] [Indexed: 10/18/2022] Open
|
22
|
|
23
|
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.
Collapse
|
24
|
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.
Collapse
Affiliation(s)
- David M Tridgell
- Division of Metabolism, Endocrinology and Nutrition, University of Washington, 1959 NE Pacific Street, Box 356426, Seattle, WA 98195, USA.
| | | | | |
Collapse
|
25
|
[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]
|
26
|
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]
|
27
|
van den Heuvel I, Vlasselaers D. Clinical benefits of tight glycaemic control: focus on the paediatric patient. Best Pract Res Clin Anaesthesiol 2010; 23:441-8. [PMID: 20108583 DOI: 10.1016/j.bpa.2009.08.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Hyperglycaemia and glucose variability occur frequently during critical illness or after major surgery in children and are associated with worse outcome. Association does not necessarily imply causality however, and the question whether tight glycaemic control (TGC) with insulin infusion improves morbidity and mortality can only be answered by randomised controlled trials (RCTs). Currently, only one single-centre RCT exists, proving the concept of TGC in critically ill children. Attenuation of inflammation and reduction of secondary infections, decreased prolonged stay in intensive care and reduced dependency on haemodynamic support were accomplished, despite a substantial increased incidence of biochemical hypoglycaemia. Before universal implementation in paediatric intensive care both long-term effects on outcome and development and issues regarding optimal levels of blood glucose control need to be cleared in multicentre prospective RCTs. Technological improvement might be helpful in optimising blood glucose control.
Collapse
Affiliation(s)
- Ingeborg van den Heuvel
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Muenster, Albert-Schweitzer-Strasse 33, 48149, Muenster, Germany.
| | | |
Collapse
|
28
|
Hirasawa H, Oda S, Nakamura M. Blood glucose control in patients with severe sepsis and septic shock. World J Gastroenterol 2009; 15:4132-6. [PMID: 19725146 PMCID: PMC2738808 DOI: 10.3748/wjg.15.4132] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The main pathophysiological feature of sepsis is the uncontrollable activation of both pro- and anti-inflammatory responses arising from the overwhelming production of mediators such as pro- and anti-inflammatory cytokines. Such an uncontrollable inflammatory response would cause many kinds of metabolic derangements. One such metabolic derangement is hyperglycemia. Accordingly, control of hyperglycemia in sepsis is considered to be a very effective therapeutic approach. However, despite the initial enthusiasm, recent studies reported that tight glycemic control with intensive insulin therapy failed to show a beneficial effect on mortality of patients with severe sepsis and septic shock. One of the main reasons for this disappointing result is the incidence of harmful hypoglycemia during intensive insulin therapy. Therefore, avoidance of hypoglycemia during intensive insulin therapy may be a key issue in effective tight glycemic control. It is generally accepted that glycemic control aimed at a blood glucose level of 80-100 mg/dL, as initially proposed by van den Berghe, seems to be too tight and that such a level of tight glycemic control puts septic patients at increased risk of hypoglycemia. Therefore, now many researchers suggest less strict glycemic control with a target blood glucose level of 140-180 mg/dL. Also specific targeting of glycemic control in diabetic patients should be considered. Since there is a significant correlation between success rate of glycemic control and the degree of hypercytokinemia in septic patients, some countermeasures to hypercytokinemia may be an important aspect of successful glycemic control. Thus, in future, use of an artificial pancreas to avoid hypoglycemia during insulin therapy, special consideration of septic diabetic patients, and control of hypercytokinemia should be considered for more effective glycemic control in patients with severe sepsis and septic shock.
Collapse
|
29
|
Abstract
PURPOSE OF REVIEW Paediatric sepsis continues to be a disease with unacceptably high morbidity and mortality, despite huge advances in paediatric intensive care organization and technology. This review examines the epidemiology, pathophysiology and advances in the treatment of paediatric sepsis. RECENT FINDINGS Many studies initially reporting encouraging or positive results on adult patients with sepsis have subsequently been disproved either in further studies on adults or in proof-of-principle studies on children. Publication of treatment guidelines for paediatric sepsis has led to better organization and implementation of care; however, this has yet to translate into demonstrable improvement in outcome. We will examine the major therapeutic advances of recent years and put them into the context of paediatric sepsis, examining why they often have not translated into survival benefit. SUMMARY This review aims to evaluate the recent therapeutic advances and potential for further developments in the management of paediatric sepsis in the ICU.
Collapse
|
30
|
Mandt MJ, Rappaport LD. Update in pediatric resuscitation. Adv Pediatr 2009; 56:359-85. [PMID: 19968956 DOI: 10.1016/j.yapd.2009.08.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Maria J Mandt
- University of Colorado School of Medicine, The Children's Hospital, Aurora, CO, USA
| | | |
Collapse
|