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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024: Executive Summary. Crit Care Med 2024; 52:649-655. [PMID: 38240482 DOI: 10.1097/ccm.0000000000006173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Honarmand K, Sirimaturos M, Hirshberg EL, Bircher NG, Agus MSD, Carpenter DL, Downs CR, Farrington EA, Freire AX, Grow A, Irving SY, Krinsley JS, Lanspa MJ, Long MT, Nagpal D, Preiser JC, Srinivasan V, Umpierrez GE, Jacobi J. Society of Critical Care Medicine Guidelines on Glycemic Control for Critically Ill Children and Adults 2024. Crit Care Med 2024; 52:e161-e181. [PMID: 38240484 DOI: 10.1097/ccm.0000000000006174] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
RATIONALE Maintaining glycemic control of critically ill patients may impact outcomes such as survival, infection, and neuromuscular recovery, but there is equipoise on the target blood levels, monitoring frequency, and methods. OBJECTIVES The purpose was to update the 2012 Society of Critical Care Medicine and American College of Critical Care Medicine (ACCM) guidelines with a new systematic review of the literature and provide actionable guidance for clinicians. PANEL DESIGN The total multiprofessional task force of 22, consisting of clinicians and patient/family advocates, and a methodologist applied the processes described in the ACCM guidelines standard operating procedure manual to develop evidence-based recommendations in alignment with the Grading of Recommendations Assessment, Development, and Evaluation Approach (GRADE) methodology. Conflict of interest policies were strictly followed in all phases of the guidelines, including panel selection and voting. METHODS We conducted a systematic review for each Population, Intervention, Comparator, and Outcomes question related to glycemic management in critically ill children (≥ 42 wk old adjusted gestational age to 18 yr old) and adults, including triggers for initiation of insulin therapy, route of administration, monitoring frequency, role of an explicit decision support tool for protocol maintenance, and methodology for glucose testing. We identified the best available evidence, statistically summarized the evidence, and then assessed the quality of evidence using the GRADE approach. We used the evidence-to-decision framework to formulate recommendations as strong or weak or as a good practice statement. In addition, "In our practice" statements were included when the available evidence was insufficient to support a recommendation, but the panel felt that describing their practice patterns may be appropriate. Additional topics were identified for future research. RESULTS This guideline is an update of the guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. It is intended for adult and pediatric practitioners to reassess current practices and direct research into areas with inadequate literature. The panel issued seven statements related to glycemic control in unselected adults (two good practice statements, four conditional recommendations, one research statement) and seven statements for pediatric patients (two good practice statements, one strong recommendation, one conditional recommendation, two "In our practice" statements, and one research statement), with additional detail on specific subset populations where available. CONCLUSIONS The guidelines panel achieved consensus for adults and children regarding a preference for an insulin infusion for the acute management of hyperglycemia with titration guided by an explicit clinical decision support tool and frequent (≤ 1 hr) monitoring intervals during glycemic instability to minimize hypoglycemia and against targeting intensive glucose levels. These recommendations are intended for consideration within the framework of the patient's existing clinical status. Further research is required to evaluate the role of individualized glycemic targets, continuous glucose monitoring systems, explicit decision support tools, and standardized glycemic control metrics.
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Mackenzie Health, Vaughan, ON, Canada
- GUIDE Canada, McMaster University, Hamilton, ON, Canada
| | - Michael Sirimaturos
- System Critical Care Pharmacy Services Leader, Houston Methodist Hospital, Houston, TX
| | - Eliotte L Hirshberg
- Adult and Pediatric Critical Care Specialist, University of Utah School of Medicine, Salt Lake City, UT
| | - Nicholas G Bircher
- Department of Nurse Anesthesia, School of Nursing, University of Pittsburgh, Pittsburgh, PA
| | - Michael S D Agus
- Harvard Medical School and Division Chief, Medical Critical Care, Boston Children's Hospital, Boston, MA
| | | | | | | | - Amado X Freire
- Pulmonary Critical Care and Sleep Medicine at the University of Tennessee Health Science Center, Memphis, TN
| | | | - Sharon Y Irving
- Department of Nursing and Clinical Care Services-Critical Care, University of Pennsylvania School of Nursing, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James S Krinsley
- Director of Critical Care, Emeritus, Vagelos Columbia University College of Physicians and Surgeons, Stamford Hospital, Stamford, CT
| | - Michael J Lanspa
- Division of Critical Care, Intermountain Medical Center, Salt Lake City, UT
| | - Micah T Long
- Department of Anesthesiology, Division of Critical Care, University of Wisconsin School of Medicine & Public Health, Madison, WI
| | - David Nagpal
- Division of Cardiac Surgery, Critical Care Western, London Health Sciences Centre, London, ON, Canada
| | - Jean-Charles Preiser
- Medical Director for Research and Teaching, Erasme Hospital, Hôpital Universitaire de Bruxelles, Brussels, Belgium
| | - Vijay Srinivasan
- Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
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Kapellen T, Agwu JC, Martin L, Kumar S, Rachmiel M, Cody D, Nirmala SVSG, Marcovecchio ML. ISPAD clinical practice consensus guidelines 2022: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2022; 23:1468-1477. [PMID: 36537521 DOI: 10.1111/pedi.13446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Affiliation(s)
- Thomas Kapellen
- Department for Women and Child Health, Hospital for Children and Adolescents, Liebigstrasse 20 Leipzig; Children's Hospital Am Nicolausholz, Bad Kösen, University of Leipzig, Leipzig, Germany
| | - Juliana Chizo Agwu
- Department of Paediatrics, Sandwell and West Birmingham, NHS Trust, Birmingham, UK
| | - Lizabeth Martin
- University of Washington Department of Anesthesiology, Division of Pediatric Anesthesia, Seattle Children's Hospital, Seattle, Washington, USA
| | - Seema Kumar
- Division of Pediatric Endocrinology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Marianna Rachmiel
- Pediatric Endocrinology and Diabetes Institute, Shamir (Assaf Haroffeh) Medical Center, Zerifin, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Declan Cody
- Children's Hospital Ireland Crumlin Dublin, University College Dublin, Dublin, Ireland
| | - Sunkara V S G Nirmala
- Department of Pediatric and Preventive Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India
| | - M Loredana Marcovecchio
- Department of Paediatrics, University of Cambridge and Cambridge University Hospitals, NHS Foundation Trust, Cambridge, UK
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Sadhwani A, Asaro LA, Goldberg CS, Ware J, Butcher J, Gaies M, Smith C, Alexander JL, Wypij D, Agus MSD. Impact of tight glycemic control and hypoglycemia after pediatric cardiac surgery on neurodevelopmental outcomes at three years of age: Findings from a randomized clinical trial. BMC Pediatr 2022; 22:531. [PMID: 36071424 PMCID: PMC9450419 DOI: 10.1186/s12887-022-03556-z] [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: 03/21/2022] [Accepted: 08/12/2022] [Indexed: 11/30/2022] Open
Abstract
Background Studies examining the impact of randomization As per standard instruction, city is required for affiliations; however, this information is missing in affiliation 6. Please check if the provided city is correct and amend if necessary. to tight glycemic control (TGC) and resultant hypoglycemia on later neurodevelopmental outcomes have produced mixed results. Our study examined this association in children undergoing cardiac surgery. Methods Participants who were enrolled in the Safe Pediatric Euglycemia after Cardiac Surgery (SPECS) trial returned for neurodevelopmental (ND) follow-up between 30 to 42.5 months of age. ND outcomes were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition. ND scores were compared between the TGC and standard care treatment groups and between patients with moderate to severe and no to mild hypoglycemia. As a secondary analysis, to increase sample size and power, we combined the three-year-old assessments with previously collected assessments done at < 30 months of age to further examine differences between groups longitudinally. Results Among the 269 participants who completed neurodevelopmental evaluation (in-person testing or questionnaires) at three years of age (follow-up rate, 31%), there were no statistically significant differences in ND outcomes according to treatment group or hypoglycemia status. In the combined analysis of all evaluations (from 9 to 42.5 months of age), we found no treatment group differences. However, in these longitudinal analyses, children who experienced moderate to severe hypoglycemia had lower scores on the Bayley-III cognitive and motor domains compared to children with no to mild hypoglycemia. Conclusions For infants undergoing cardiac surgery, there was no impact of tight glycemic control on neurodevelopmental outcomes. Moderate to severe hypoglycemia was associated with worse ND outcomes in longitudinal analyses. Trial registration ClinicalTrials.gov NCT00443599. Registered: November 2016.
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Affiliation(s)
- Anjali Sadhwani
- Departments of Psychiatry and Behavioral Sciences, Boston Children's Hospital and Harvard Medical School, 300 Longwood Ave, Boston, MA, 02115, USA.
| | - Lisa A Asaro
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Caren S Goldberg
- Division of Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA.,Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Janice Ware
- Department of Medicine, Boston Children's Hospital and Harvard Medical School, Boston, USA
| | - Jennifer Butcher
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA.,Division of Pediatric Psychology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI, USA
| | - Michael Gaies
- Division of Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA.,Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Cynthia Smith
- Division of Cardiology, C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Jamin L Alexander
- Division of Medical Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA.,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
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Meoli A, Ciavola L, Rahman S, Masetti M, Toschetti T, Morini R, Dal Canto G, Auriti C, Caminiti C, Castagnola E, Conti G, Donà D, Galli L, La Grutta S, Lancella L, Lima M, Lo Vecchio A, Pelizzo G, Petrosillo N, Simonini A, Venturini E, Caramelli F, Gargiulo GD, Sesenna E, Sgarzani R, Vicini C, Zucchelli M, Mosca F, Staiano A, Principi N, Esposito S. Prevention of Surgical Site Infections in Neonates and Children: Non-Pharmacological Measures of Prevention. Antibiotics (Basel) 2022; 11:antibiotics11070863. [PMID: 35884117 PMCID: PMC9311619 DOI: 10.3390/antibiotics11070863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 06/19/2022] [Accepted: 06/23/2022] [Indexed: 12/04/2022] Open
Abstract
A surgical site infection (SSI) is an infection that occurs in the incision created by an invasive surgical procedure. Although most infections are treatable with antibiotics, SSIs remain a significant cause of morbidity and mortality after surgery and have a significant economic impact on health systems. Preventive measures are essential to decrease the incidence of SSIs and antibiotic abuse, but data in the literature regarding risk factors for SSIs in the pediatric age group are scarce, and current guidelines for the prevention of the risk of developing SSIs are mainly focused on the adult population. This document describes the current knowledge on risk factors for SSIs in neonates and children undergoing surgery and has the purpose of providing guidance to health care professionals for the prevention of SSIs in this population. Our aim is to consider the possible non-pharmacological measures that can be adopted to prevent SSIs. To our knowledge, this is the first study to provide recommendations based on a careful review of the available scientific evidence for the non-pharmacological prevention of SSIs in neonates and children. The specific scenarios developed are intended to guide the healthcare professional in practice to ensure standardized management of the neonatal and pediatric patients, decrease the incidence of SSIs and reduce antibiotic abuse.
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Affiliation(s)
- Aniello Meoli
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Lorenzo Ciavola
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Sofia Rahman
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Marco Masetti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Tommaso Toschetti
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Riccardo Morini
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Giulia Dal Canto
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
| | - Cinzia Auriti
- Neonatology and Neonatal Intensive Care Unit, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Caterina Caminiti
- Research and Innovation Unit, University Hospital of Parma, 43126 Parma, Italy;
| | - Elio Castagnola
- Infectious Diseases Unit, IRCCS Giannina Gaslini, 16147 Genoa, Italy;
| | - Giorgio Conti
- Pediatric ICU and Trauma Center, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00165 Rome, Italy;
| | - Daniele Donà
- Division of Paediatric Infectious Diseases, Department for Woman and Child Health, University of Padua, 35100 Padua, Italy;
| | - Luisa Galli
- Infectious Disease Unit, Meyer Children’s Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Stefania La Grutta
- Institute of Translational Pharmacology IFT, National Research Council, 90146 Palermo, Italy;
| | - Laura Lancella
- Paediatric Infectious Disease Unit, Academic Department of Pediatrics, IRCCS Bambino Gesù Children’s Hospital, 00165 Rome, Italy;
| | - Mario Lima
- Pediatric Surgery, IRCCS Azienda Ospedaliera-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy; (A.L.V.); (A.S.)
| | - Gloria Pelizzo
- Pediatric Surgery Department, “Vittore Buzzi” Children’s Hospital, 20154 Milano, Italy;
| | - Nicola Petrosillo
- Infection Prevention and Control—Infectious Disease Service, Foundation University Hospital Campus Bio-Medico, 00128 Rome, Italy;
| | - Alessandro Simonini
- Pediatric Anesthesia and Intensive Care Unit, Salesi Children’s Hospital, 60123 Ancona, Italy;
| | - Elisabetta Venturini
- Infectious Disease Unit, Meyer Children’s Hospital, 50139 Florence, Italy; (L.G.); (E.V.)
| | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Gaetano Domenico Gargiulo
- Department of Cardio-Thoracic and Vascular Medicine, Adult Cardiac Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy;
| | - Enrico Sesenna
- Maxillo-Facial Surgery Unit, Head and Neck Department, University Hospital of Parma, 43126 Parma, Italy;
| | - Rossella Sgarzani
- Servizio di Chirurgia Plastica, Centro Grandi Ustionati, Ospedale M. Bufalini, AUSL Romagna, 47521 Cesena, Italy;
| | - Claudio Vicini
- Head-Neck and Oral Surgery Unit, Department of Head-Neck Surgery, Otolaryngology, Morgagni Piertoni Hospital, 47121 Forli, Italy;
| | - Mino Zucchelli
- Pediatric Neurosurgery, IRCCS Istituto delle Scienze Neurologiche di Bologna, 40138 Bologna, Italy;
| | - Fabio Mosca
- Neonatal Intensive Care Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Department of Mother, Child and Infant, 20122 Milan, Italy;
| | - Annamaria Staiano
- Department of Translational Medical Science, Section of Pediatrics, University of Naples “Federico II”, 80138 Naples, Italy; (A.L.V.); (A.S.)
| | | | - Susanna Esposito
- Pediatric Clinic, University Hospital, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy; (A.M.); (L.C.); (S.R.); (M.M.); (T.T.); (R.M.); (G.D.C.)
- Correspondence: ; Tel.: +39-0521-903524
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Naghipour B, Bagerpour M, Shadvar K, Golzari SE, Faridaalaee G. Effect of hyperglycemia treatment on complications rate after pediatric cardiac surgery. J Cardiovasc Thorac Res 2022; 14:18-22. [PMID: 35620747 PMCID: PMC9106938 DOI: 10.34172/jcvtr.2022.05] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 02/25/2022] [Indexed: 11/09/2022] Open
Abstract
Introduction: The goal of this study was to elucidate harmful complications of intraoperative hyperglycemia following children cardiac surgery and benefits of insulin administration for accurate blood sugar controlling.
Methods: this study is a Randomized clinical trial. We conducted this study in the operating room of shahid madani hospital. Fifty patients who were children under 12 years old undergone cardiac surgery using cardiopulmonary bypass (CPB). Intraoperative insulin infusion was administered intravenously targeting blood sugar levels of 110-140 mg/dL. Blood sugar and arterial blood gas (ABG) were measured every 30 min during operation.
Results: Inotropes were used less in the study than the placebo group during surgery. The means of hospitalization and extubation time were more in the placebo group than the study group(P =0.03) and (P =0.005), respectively. However, the mean time of hospitalization in the ICU ward did not differ significantly between the two groups.
Conclusion: Hyperglycemia has a relation with long time of intubation and hospitalization in ICU. These findings suggest the positive effect of accurate blood sugar control on reducing complication and hospitalization time in children undergoing cardiac surgery.
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Affiliation(s)
- Bahman Naghipour
- Department of Anesthesiology and Intensive Care, Medical Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Mahdieh Bagerpour
- Department of Gynecology and obestetric, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kamran Shadvar
- Department of Anesthesiology and Intensive Care, Medical Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Samad E.J. Golzari
- Department of Anesthesiology and Intensive Care, Medical Faculty, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Gholamreza Faridaalaee
- Emergency Medicine Research Team, Faculty of Medicine, Tabriz University of Medical Sciences, Tabriz, Iran
- Department of Emergency Medicine, Maragheh University of Medical Sciences, Maragheh, Iran
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Kobayashi K, Liu C, Jonas RA, Ishibashi N. The Current Status of Neuroprotection in Congenital Heart Disease. CHILDREN 2021; 8:children8121116. [PMID: 34943311 PMCID: PMC8700367 DOI: 10.3390/children8121116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 11/26/2021] [Accepted: 11/29/2021] [Indexed: 11/16/2022]
Abstract
Neurological deficits are a serious and common sequelae of congenital heart disease (CHD). While their underlying mechanisms have not been fully characterized, their manifestations are well-known and understood to persist through adulthood. Development of therapies to address or prevent these deficits are critical to attenuate future morbidity and improve quality of life. In this review, we aim to summarize the current status of neuroprotective therapy in CHD. Through an exploration of present research in the pre-operative, intra-operative, and post-operative phases of patient management, we will describe existing clinical and bench efforts as well as current endeavors underway within this research area.
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Affiliation(s)
- Kei Kobayashi
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
| | - Christopher Liu
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- School of Medicine, Virginia Commonwealth University, Richmond, VA 23298, USA
| | - Richard A. Jonas
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
- School of Medicine and Health Science, George Washington University, Washington, DC 20052, USA
| | - Nobuyuki Ishibashi
- Center for Neuroscience Research, Sheikh Zayed Institute for Pediatric Surgical Innovation, Children’s National Hospital, Washington, DC 20010, USA; (K.K.); (C.L.); (R.A.J.)
- Children’s National Heart Institute, Children’s National Hospital, Washington, DC 20010, USA
- School of Medicine and Health Science, George Washington University, Washington, DC 20052, USA
- Correspondence:
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de Andrade GV, de Souza NMG, Rocha ACF, Ribeiro SB, da Silva VM, Oliveira LAF. Surgical site infection prevention bundle for children submitted to cardiac surgery. Rev Esc Enferm USP 2021; 55:e20200470. [PMID: 34435612 DOI: 10.1590/1980-220x-reeusp-2020-0470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 04/22/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To build and validate the content and appearance of a surgical site infection prevention bundle for children submitted to cardiac surgery. METHOD Methodological study in two phases: 1) Bundle construction from an integrative literature review from which interventions have been extracted to compose the instrument; 2) Bundle content and appearance validation by 24 judges. RESULTS The 24 found articles presented 17 interventions for surgical site infection prevention in this population. Out of them, seven intervention proposals have been chosen to compose the bundle and sent for assessment by judges. The final proposal includes all the seven items chosen in the construction phase and has achieved a content validity index over 0.8 in all items referring to content and appearance. CONCLUSION The content and appearance of the developed bundle proposes care for the prevention of surgical site infection throughout the perioperative period.
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Abstract
BACKGROUND Targeted drug development efforts in patients with CHD are needed to standardise care, improve outcomes, and limit adverse events in the post-operative period. To identify major gaps in knowledge that can be addressed by drug development efforts and provide a rationale for current clinical practice, this review evaluates the evidence behind the most common medication classes used in the post-operative care of children with CHD undergoing cardiac surgery with cardiopulmonary bypass. METHODS We systematically searched PubMed and EMBASE from 2000 to 2019 using a controlled vocabulary and keywords related to diuretics, vasoactives, sedatives, analgesics, pulmonary vasodilators, coagulation system medications, antiarrhythmics, steroids, and other endocrine drugs. We included studies of drugs given post-operatively to children with CHD undergoing repair or palliation with cardiopulmonary bypass. RESULTS We identified a total of 127 studies with 51,573 total children across medication classes. Most studies were retrospective cohorts at single centres. There is significant age- and disease-related variability in drug disposition, efficacy, and safety. CONCLUSION In this study, we discovered major gaps in knowledge for each medication class and identified areas for future research. Advances in data collection through electronic health records, novel trial methods, and collaboration can aid drug development efforts in standardising care, improving outcomes, and limiting adverse events in the post-operative period.
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Das D, Dutta N, Roy Chowdhuri K. Total circulatory arrest as a support modality in congenital heart surgery: review and current evidence. Indian J Thorac Cardiovasc Surg 2021; 37:165-173. [PMID: 33584032 PMCID: PMC7859125 DOI: 10.1007/s12055-020-00930-3] [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: 11/29/2019] [Revised: 01/21/2020] [Accepted: 01/27/2020] [Indexed: 11/24/2022] Open
Abstract
The use of total circulatory arrest (TCA)/deep hypothermic circulatory arrest (DHCA) as a support modality in congenital heart surgery is a time-tested strategy. However, with technological advances, the widespread use of this technique has decreased. Adjunctive cerebral perfusion with continuous cardiopulmonary bypass (CPB) gradually has become more popular with a view to reduce the complications related to DHCA. In addition, better neuromonitoring and neuroprotective strategies have made DHCA much safer. However, the level of evidence to support the best way to protect the brain during congenital heart surgery is insufficient. This review analyzes the history, physiology, techniques of DHCA, as well as other alternative strategies like selective cerebral perfusion and presents the current available evidence.
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Affiliation(s)
- Debasis Das
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103 India
| | - Nilanjan Dutta
- Department of Cardiac Surgery, Narayana Superspeciality Hospital, 120/1 Andul Road, Howrah, 711103 India
| | - Kuntal Roy Chowdhuri
- Department of Cardiac Surgery, BM Birla Heart Research Centre, 1, National Library Avenue, Alipore, Kolkata, 700027 India
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11
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Sopfe J, Campbell K, Keating AK, Pyle L, Liu AK, Verneris MR, Giller RH, Forlenza GP. Glycemic variability is associated with poor outcomes in pediatric hematopoietic stem cell transplant patients. Pediatr Blood Cancer 2020; 67:e28626. [PMID: 33480469 DOI: 10.1002/pbc.28626] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 06/23/2020] [Accepted: 07/15/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Among pediatric hematopoietic stem cell transplant (HSCT) recipients, abnormal glycemic control is shown to be associated with increased risk of transplant-related mortality, death from any cause, risk of infection, increased hospitalized, and intensive care days. Independent effects of higher glycemic variability, a component of glycemic control, have not been described. This study aimed to characterize risk factors for, and consequences of, higher glycemic variability in HSCT patients. PROCEDURE Medical records for a cohort of 344 patients, age 0-30 years, who underwent first HSCT from 2007 to 2016 at Children's Hospital Colorado were retrospectively reviewed. Glucose coefficients of variation (CV) were analyzed for HSCT days -14 to 0 and 0-30, and patients were assessed for potential risk factors and outcomes. RESULTS Roughly one-third of patients had pre-HSCT and day 0-30 glucose CV above the reported healthy adult range. Independent of HSCT type, doubling of pre-HSCT glucose CV was associated with a 4.91-fold (95% confidence interval [CI], 1.40-17.24) increased hazard of infection, as well as increased risk for intensive care hospitalization for allogenic HSCT patients. Multivariable analysis demonstrated that allogeneic HSCT patients had a 1.40- and 1.38-fold (95% CI, 0.98-1.99 and 1.00-1.91) increased hazard of death for every doubling of pre-HSCT and day 0-30 glucose CV, respectively. CONCLUSIONS Just as with higher mean glucose, higher glycemic variability in the pediatric HSCT population is independently associated with significantly increased morbidity. Additional research is required to evaluate the utility of glucose control to mitigate these relationships and improve HSCT outcomes.
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Affiliation(s)
- Jenna Sopfe
- Bone Marrow Transplant Program, Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado School of Medicine, Colorado
| | - Kristen Campbell
- Department of Pediatrics, University of Colorado School of Medicine, Colorado
| | - Amy K Keating
- Bone Marrow Transplant Program, Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado School of Medicine, Colorado
| | - Laura Pyle
- Department of Pediatrics, University of Colorado School of Medicine, Colorado.,Department of Biostatistics and Informatics, University of Colorado, Colorado
| | - Arthur K Liu
- Department of Radiation Oncology, University of Colorado School of Medicine, Colorado
| | - Michael R Verneris
- Bone Marrow Transplant Program, Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado School of Medicine, Colorado
| | - Roger H Giller
- Bone Marrow Transplant Program, Center for Cancer and Blood Disorders, Department of Pediatrics, University of Colorado School of Medicine, Colorado
| | - Gregory P Forlenza
- Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Colorado
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12
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Bischoff AR, Grass B, Fan CPS, Tomlinson C, Lee KS. Risk factors for postoperative hyperglycemia in neonates. J Neonatal Perinatal Med 2020; 14:183-191. [PMID: 32925115 DOI: 10.3233/npm-200535] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Postoperative hyperglycemia has been shown to be associated with higher morbidity and mortality in pediatric patients. Data on risk factors for neonatal patients is limited. The objective of this study was to identify pre- and intraoperative risk factors associated with postoperative glucose in neonates. METHODS We conducted a retrospective cohort study of neonates after surgical procedures between January and December 2016 in a quaternary neonatal intensive care unit. The primary outcome was hyperglycemia defined as serum glucose ≥8.3 mmol/L during the first 4 hours postoperatively. Secondary outcomes included death and length of stay. We assessed the association of risk factors with the postoperative glucose. RESULTS In total, 206 surgical procedures (171 patients) were evaluated, among which 178 had serum glucose values during the first 4 hours postoperatively available. The incidence of hyperglycemia was 54% (n = 96). The median (IQR) glucose during the first 4 hours in NICU was 8.4 (6.52-10.65) mmol/L. Risk factors for postoperative hyperglycemia were intraoperative glucose infusion rate (GIR) and gestational age. There was a non-linear relationship between gestational age and postoperative hyperglycemia. Mortality occurred in 6 (7%) in the no-hyperglycemia group and 3 (3%) in the hyperglycemia group (p = 0.31). CONCLUSIONS Among the risk factors, intraoperative GIR was identified as a modifiable factor that can reduce postoperative hyperglycemia. A non-linear relationship of gestational age with postoperative glucose provides new insights that may help advance our understanding of the complex mechanisms of glucose homeostasis in neonates.
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Affiliation(s)
- Adrianne R Bischoff
- Division of Neonatology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Beate Grass
- Division of Neonatology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Cardiovascular Data Management Centre, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Christopher Tomlinson
- Division of Neonatology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
| | - Kyong-Soon Lee
- Division of Neonatology, The Hospital for Sick Children, Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
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13
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Malglycemia is associated with poor outcomes in pediatric and adolescent hematopoietic stem cell transplant patients. Blood Adv 2020; 3:350-359. [PMID: 30718242 DOI: 10.1182/bloodadvances.2018021014] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 12/17/2018] [Indexed: 12/14/2022] Open
Abstract
Malglycemia (hypoglycemia, hyperglycemia, and/or glycemic variability) in adult hematopoietic stem cell transplant (HSCT) recipients is associated with increased infection, graft-versus-host disease, organ dysfunction, delayed engraftment, and mortality. Malglycemia has not been studied in pediatric HSCT recipients. This study aimed to characterize the incidence and consequences of malglycemia in this population. Medical records for a cohort of 344 patients, age 0 to 30 years, who underwent first HSCT from 2007 to 2016 at Children's Hospital Colorado were retrospectively reviewed. Glucose data were analyzed in intervals and assessed for potential risk factors and associated outcomes. Malglycemia occurred in 43.9% of patients. Patients with a day 0 to 100 mean glucose of 100 to 124 mg/dL had a 1.76-fold (95% confidence interval [CI], 1.10-2.82; P = .02) increased risk of death and patients with a day 0 to 100 mean glucose ≥ 125 mg/dL had a 7.06-fold (95% CI, 3.84-12.99; P < .0001) increased risk of death compared with patients with a day 0 to 100 mean glucose < 100 mg/dL. For each 10 mg/dL increase in pre-HSCT glucose, there was a 1.11-fold (95% CI, 1.04-1.18; P = .0013) increased risk of post-HSCT infection. These adverse impacts of malglycemia occurred independent of transplant type, graft-versus-host disease, and steroid therapy. Malglycemia in the pediatric HSCT population is independently associated with significantly increased risk of morbidity and mortality. Further research is required to evaluate the utility of glucose control to mitigate these relationships and improve HSCT outcomes. This trial was registered at www.clinicaltrials.gov as #NCT03482154.
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14
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Du Y, Liu C, Li J, Dang H, Zhou F, Sun Y, Xu F. Glycemic Variability: An Independent Predictor of Mortality and the Impact of Age in Pediatric Intensive Care Unit. Front Pediatr 2020; 8:403. [PMID: 32850528 PMCID: PMC7412867 DOI: 10.3389/fped.2020.00403] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Accepted: 06/11/2020] [Indexed: 12/31/2022] Open
Abstract
Objective: To compare the ability of different indices of glycemic variability (GV) in the prognostic evaluation of critically ill children and investigate whether heterogeneity of glucose control exists within this population group. Methods: We conducted a retrospective study of the GV data collected from patients admitted to the pediatric intensive care unit, Children's Hospital of Chongqing Medical University between January 2016 and December 2016. We calculated the mean glucose level (MGL) and four indices of GV, namely, standard deviation (SD), coefficient of variation (CV), mean amplitude of glycemic excursion (MAGE), and glycemic lability index (GLI). The 28-day mortality was considered as the primary endpoint. Results: Survivors and non-survivors showed significant differences in terms of the SD, CV, MAGE, and GLI (P < 0.05, for all). However, GLI was superior to the other indices and showed an independent association with ICU mortality (odds ratio [OR], 1.082; 95% confidence interval [CI], 1.031-1.135; P < 0.01). Sub-group analysis disaggregated by quartiles of MGL and GV revealed that younger subjects (age ≤ 36 months) had significantly higher mortality in the lowest quartile of the MGL and in the highest quartile of GV; the older children (age > 36 months) experienced significantly higher mortality in the highest quartiles of MGL and GV. Conclusion: GV is closely associated with mortality, and among all glucose parameters evaluated, GLI was found to be the strongest predictor of outcomes. This paper is the first report of age being a potentially important modifier of the association between GV, MGL, and mortality in critically ill children.
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Affiliation(s)
- Yuhui Du
- Department of Medicine Intensive Care Unit, Children's Hospital Affiliated to Zhengzhou University, Henan Children's Hospital, Zhengzhou Children's Hospital, Zhengzhou, China
| | - Chengjun Liu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Jing Li
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Hongxing Dang
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Zhou
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Yuelin Sun
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Pediatric Intensive Care Unit, Children's Hospital of Chongqing Medical University, Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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15
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Davidson JA, Pfeifer Z, Frank B, Tong S, Urban TT, Wischmeyer PA, Mourani P, Landeck B, Christians U, Klawitter J. Metabolomic Fingerprinting of Infants Undergoing Cardiopulmonary Bypass: Changes in Metabolic Pathways and Association With Mortality and Cardiac Intensive Care Unit Length of Stay. J Am Heart Assoc 2018; 7:e010711. [PMID: 30561257 PMCID: PMC6405618 DOI: 10.1161/jaha.118.010711] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 11/08/2018] [Indexed: 12/30/2022]
Abstract
Background Mortality for infants undergoing complex cardiac surgery is >10% with a 30% to 40% risk of complications. Early identification and treatment of high-risk infants remains challenging. Metabolites are small molecules that determine the minute-to-minute cellular phenotype, making them ideal biomarkers for postsurgical monitoring and potential targets for intervention. Methods and Results We measured 165 serum metabolites by tandem mass spectroscopy in infants ≤120 days old undergoing cardiopulmonary bypass. Samples were collected prebypass, during rewarming, and 24 hours after surgery. Partial least squares-discriminant analysis, pathway analysis, and receiver operator characteristic curve analysis were used to evaluate changes in the metabolome, assess altered metabolic pathways, and discriminate between survivors/nonsurvivors as well as upper/lower 50% intensive care unit length of stay. Eighty-two infants had preoperative samples for analysis; 57 also had rewarming and 24-hour samples. Preoperation, the metabolic fingerprint of neonates differed from older infants ( R2=0.89, Q2=0.77; P<0.001). Cardiopulmonary bypass resulted in progressive, age-independent metabolic disturbance ( R2=0.92, Q2=0.83; P<0.001). Multiple pathways demonstrated changes, with arginine/proline ( P=1.2×10-35), glutathione ( P=3.3×10-39), and alanine/aspartate/glutamate ( P=1.4×10-26) metabolism most affected. Six subjects died. Nonsurvivors demonstrated altered aspartate ( P=0.007) and nicotinate/nicotinamide metabolism ( P=0.005). The combination of 24-hour aspartate and methylnicotinamide identified nonsurvivors versus survivors (area under the curve, 0.86; P<0.01), as well as upper/lower 50% intensive care unit length of stay (area under the curve, 0.89; P<0.01). Conclusions The preoperative metabolic fingerprint of neonates differed from older infants. Large metabolic shifts occurred after cardiopulmonary bypass, independent of age. Nonsurvivors and subjects requiring longer intensive care unit length of stay showed distinct changes in metabolism. Specific metabolites, including aspartate and methylnicotinamide, may differentiate sicker patients from those experiencing a more benign course.
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Affiliation(s)
- Jesse A. Davidson
- Department of PediatricsUniversity of Colorado/Children's Hospital ColoradoAuroraCO
| | | | - Benjamin Frank
- Department of PediatricsUniversity of Colorado/Children's Hospital ColoradoAuroraCO
| | - Suhong Tong
- Department of BiostatisticsUniversity of Colorado/Children's Hospital ColoradoAuroraCO
| | - Tracy T. Urban
- Department of Research InstituteChildren's Hospital ColoradoAuroraCO
| | | | - Peter Mourani
- Department of PediatricsUniversity of Colorado/Children's Hospital ColoradoAuroraCO
| | - Bruce Landeck
- Department of PediatricsUniversity of Colorado/Children's Hospital ColoradoAuroraCO
| | - Uwe Christians
- Department of AnesthesiologyUniversity of ColoradoAuroraCO
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16
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Jefferies C, Rhodes E, Rachmiel M, Agwu JC, Kapellen T, Abdulla MA, Hofer SE. ISPAD Clinical Practice Consensus Guidelines 2018: Management of children and adolescents with diabetes requiring surgery. Pediatr Diabetes 2018; 19 Suppl 27:227-236. [PMID: 30039617 DOI: 10.1111/pedi.12733] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/10/2018] [Indexed: 12/13/2022] Open
Affiliation(s)
- Craig Jefferies
- Starship Children's Health, Auckland District Health Board, Auckland, New Zealand
| | - Erinn Rhodes
- Division of Endocrinology, Boston Children's Hospital, Boston, Massachusetts
| | - Marianna Rachmiel
- Assaf Haroffeh Medical Center, Zerifin, Sackler School of Medicine, Tel Aviv University, Israel
| | - Juliana C Agwu
- Department of Paediatrics, Sandwell and West Birmingham NHS Trust, Birmingham, UK
| | - Thomas Kapellen
- Department for Women and Child Health, Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | | | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
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17
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Yamamoto N, Irie T, Takaki S, Yamaguchi O, Goto T. Predictors of severe postoperative hyperglycemia after cardiac surgery in infants: a single-center, retrospective, observational study. J Anesth 2018; 32:160-166. [PMID: 29330638 DOI: 10.1007/s00540-017-2444-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/29/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE Hyperglycemia is a common issue in infants after cardiac surgery for congenital heart disease. Poor glycemic control is suspected to be associated with adverse postoperative outcomes. This study was performed to investigate clinical factors contributing to hyperglycemia in the perioperative period in infats. METHODS A total of 69 infants (aged 1-12 months) who were admitted to Yokohama City University Hospital Intensive Care Unit (ICU) after surgical repair of congenital heart diseases with cardiopulmonary bypass (CPB) were retrospectively analysed. Hyperglycemia was defined as blood glucose ≥ 250 mg/dL on ICU admission. Clinical background, operative factors, and postoperative factors were compared between the hyperglycemic and non-hyperglycemic groups. Additionally, multivariate analysis was performed to identify factors contributing to hyperglycemia. RESULTS Nineteen (27.5%) and 50 (72.5%) infants were classified into the hyperglycemic and non-hyperglycemic groups, respectively. Hyperglycemic infants were significantly younger, shorter, and weighed less, with a higher rate of chromosomal abnormalities. Intraoperatively, they also experienced longer CPB and surgery times and had higher peak lactate levels and higher inotropic requirements. Hyperglycemia was related to longer mechanical ventilation and longer ICU stays. Multivariate analysis detected intraoperative hyperglycemia, longer CPB time, younger age and chromosomal abnormality as significant factors. CONCLUSION Adding to hyperglycemia during the operation, longer CPB time younger age and chromosomal abnormality were identified as predictors of high blood glucose levels at ICU admission.
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Affiliation(s)
- Natsuhiro Yamamoto
- Department of Intensive Care Unit, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan.
| | - Tomoya Irie
- Department of Anesthesiology, Yokohama City University Hospital, Yokohama, Japan
| | - Shunsuke Takaki
- Department of Intensive Care Unit, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Osamu Yamaguchi
- Department of Intensive Care Unit, Yokohama City University Hospital, 3-9 Fukuura, Kanazawa-ku, Yokohama, Kanagawa, 236-0004, Japan
| | - Takahisa Goto
- Department of Anesthesiology, Yokohama City University Hospital, Yokohama, Japan
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18
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Morton PD, Ishibashi N, Jonas RA. Neurodevelopmental Abnormalities and Congenital Heart Disease: Insights Into Altered Brain Maturation. Circ Res 2017; 120:960-977. [PMID: 28302742 PMCID: PMC5409515 DOI: 10.1161/circresaha.116.309048] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 12/14/2016] [Accepted: 12/15/2016] [Indexed: 01/14/2023]
Abstract
In the past 2 decades, it has become evident that individuals born with congenital heart disease (CHD) are at risk of developing life-long neurological deficits. Multifactorial risk factors contributing to neurodevelopmental abnormalities associated with CHD have been identified; however, the underlying causes remain largely unknown, and efforts to address this issue have only recently begun. There has been a dramatic shift in focus from newly acquired brain injuries associated with corrective and palliative heart surgery to antenatal and preoperative factors governing altered brain maturation in CHD. In this review, we describe key time windows of development during which the immature brain is vulnerable to injury. Special emphasis is placed on the dynamic nature of cellular events and how CHD may adversely impact the cellular units and networks necessary for proper cognitive and motor function. In addition, we describe current gaps in knowledge and offer perspectives about what can be done to improve our understanding of neurological deficits in CHD. Ultimately, a multidisciplinary approach will be essential to prevent or improve adverse neurodevelopmental outcomes in individuals surviving CHD.
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Affiliation(s)
- Paul D Morton
- From the Center for Neuroscience Research and Children's National Heart Institute, Children's National Health System, Washington, DC
| | - Nobuyuki Ishibashi
- From the Center for Neuroscience Research and Children's National Heart Institute, Children's National Health System, Washington, DC.
| | - Richard A Jonas
- From the Center for Neuroscience Research and Children's National Heart Institute, Children's National Health System, Washington, DC.
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19
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Doctor A, Zimmerman J, Agus M, Rajasekaran S, Wardenburg JB, Fortenberry J, Zajicek A, Typpo K. Pediatric Multiple Organ Dysfunction Syndrome: Promising Therapies. Pediatr Crit Care Med 2017; 18:S67-S82. [PMID: 28248836 PMCID: PMC5333132 DOI: 10.1097/pcc.0000000000001053] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To describe the state of the science, identify knowledge gaps, and offer potential future research questions regarding promising therapies for children with multiple organ dysfunction syndrome presented during the Eunice Kennedy Shriver National Institute of Child Health and Human Development Workshop on Pediatric Multiple Organ Dysfunction Syndrome (March 26-27, 2015). DATA SOURCES Literature review, research data, and expert opinion. STUDY SELECTION Not applicable. DATA EXTRACTION Moderated by an expert from the field, issues relevant to the association of multiple organ dysfunction syndrome with a variety of conditions were presented, discussed, and debated with a focus on identifying knowledge gaps and research priorities. DATA SYNTHESIS Summary of presentations and discussion supported and supplemented by relevant literature. CONCLUSIONS Among critically ill children, multiple organ dysfunction syndrome is relatively common and associated with significant morbidity and mortality. For outcomes to improve, effective therapies aimed at preventing and treating this condition must be discovered and rigorously evaluated. In this article, a number of potential opportunities to enhance current care are highlighted including the need for a better understanding of the pharmacokinetics and pharmacodynamics of medications, the effect of early and optimized nutrition, and the impact of effective glucose control in the setting of multiple organ dysfunction syndrome. Additionally, a handful of the promising therapies either currently being implemented or developed are described. These include extracorporeal therapies, anticytokine therapies, antitoxin treatments, antioxidant approaches, and multiple forms of exogenous steroids. For the field to advance, promising therapies and other therapies must be assessed in rigorous manner and implemented accordingly.
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Affiliation(s)
- Allan Doctor
- Departments of Pediatrics (Critical Care Medicine) and Biochemistry, Washington University in Saint Louis
| | - Jerry Zimmerman
- Department of Pediatrics (Critical Care Medicine), University of Washington, Seattle, WA
| | - Michael Agus
- Department of Pediatrics (Critical Care Medicine), Harvard University, Boston, MA
| | - Surender Rajasekaran
- Department of Pediatrics (Critical Care Medicine), Michigan State University, Grand Rapids, MI
| | | | - James Fortenberry
- Department of Pediatrics (Critical Care Medicine), Emory University, Atlanta, GA
| | - Anne Zajicek
- Obstetric and Pediatric Pharmacology and Therapeutics Branch, NICHD
| | - Katri Typpo
- Department of Pediatrics (Critical Care Medicine), University of Arizona, Phoenix, AZ
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20
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Ingels C, Vanhorebeek I, Van den Berghe G. Glucose homeostasis, nutrition and infections during critical illness. Clin Microbiol Infect 2017; 24:10-15. [PMID: 28082192 DOI: 10.1016/j.cmi.2016.12.033] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 12/20/2016] [Accepted: 12/27/2016] [Indexed: 12/17/2022]
Abstract
Critical illness is a complex life-threatening disease characterized by profound endocrine and metabolic alterations and by a dysregulated immune response, together contributing to the susceptibility for nosocomial infections and sepsis. Hitherto, two metabolic strategies have been shown to reduce nosocomial infections in the critically ill, namely tight blood glucose control and early macronutrient restriction. Hyperglycaemia, as part of the endocrine-metabolic responses to stress, is present in virtually all critically ill patients and is associated with poor outcome. Maintaining normoglycaemia with intensive insulin therapy has been shown to reduce morbidity and mortality, by prevention of vital organ dysfunction and prevention of new severe infections. The favourable effects of this intervention were attributed to the avoidance of glucose toxicity and mitochondrial damage in cells of vital organs and in immune cells. Hyperglycaemia was shown to impair macrophage phagocytosis and oxidative burst capacity, which could be restored by targeting normoglycaemia. An anti-inflammatory effect of insulin may have contributed to prevention of collateral damage to host tissues. Not using parenteral nutrition during the first week in intensive care units, and so accepting a large macronutrient deficit, also resulted in fewer secondary infections, less weakness and accelerated recovery. This was at least partially explained by a suppressive effect of early parenteral nutrition on autophagic processes, which may have jeopardized crucial antimicrobial defences and cell damage removal. The beneficial impact of these two metabolic strategies has opened a new field of research that will allow us to improve the understanding of the determinants of nosocomial infections, sepsis and organ failure in the critically ill.
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Affiliation(s)
- C Ingels
- Clinical Department and Laboratory of Intensive Care Medicine, Division Cellular and Molecular Medicine, KU Leuven, Belgium
| | - I Vanhorebeek
- Clinical Department and Laboratory of Intensive Care Medicine, Division Cellular and Molecular Medicine, KU Leuven, Belgium
| | - G Van den Berghe
- Clinical Department and Laboratory of Intensive Care Medicine, Division Cellular and Molecular Medicine, KU Leuven, Belgium.
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21
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Sadhwani A, Asaro LA, Goldberg C, Ware J, Butcher J, Gaies M, Smith C, Alexander JL, Wypij D, Agus MSD. Impact of Tight Glycemic Control on Neurodevelopmental Outcomes at 1 Year of Age for Children with Congenital Heart Disease: A Randomized Controlled Trial. J Pediatr 2016; 174:193-198.e2. [PMID: 27112038 PMCID: PMC4925287 DOI: 10.1016/j.jpeds.2016.03.048] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Revised: 02/03/2016] [Accepted: 03/21/2016] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To assess the association of postoperative tight glycemic control and hypoglycemia in children undergoing cardiac surgery with neurodevelopmental outcomes at 1 year of age. STUDY DESIGN A 2-center, prospective, randomized trial of postoperative tight glycemic control vs standard care was conducted in 980 children undergoing cardiac surgery. Neurodevelopmental outcomes were assessed at nine to 18 months using the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III), the Adaptive Behavior Assessment System, Second Edition, the Ages and Stages Questionnaire, Third Edition, and the Brief Infant Toddler Social-Emotional Assessment. RESULTS Neurodevelopmental follow-up was performed on 237 patients with a mean age of 13 months. No significant treatment group differences were found in the Bayley-III and Adaptive Behavior Assessment System, Second Edition composite scores or percentage at risk based on the Ages and Stages Questionnaire, Third Edition and the Brief Infant Toddler Social-Emotional Assessment. Patients who experienced moderate to severe hypoglycemia (n = 8) had lower Bayley-III composite scores compared with patients with no to mild hypoglycemia, even after controlling for factors known to be associated with poorer neurodevelopmental outcomes. CONCLUSION For infants undergoing cardiac surgery, tight glycemic control did not impact neurodevelopmental outcomes compared with standard care. These data suggest a possible association between moderate to severe hypoglycemia and poorer neurodevelopmental outcomes at 1 year of age. TRIAL REGISTRATION ClinicalTrials.gov: NCT00443599.
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Affiliation(s)
- Anjali Sadhwani
- Cardiac Neurodevelopmental Program, Boston Children's Hospital and Harvard Medical School, Boston, MA; Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, MA.
| | - Lisa A. Asaro
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Caren Goldberg
- Division of Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Janice Ware
- Cardiac Neurodevelopmental Program, Boston Children's Hospital and Harvard Medical School, Boston, MA,Department of Psychiatry, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - Jennifer Butcher
- Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Division of Pediatric Psychology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Michael Gaies
- Division of Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Cynthia Smith
- Division of Cardiology, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI,Department of Pediatrics and Communicable Diseases, C.S. Mott Children's Hospital and University of Michigan Medical School, Ann Arbor, MI
| | - Jamin L. Alexander
- Division of Medicine Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, MA
| | - David Wypij
- Department of Cardiology, Boston Children's Hospital and Harvard Medical School, Boston, MA,Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Michael S. D. Agus
- Division of Medicine Critical Care, Boston Children's Hospital and Harvard Medical School, Boston, MA
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Soto-Rivera CL, Agus MSD. Tight Glycemic Control in the Pediatric Intensive Care Unit. J Pediatr Intensive Care 2016; 5:198-204. [PMID: 31110905 DOI: 10.1055/s-0036-1583281] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2015] [Accepted: 11/24/2015] [Indexed: 01/04/2023] Open
Abstract
Hyperglycemia is a common complication in critically ill, nondiabetic children. Four large pediatric randomized controlled trials of tight glycemic control (TGC) have been conducted to date with contradicting results. This review will highlight the design and outcomes of these trials and other relevant studies to provide an overview of the advantages and disadvantages of TGC for different populations at risk of hyperglycemia along with future directions for research.
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Affiliation(s)
- Carmen L Soto-Rivera
- Divisions of Endocrinology and Medicine Critical Care, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Michael S D Agus
- Divisions of Endocrinology and Medicine Critical Care, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Pediatric Cardiac Intensive Care Society 2014 Consensus Statement: Pharmacotherapies in Cardiac Critical Care Hormone Replacement Therapy. Pediatr Crit Care Med 2016; 17:S59-68. [PMID: 26945330 DOI: 10.1097/pcc.0000000000000625] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To provide an overview of the current literature on the use of hormone replacement therapies in pediatric cardiac critical care. DATA SOURCES PubMed, EMBASE, and the Cochrane Library were searched using keywords relevant to the hormonal therapy, with no limits on language but restricting the search to children 0-18 years old. STUDY SELECTION All clinical studies believed to have relevance were considered. Where studies in children were sparse, additional evidence was sought from adult studies. DATA EXTRACTION All relevant studies were reviewed, and the most relevant data were incorporated in this review. DATA SYNTHESIS All authors of this review contributed to the appraisal of the data extracted. Challenges and revisions by the authors were conducted by group e-mail debate. CONCLUSIONS Glycemic control: although it is likely that some children could benefit, the routine use of tight glycemic control cannot be recommended in children after cardiac surgery. Thyroid hormone replacement: routine use of thyroid hormone replacement to normalize levels after cardiac surgery cannot be recommended on current evidence. Until further evidence from adequately powered studies is available, therapeutic decisions should be based on individual patient circumstances. Corticosteroids: 1) cardiopulmonary bypass: although studies seem to favor steroid administration during surgery with cardiopulmonary bypass, a large randomized controlled trial is required before strong recommendations can be made; 2) refractory hypotension: the evidence for the use of steroid replacement in refractory hypotension is poor, and no firm recommendations can be made; and 3) abnormal adrenal function after cardiac surgery: there is inadequate evidence on which to make recommendations on the use of corticosteroid replacement in children with critical illness-related corticosteroid insufficiency in children following cardiac surgery.
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Mahle WT. A Little Sugar Never Hurt Anyone: Hyperglycemia after Infant Heart Surgery. J Pediatr 2015; 167:1185-6. [PMID: 26411861 DOI: 10.1016/j.jpeds.2015.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 09/01/2015] [Indexed: 10/23/2022]
Affiliation(s)
- William T Mahle
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
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Targeting Glycemic Control After Pediatric Cardiac Surgery. Pediatr Crit Care Med 2015; 16:887-8. [PMID: 26536554 DOI: 10.1097/pcc.0000000000000556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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.
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Abstract
PURPOSE OF REVIEW The focus of postoperative care in the pediatric patient with congenital heart disease has become a reduction in length of stay and morbidity. This review will discuss strategies to achieve this goal and recent studies to support current practices. RECENT FINDINGS Most agree that prolongation of the length of stay following a cardiac surgery contributes to morbidity. Postoperative feeding difficulty, hyperglycemia, acute kidney injury, fluid overload, and prolonged intubation contribute significantly to length of stay. SUMMARY Postoperative care of the neonate and child following a cardiac surgery remains challenging with limited data to drive our practices. Patients remain at risk for significant morbidity, and future studies should focus on recognizing predictors of morbidity, prevention, and treatment.
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Karamlou T, Oishi P. Glucose metabolism after pediatric cardiac surgery: Too many sweets will ruin your appetite. J Thorac Cardiovasc Surg 2015; 150:505-6. [PMID: 26253871 DOI: 10.1016/j.jtcvs.2015.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Accepted: 07/14/2015] [Indexed: 11/15/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, University of California, San Francisco, Benioff Children's Hospital, San Francisco, Calif.
| | - Peter Oishi
- Department of Pediatrics, University of California, San Francisco, Benioff Children's Hospital, and Associate Investigator, Cardiovascular Research Institute, San Francisco, Calif
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Tight Glycemic Control With Insulin Does Not Affect Skeletal Muscle Degradation During the Early Postoperative Period Following Pediatric Cardiac Surgery. Pediatr Crit Care Med 2015; 16:515-21. [PMID: 25850865 PMCID: PMC4497866 DOI: 10.1097/pcc.0000000000000413] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Critical illness is associated with significant catabolism, and persistent protein loss correlates with increased morbidity and mortality. Insulin is a potent anticatabolic hormone; high-dose insulin decreases skeletal muscle protein breakdown in critically ill pediatric surgical patients. However, insulin's effect on protein catabolism when given at clinically utilized doses has not been studied. The objective was to evaluate the effect of postoperative tight glycemic control and clinically dosed insulin on skeletal muscle degradation in children after cardiac surgery with cardiopulmonary bypass. DESIGN Secondary analysis of a two-center, prospective randomized trial comparing tight glycemic control with standard care. Randomization was stratified by study center. PATIENTS Children 0-36 months who were admitted to the ICU after cardiac surgery requiring cardiopulmonary bypass. INTERVENTIONS In the tight glycemic control arm, insulin was titrated to maintain blood glucose between 80 and 110 mg/dL. Patients in the control arm received standard care. Skeletal muscle breakdown was quantified by a ratio of urinary 3-methylhistidine to urinary creatinine. MEASUREMENTS AND MAIN RESULTS A total of 561 patients were included: 281 in the tight glycemic control arm and 280 receiving standard care. There was no difference in 3-methylhistidine to creatinine between groups (tight glycemic control, 249 ± 127 vs standard care, 253 ± 112, mean ± SD in μmol/g; p = 0.72). In analyses restricted to the patients in tight glycemic control arm, higher 3-methylhistidine to creatinine correlated with younger age, as well as lower weight, weight-for-age z score, length, and body surface area (p < 0.005 for each) and lower postoperative day 3 serum creatinine (r = -0.17; p = 0.02). Sex, prealbumin, and albumin were not associated with 3-methylhistidine to creatinine. During urine collection, 245 patients (87%) received insulin. However, any insulin exposure did not impact 3-methylhistidine to creatinine (t test, p = 0.45), and there was no dose-dependent effect of insulin on 3-methylhistidine to creatinine (r = -0.03; p = 0.60). CONCLUSION Although high-dose insulin has an anabolic effect in experimental conditions, at doses necessary to achieve normoglycemia, insulin appears to have no discernible impact on skeletal muscle degradation in critically ill pediatric cardiac surgical patients.
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Thiessen S, Vanhorebeek I, Van den Berghe G. Glycemic control and outcome related to cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol 2015; 29:177-87. [DOI: 10.1016/j.bpa.2015.03.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 02/17/2015] [Accepted: 03/19/2015] [Indexed: 12/13/2022]
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Cochius-den Otter SCM, Joosten KFM, de Jongste JC, Hop WCJ, de Hoog M, Buysse CMP. Insulin therapy in hyperglycemic children with severe acute asthma. J Asthma 2015; 52:681-6. [PMID: 25982907 DOI: 10.3109/02770903.2015.1008139] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
OBJECTIVES The aim of this study was to assess the effect of intravenous (IV) insulin administration in children with severe acute asthma (SAA) and hyperglycemia on IV salbutamol consumption and length of stay (LOS) in a pediatric intensive care unit (PICU). METHODS Retrospective, descriptive study of the clinical course before and after implementation of an insulin protocol for the treatment of hyperglycemia (i.e. blood glucose >8 mmol/L or 144 mg/dL, respectively) in the PICU of a tertiary care university hospital. Admissions between 1994 and 2010 were reviewed. The insulin protocol was introduced in 2006. RESULTS A total of 131 pediatric patients with SAA complicated by hyperglycemia requiring IV salbutamol were included. Severity of illness before and after implementation of the insulin protocol did not significantly differ. The insulin-treated patient group had significantly higher maximum blood glucose levels and higher cumulative IV salbutamol dose than the non-treated group. There were no differences between these groups in the duration of IV salbutamol administration and LOS. CONCLUSIONS In view of the lack of difference in outcomes and considering that the insulin protocol is labor-intensive, the question is whether this protocol is efficacious for the treatment of pediatric SAA associated with hyperglycemia.
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