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Al-Zubeidi D, Davis MB, Rahhal R. Prevention of complications for hospitalized patients receiving parenteral nutrition: A narrative review. Nutr Clin Pract 2024. [PMID: 39152093 DOI: 10.1002/ncp.11201] [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: 05/03/2024] [Revised: 07/17/2024] [Accepted: 07/21/2024] [Indexed: 08/19/2024] Open
Abstract
Hospitalized patients may benefit from parenteral nutrition to address their compromised nutrition status attributed to limited oral/enteral intake and increased nutrient/energy requirement during acute illness. Parenteral nutrition, however, can be associated with many complications that can negatively impact patient outcomes. In this review, we focus on potential metabolic and catheter-related complications associated with parenteral nutrition use. We report on potential risk factors for such complications and highlight strategies for prevention and early recognition. To optimize outcomes, key findings include the creation and implementation of evidence-based protocols with proven efficacy. For each hospital unit delivering parenteral nutrition to patients, tracking compliance with established protocols and patient outcomes is crucial for ongoing improvement through identification of gaps, proper reeducation and training, and ongoing refinement of care protocols. Establishment of specialized inpatient nutrition support teams should be considered.
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Affiliation(s)
- Dina Al-Zubeidi
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
| | - Mary Beth Davis
- College of Nursing, University of Iowa Children's Hospital, Iowa City, Iowa, USA
| | - Riad Rahhal
- Division of Pediatric Gastroenterology, Department of Pediatrics, University of Iowa, Iowa City, Iowa, USA
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Şiklar Z. Management of endocrinological problems in children on home invasive mechanical ventilation. Pediatr Pulmonol 2024; 59:2163-2169. [PMID: 38088200 DOI: 10.1002/ppul.26800] [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] [Received: 07/04/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 07/27/2024]
Abstract
OBJECTIVE Children with home invasive mechanical ventilation (HIMV) face numerous difficulties, including endocrine problems that can arise as a consequence of their condition. Endocrine problems seen in children treated with HIMV may develop due to the underlying disease, drugs used, or prolonged mechanical ventilation. METHOD This manuscript will review the most common endocrine problems encountered in children with HIMV, including problems in glucose metabolism, thyroid dysfunction, bone metabolism, adrenal dysfunctions, growth, and puberty. CONCLUSION Close monitoring, multidisciplinary care, and regular assessments are essential to optimize the endocrine system functions of children requiring home mechanical ventilation. By understanding these complications, it can develop effective management strategies to optimize the health and well-being of these vulnerable individuals.
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Affiliation(s)
- Zeynep Şiklar
- Division of Pediatric Endocrinology, Ankara University School of Medicine, Ankara, Turkey
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Srinivasan V. Glucose Metabolism and Stress Hyperglycemia in Critically Ill Children. Indian J Pediatr 2023; 90:272-279. [PMID: 36645581 DOI: 10.1007/s12098-022-04439-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 11/13/2022] [Indexed: 01/17/2023]
Abstract
Abnormalities in glucose metabolism and stress hyperglycemia (SH) are commonly seen in critically ill children. While SH may represent an adaptive stress response as a source of fuel for the body during the "fight or flight response" of critical illness, several studies have observed the association of SH with worse outcomes in different disease states. In addition to alterations in glucose metabolism and acquired insulin resistance from inflammation and organ dysfunction, specific intensive care unit (ICU) interventions can also affect glucose homeostasis and SH during critical illness. Common ICU interventions can mediate the development of SH in critical illness. The strategy of tight glucose control combined with intensive insulin therapy (TGC-IIT) has been well studied to improve outcomes in both adult and pediatric critical illness. Though early single-center studies of TGC-IIT observed benefits with better outcomes albeit with greater incidence of hypoglycemia, subsequent larger multicenter studies in both children and adults have not conclusively demonstrated benefits and have even observed harm. Several possible reasons for these contrasting results include differences in patient populations, glycemic control targets, and glucose control protocols including nutrition support, and variability in achieving these targets, measurement methods, and expertise in protocol implementation. Future studies may need to individualize management of SH in critically ill children with improved monitoring of indices of glycemia utilizing continuous sensors and closed-loop insulin administration.
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Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA, 19104, USA. .,Departments of Anesthesiology, Critical Care and Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
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Terashita S. Response to the Letter to the Editor entitled “Glucokinase maturity-onset diabetes of the young as a mimicker of stress hyperglycemia: a case report” by Amanda Doherty-Kirby, Clin Pediatr Endocrinol 2023;32:72–75. Clin Pediatr Endocrinol 2023; 32:124. [PMID: 37020701 PMCID: PMC10068623 DOI: 10.1297/cpe.2023-0001-2] [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: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 04/03/2023] Open
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Saritas Nakip O, Kesici S, Bozkurt BS, Ozsurekci Y, Demirbilek H, Bayrakci B. Incidence and Risk Factors of Hyperglycemia in Severe Multisystem Inflammatory Syndrome in Children: A Retrospective Case-Control Study. J PEDIAT INF DIS-GER 2022. [DOI: 10.1055/s-0042-1758744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Abstract
Objective Multisystem inflammatory syndrome in children (MIS-C) patients might be at risk for hyperglycemia and associated complications. Herein, we aimed to determine the incidence of hyperglycemia, understanding the underlying risk factors in MIS-C patients.
Methods All MIS-C patients were retrospectively evaluated and compared according to the presence of hyperglycemia and the need of insulin. Inflammatory markers and body mass index Z-scores were also compared.
Results The median age of the patients with hyperglycemia was higher than those without (p = 0.001). Disease severity scores of patients with hyperglycemia were higher. Procalcitonin levels of patients with hyperglycemia were higher, while ferritin, CRP, and interleukin-6 levels were not. BMIs of patients with hyperglycemia were higher (p = 0.01) but BMI Z-scores were similar (p = 0.055). There was a positive correlation between BMIs and CRP (r: 0.31, p = 0.015). There was a positive correlation between procalcitonin (r: 0.431, p = 0.001) and CRP (r: 0.279, p = 0.029) and maximum PG.
Conclusion Hyperglycemia is a common feature of MIS-C patients and is associated with the severity of the inflammation. As a novel finding, high CRP and procalcitonin should be considered as predictive markers for impaired glucose homeostasis in MIS-C patients.
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Affiliation(s)
- Ozlem Saritas Nakip
- Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Selman Kesici
- Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Betul Seda Bozkurt
- Department of Pediatrics, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Yasemin Ozsurekci
- Pediatric Infectious Disease, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Huseyin Demirbilek
- Pediatric Endocrinology, Hacettepe University, Faculty of Medicine, Ankara, Turkey
| | - Benan Bayrakci
- Pediatric Critical Care Medicine, Life Support Practice and Research Center, Hacettepe University, Faculty of Medicine, Ankara, Turkey
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Son MBF, Berbert L, Young C, Dallas J, Newhams M, Chen S, Ardoin SP, Basiaga ML, Canny SP, Crandall H, Dhakal S, Dhanrajani A, Sagcal-Gironella ACP, Hobbs CV, Huie L, James K, Jones M, Kim S, Lionetti G, Mannion ML, Muscal E, Prahalad S, Schulert GS, Tejtel KS, Villacis-Nunez DS, Wu EY, Zambrano LD, Campbell AP, Patel MM, Randolph AG. Postdischarge Glucocorticoid Use and Clinical Outcomes of Multisystem Inflammatory Syndrome in Children. JAMA Netw Open 2022; 5:e2241622. [PMID: 36367723 PMCID: PMC9652757 DOI: 10.1001/jamanetworkopen.2022.41622] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
IMPORTANCE Minimal data are available regarding the postdischarge treatment of multisystem inflammatory syndrome in children (MIS-C). OBJECTIVES To evaluate clinical characteristics associated with duration of postdischarge glucocorticoid use and assess postdischarge clinical course, laboratory test result trajectories, and adverse events in a multicenter cohort with MIS-C. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included patients with MIS-C hospitalized with severe illness and followed up for 3 months in an ambulatory setting. Patients younger than 21 years who were admitted between May 15, 2020, and May 31, 2021, at 13 US hospitals were included. Inclusion criteria were inpatient treatment comprising intravenous immunoglobulin, diagnosis of cardiovascular dysfunction (vasopressor requirement or left ventricular ejection fraction ≤55%), and availability of complete outpatient data for 3 months. EXPOSURES Glucocorticoid treatment. MAIN OUTCOMES AND MEASURES Main outcomes were patient characteristics associated with postdischarge glucocorticoid treatment, laboratory test result trajectories, and adverse events. Multivariable regression was used to evaluate factors associated with postdischarge weight gain (≥2 kg in 3 months) and hyperglycemia during illness. RESULTS Among 186 patients, the median age was 10.4 years (IQR, 6.7-14.2 years); most were male (107 [57.5%]), Black non-Hispanic (60 [32.3%]), and Hispanic or Latino (59 [31.7%]). Most children were critically ill (intensive care unit admission, 163 [87.6%]; vasopressor receipt, 134 [72.0%]) and received inpatient glucocorticoid treatment (178 [95.7%]). Most were discharged with continued glucocorticoid treatment (173 [93.0%]); median discharge dose was 42 mg/d (IQR, 30-60 mg/d) or 1.1 mg/kg/d (IQR, 0.7-1.7 mg/kg/d). Inpatient severity of illness was not associated with duration of postdischarge glucocorticoid treatment. Outpatient treatment duration varied (median, 23 days; IQR, 15-32 days). Time to normalization of C-reactive protein and ferritin levels was similar for glucocorticoid duration of less than 3 weeks vs 3 or more weeks. Readmission occurred in 7 patients (3.8%); none was for cardiovascular dysfunction. Hyperglycemia developed in 14 patients (8.1%). Seventy-five patients (43%) gained 2 kg or more after discharge (median 4.1 kg; IQR, 3.0-6.0 kg). Inpatient high-dose intravenous and oral glucocorticoid therapy was associated with postdischarge weight gain (adjusted odds ratio, 6.91; 95% CI, 1.92-24.91). CONCLUSIONS AND RELEVANCE In this multicenter cohort of patients with MIS-C and cardiovascular dysfunction, postdischarge glucocorticoid treatment was often prolonged, but clinical outcomes were similar in patients prescribed shorter courses. Outpatient weight gain was common. Readmission was infrequent, with none for cardiovascular dysfunction. These findings suggest that strategies are needed to optimize postdischarge glucocorticoid courses for patients with MIS-C.
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Affiliation(s)
- Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Laura Berbert
- Institute Centers for Clinical and Translational Research, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Cameron Young
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Johnathan Dallas
- Division of Immunology, Boston Children’s Hospital, Boston, Massachusetts
- Western Atlantic University School of Medicine, Freeport, Grand Bahama, Bahamas
| | - Margaret Newhams
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Sabrina Chen
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Stacy P. Ardoin
- Rheumatology, Nationwide Children’s Hospital, Department of Pediatrics, Ohio State College of Medicine, Columbus
| | - Matthew L. Basiaga
- Division of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Susan P. Canny
- Division of Pediatric Rheumatology, Seattle Children’s Hospital, Department of Pediatrics, University of Washington, Seattle
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Sanjeev Dhakal
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Anita Dhanrajani
- Pediatric Rheumatology, Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Anna Carmela P. Sagcal-Gironella
- Department of Pediatrics, Hackensack Meridian School of Medicine, Hackensack, New Jersey
- Division of Rheumatology, Joseph M. Sanzari Children’s Hospital, Hackensack, New Jersey
| | - Charlotte V. Hobbs
- Division of Pediatric Infectious Disease, Department of Pediatrics, University of Mississippi Medical Center, Jackson
| | - Livie Huie
- Division of Pediatric Rheumatology, University of Alabama at Birmingham
| | - Karen James
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Utah, Primary Children’s Hospital, Salt Lake City
| | - Madelyn Jones
- Rheumatology, Nationwide Children’s Hospital, Department of Pediatrics, Ohio State College of Medicine, Columbus
| | - Susan Kim
- Pediatric Rheumatology, UCSF Benioff Children’s Hospital, Department of Pediatrics, University of California at San Francisco School of Medicine
| | - Geraldina Lionetti
- Pediatric Rheumatology, UCSF Benioff Children’s Hospital, Department of Pediatrics, University of California at San Francisco School of Medicine
| | | | - Eyal Muscal
- Division of Rheumatology, Texas Children’s Hospital, Department of Pediatrics, Baylor School of Medicine, Houston
| | - Sampath Prahalad
- Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Grant S. Schulert
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Kristen Sexson Tejtel
- Division of Cardiology, Texas Children’s Hospital, Department of Pediatrics, Baylor School of Medicine, Houston
| | - D. Sofia Villacis-Nunez
- Children’s Healthcare of Atlanta, Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Eveline Y. Wu
- Division of Pediatric Rheumatology, UNC Children’s Hospital, Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill
| | - Laura D. Zambrano
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Angela P. Campbell
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Manish M. Patel
- COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
- Public Health Service Commissioned Corps, Rockville, Maryland
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, Massachusetts
- Departments of Pediatrics and Anesthesiology, Harvard Medical School, Boston, Massachusetts
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Elliott E, Shoykhet M, Bell MJ, Wai K. Nutritional Support for Pediatric Severe Traumatic Brain Injury. Front Pediatr 2022; 10:904654. [PMID: 35656382 PMCID: PMC9152222 DOI: 10.3389/fped.2022.904654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 04/25/2022] [Indexed: 11/13/2022] Open
Abstract
In critically ill children with severe traumatic brain injury (sTBI), nutrition may help facilitate optimal recovery. There is ongoing research regarding nutritional practices in the pediatric intensive care unit (PICU). These are focused on identifying a patient's most appropriate energy goal, the mode and timing of nutrient delivery that results in improved outcomes, as well as balancing these goals against inherent risks associated with nutrition therapy. Within the PICU population, children with sTBI experience complex physiologic derangements in the acute post-injury period that may alter metabolic demand, leading to nutritional needs that may differ from those in other critically ill patients. Currently, there are relatively few studies examining nutrition practices in PICU patients, and even fewer studies that focus on pediatric sTBI patients. Available data suggest that contemporary neurocritical care practices may largely blunt the expected hypermetabolic state after sTBI, and that early enteral nutrition may be associated with lower morbidity and mortality. In concordance with these data, the most recent guidelines for the management of pediatric sTBI released by the Brain Trauma Foundation recommend initiation of enteral nutrition within 72 h to improve outcome (Level 3 evidence). In this review, we will summarize available literature on nutrition therapy for children with sTBI and identify gaps for future research.
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Affiliation(s)
- Elizabeth Elliott
- Critical Care Medicine, Children's National Hospital, Washington, DC, United States
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Association between Stress Hyperglycemia and Adverse Outcomes in Children Visiting the Pediatric Emergency Department. CHILDREN (BASEL, SWITZERLAND) 2022; 9:children9040505. [PMID: 35455548 PMCID: PMC9026823 DOI: 10.3390/children9040505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/25/2022] [Accepted: 04/01/2022] [Indexed: 11/17/2022]
Abstract
Stress hyperglycemia (SH) is often identified in patients visiting the pediatric emergency department (PED), and SH in adults has been associated with adverse outcomes, including mortality. In this retrospective study, we determined the adverse outcomes according to blood glucose (BG) levels of children visiting the PED of tertiary hospitals. Data were collected from the electronic medical records of children aged <18 years between 1 January 2011 and 31 December 2020. A total of 44,905 visits were included in the analysis. SH was identified in 1506 patients, with an incidence rate of 3.4%. Compared to those without SH, patients with SH had significantly higher ward admission rates (52.6% vs. 35.9%, p < 0.001), intensive care unit admission rates (2.6% vs. 0.7%, p < 0.001), and mortality rates (2.7% vs. 0.3%, p < 0.001). Compared to the normoglycemic group of 45 ≤ BG < 150 mg/dL, the odds ratios (95% CI) for mortality were 5.61 (3.35−9.37), 27.96 (14.95−52.26), 44.22 (17.03−114.82), and 39.94 (16.31−97.81) for levels 150 ≤ BG < 200, 200 ≤ BG < 250, 250 ≤ BG < 300 and ≥300 mg/dL, respectively. This suggests that SH is common in children visiting the PED and is associated with higher adverse outcomes. Thus, there is a need to quickly identify its cause and take prompt intervention to resolve it.
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Prevalence and Prognostic Factors of Stress Hyperglycemia in a Pediatric Population with Acute Illness in Greece-A Prospective Observational Study. J Clin Med 2022; 11:jcm11051301. [PMID: 35268392 PMCID: PMC8911079 DOI: 10.3390/jcm11051301] [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: 12/24/2021] [Revised: 02/12/2022] [Accepted: 02/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background: stress hyperglycemia (SH) is a relatively frequent finding in pediatric patients. The purpose of this prospective observational study was to identify the prevalence of pediatric SH and its associated risk factors in Greece. Methods: A total of 1005 patients without diabetes who were admitted consecutively for acute illness in a Pediatric Emergency Department were included in the study. Medical history, anthropometric measurements, blood glucose levels, and the medication administered were recorded. A questionnaire was distributed to parents regarding medical and perinatal history and sociodemographic characteristics. Results: There were 72 cases of SH on admission (7.2%) and 39 (3.9%) during hospitalization. Mean age was 6.4 years; 50.3% were male. SH on admission was associated with oral corticosteroid therapy (21.1% vs. 4.7%, p < 0.001), inhaled corticosteroids (12.7% vs. 3%, p < 0.001), and inhaled β2-agonists (30.6% vs. 10.7%, p < 0.001). In-hospital hyperglycemia was associated with oral corticosteroids (adjusted OR = 3.32), inhaled corticosteroids (OR = 10.03) and inhaled β2-agonists (OR = 5.01). Children with asthma were 5.58 and 7.86 times more likely to present admission and in-hospital hyperglycemia, respectively. Conclusions: This is the first report of SH prevalence in pediatric patients in Greece. Asthma, corticosteroids, and β2-agonists significantly increase the risk of SH. No parental factors seem to predispose to SH.
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Providing the Best Parenteral Nutrition before and after Surgery for NEC: Macro and Micronutrients Intakes. Nutrients 2022; 14:nu14050919. [PMID: 35267894 PMCID: PMC8912377 DOI: 10.3390/nu14050919] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/16/2022] [Accepted: 02/17/2022] [Indexed: 11/18/2022] Open
Abstract
Necrotizing enterocolitis (NEC) is the main gastrointestinal emergency of preterm infants for whom bowel rest and parenteral nutrition (PN) is essential. Despite the improvements in neonatal care, the incidence of NEC remains high (11% in preterm newborns with a birth weight <1500 g) and up to 20−50% of cases still require surgery. In this narrative review, we report how to optimize PN in severe NEC requiring surgery. PN should begin as soon as possible in the acute phase: close fluid monitoring is advocated to maintain volemia, however fluid overload and electrolytes abnormalities should be prevented. Macronutrients intake (protein, glucose, and lipids) should be adequately guaranteed and is essential in each phase of the disease. Composite lipid emulsion should be the first choice to reduce the risk of parenteral nutrition associated liver disease (PNALD). Vitamin and trace elements deficiency or overload are frequent in long-term PN, therefore careful monitoring should be planned starting from the recovery phase to adjust their parenteral intake. Neonatologists must be aware of the role of nutrition especially in patients requiring long-term PN to sustain growth, limiting possible adverse effects and long-term deficiencies.
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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.
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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.
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Srinivasan V, Lee JH, Menon K, Zimmerman JJ, Bembea MM, Agus MSD. Endocrine Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S84-S90. [PMID: 34970672 DOI: 10.1542/peds.2021-052888m] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Endocrine dysfunction is common in critically ill children and is manifested by abnormalities in glucose, thyroid hormone, and cortisol metabolism. OBJECTIVE To develop consensus criteria for endocrine dysfunction in critically ill children by assessing the association of various biomarkers with clinical and functional outcomes. DATA SOURCES PubMed and Embase were searched from January 1992 to January 2020. STUDY SELECTION We included studies in which researchers evaluated critically ill children with abnormalities in glucose homeostasis, thyroid function and adrenal function, performance characteristics of assessment and/or scoring tools to screen for endocrine dysfunction, and outcomes related to mortality, organ-specific status, and patient-centered outcomes. Studies of adults, premature infants or animals, reviews and/or commentaries, case series with sample size ≤10, and non-English-language studies were excluded. DATA EXTRACTION Data extraction and risk-of-bias assessment for each eligible study were performed by 2 independent reviewers. RESULTS The systematic review supports the following criteria for abnormal glucose homeostasis (blood glucose [BG] concentrations >150 mg/dL [>8.3 mmol/L] and BG concentrations <50 mg/dL [<2.8 mmol/L]), abnormal thyroid function (serum total thyroxine [T4] <4.2 μg/dL [<54 nmol/L]), and abnormal adrenal function (peak serum cortisol concentration <18 μg/dL [500 nmol/L]) and/or an increment in serum cortisol concentration of <9 μg/dL (250 nmol/L) after adrenocorticotropic hormone stimulation. LIMITATIONS These included variable sampling for BG measurements, limited reporting of free T4 levels, and inconsistent interpretation of adrenal axis testing. CONCLUSIONS We present consensus criteria for endocrine dysfunction in critically ill children that include specific measures of BG, T4, and adrenal axis testing.
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Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania and Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital and Duke-National University of Singapore Medical School, Singapore
| | - Kusum Menon
- Division of Pediatric Critical Care, Department of Pediatrics, Children's Hospital of Eastern Ontario and University of Ottawa, Ottawa, Ontario, Canada
| | - Jerry J Zimmerman
- Pediatric Critical Care Medicine, Seattle Children's Hospital, Harborview Medical Center and School of Medicine, University of Washington, Seattle, Washington
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Michael S D Agus
- Division of Medical Critical Care, Boston Children's Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts
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Friedman ER, Seidel S, Heiser S, Prybys K. Silently Suffering: A Pediatric Black Widow Spider Envenomation. J Emerg Med 2021; 61:e151-e154. [PMID: 33994256 DOI: 10.1016/j.jemermed.2021.02.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 02/02/2021] [Accepted: 02/21/2021] [Indexed: 11/24/2022]
Abstract
BACKGROUND Black widow spiders are distributed worldwide and, although rarely fatal, account for significant morbidity. Diagnosis can be challenging, and children are at risk of increased morbidity due to their small size. CASE REPORT We present a case of a 3-year-old boy who was brought to our emergency department because of sudden ear pain followed by labored breathing, abdominal pain, refusal or inability to speak, and grunting respirations. A black widow spider bite was suspected based on additional history obtained, and the spider was found in his helmet, confirming the diagnosis. The patient had progressive respiratory distress and somnolence and was intubated and transferred to a local pediatric intensive care unit. Antivenom was not initially available and eventually declined by the family. The child received supportive care and recovered after several days. Why Should an Emergency Physician Be Aware of This? This case illustrates the potentially deadly effects a black widow envenomation could cause in a child, and that bite location can affect the constellation of symptoms. It is a reminder that toxins, including that of the black widow spider, should be on the differential for acute abdominal pain, especially with autonomic features.
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Affiliation(s)
- Eric R Friedman
- Department of Emergency Medicine, University of Maryland, Baltimore, Maryland
| | - Stacey Seidel
- Department of Emergency Medicine, University of Maryland Upper Chesapeake Medical Center, Bel Air, Maryland
| | - Samantha Heiser
- University of Maryland Upper Chesapeake Medical Center, Bel Air, Maryland
| | - Katherine Prybys
- Department of Emergency Medicine, University of Maryland, Baltimore, Maryland
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Scheen M, Giraud R, Bendjelid K. Stress hyperglycemia, cardiac glucotoxicity, and critically ill patient outcomes current clinical and pathophysiological evidence. Physiol Rep 2021; 9:e14713. [PMID: 33463901 PMCID: PMC7814494 DOI: 10.14814/phy2.14713] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 12/09/2020] [Accepted: 12/12/2020] [Indexed: 01/07/2023] Open
Abstract
Stress hyperglycemia is a transient increase in blood glucose during acute physiological stress in the absence of glucose homeostasis dysfunction. Its's presence has been described in critically ill patients who are subject to many physiological insults. In this regard, hyperglycemia and impaired glucose tolerance are also frequent in patients who are admitted to the intensive care unit for heart failure and cardiogenic shock. The hyperglycemia observed at the beginning of these cardiac disorders appears to be related to a variety of stress mechanisms. The release of major stress and steroid hormones, catecholamine overload, and glucagon all participate in generating a state of insulin resistance with increased hepatic glucose output and glycogen breakdown. In fact, the observed pathophysiological response, which appears to regulate a stress situation, is harmful because it induces mitochondrial impairment, oxidative stress-related injury to cells, endothelial damage, and dysfunction of several cellular channels. Paradigms are now being challenged by growing evidence of a phenomenon called glucotoxicity, providing an explanation for the benefits of lowering glucose levels with insulin therapy in these patients. In the present review, the authors present the data published on cardiac glucotoxicity and discuss the benefits of lowering plasma glucose to improve heart function and to positively affect the course of critical illness.
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Affiliation(s)
- Marc Scheen
- Intensive Care Division, University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Faculty of Medicine, Geneva, Switzerland
| | - Raphael Giraud
- Intensive Care Division, University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Faculty of Medicine, Geneva, Switzerland
| | - Karim Bendjelid
- Intensive Care Division, University Hospitals, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland.,Faculty of Medicine, Geneva, Switzerland
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Argyropoulos T, Korakas E, Gikas A, Kountouri A, Kostaridou-Nikolopoulou S, Raptis A, Lambadiari V. Stress Hyperglycemia in Children and Adolescents as a Prognostic Indicator for the Development of Type 1 Diabetes Mellitus. Front Pediatr 2021; 9:670976. [PMID: 33981655 PMCID: PMC8107212 DOI: 10.3389/fped.2021.670976] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/01/2021] [Indexed: 12/16/2022] Open
Abstract
Hyperglycemia is a common manifestation in the course of severe disease and is the result of acute metabolic and hormonal changes associated with various factors such as trauma, stress, surgery, or infection. Numerous studies demonstrate the association of adverse clinical events with stress hyperglycemia. This article briefly describes the pathophysiological mechanisms which lead to hyperglycemia under stressful circumstances particularly in the pediatric and adolescent population. The importance of prevention of hyperglycemia, especially for children, is emphasized and the existing models for the prediction of diabetes are presented. The available studies on the association between stress hyperglycemia and progress to type 1 diabetes mellitus are presented, implying a possible role for stress hyperglycemia as part of a broader prognostic model for the prediction and prevention of overt disease in susceptible patients.
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Affiliation(s)
| | - Emmanouil Korakas
- Second Department of Internal Medicine and Research Institute, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Aikaterini Kountouri
- Second Department of Internal Medicine and Research Institute, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Athanasios Raptis
- Second Department of Internal Medicine and Research Institute, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Vaia Lambadiari
- Second Department of Internal Medicine and Research Institute, Medical School, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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16
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Abdul Razak A, Abu-Samah A, Abdul Razak NN, Jamaludin U, Suhaimi F, Ralib A, Mat Nor MB, Pretty C, Knopp JL, Chase JG. Assessment of Glycemic Control Protocol (STAR) Through Compliance Analysis Amongst Malaysian ICU Patients. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2020; 13:139-149. [PMID: 32607009 PMCID: PMC7282801 DOI: 10.2147/mder.s231856] [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: 09/20/2019] [Accepted: 01/15/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose This paper presents an assessment of an automated and personalized stochastic targeted (STAR) glycemic control protocol compliance in Malaysian intensive care unit (ICU) patients to ensure an optimized usage. Patients and Methods STAR proposes 1–3 hours treatment based on individual insulin sensitivity variation and history of blood glucose, insulin, and nutrition. A total of 136 patients recorded data from STAR pilot trial in Malaysia (2017–quarter of 2019*) were used in the study to identify the gap between chosen administered insulin and nutrition intervention as recommended by STAR, and the real intervention performed. Results The results show the percentage of insulin compliance increased from 2017 to first quarter of 2019* and fluctuated in feed administrations. Overall compliance amounted to 98.8% and 97.7% for administered insulin and feed, respectively. There was higher average of 17 blood glucose measurements per day than in other centres that have been using STAR, but longer intervals were selected when recommended. Control safety and performance were similar for all periods showing no obvious correlation to compliance. Conclusion The results indicate that STAR, an automated model-based protocol is positively accepted among the Malaysian ICU clinicians to automate glycemic control and the usage can be extended to other hospitals already. Performance could be improved with several propositions.
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Affiliation(s)
| | - Asma Abu-Samah
- Department of Electrical, Electronics and Systems, Faculty of Engineering and Built Environment, Universiti Kebangsaan Malaysia, Bangi, Malaysia
| | | | - Ummu Jamaludin
- Department of Mechanical Engineering, Universiti Malaysia Pahang, Kuantan, Malaysia
| | - Fatanah Suhaimi
- Advanced Medical and Dental Institute, Universiti Sains Malaysia, Pulau Pinang, Malaysia
| | - Azrina Ralib
- Department of Anesthesiology, International Islamic University Malaysia, Kuantan, Malaysia
| | - Mohd Basri Mat Nor
- Intensive Care Unit, International Islamic University Medical Centre, Kuantan, Malaysia
| | - Christopher Pretty
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - Jennifer Laura Knopp
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
| | - James Geoffrey Chase
- Department of Mechanical Engineering, University of Canterbury, Christchurch, New Zealand
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17
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Miyauchi H, Fujioka K, Okubo S, Nishida K, Ashina M, Ikuta T, Okata Y, Maeda K, Iijima K, Bitoh Y. Insulin therapy for hyperglycemia in neonatal sepsis using a preterm mouse model. Pediatr Int 2020; 62:581-586. [PMID: 31885143 DOI: 10.1111/ped.14126] [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: 06/05/2019] [Revised: 11/21/2019] [Accepted: 12/25/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Stress-induced hyperglycemia is a frequent complication of neonatal sepsis. Hyperglycemia induces oxidative stress and immunosuppression. We investigated the glucose kinetics and effect of insulin administration during stress-induced hyperglycemia in a neonatal sepsis mouse model. METHODS A stock cecal slurry (CS) solution was prepared from adult cecums and 3.0 mg of CS/g (LD40 ) was administered intraperitoneally to 4-day-old FVB mouse pups. Blood glucose levels were measured at 1.5, 3, 6, and 9 h post-sepsis induction and compared with basal levels. Two different doses of ultrafast-acting insulin were administered subcutaneously, and blood glucose levels and survival rates were monitored. RESULTS Blood glucose levels were significantly higher than those of baseline levels with a peak at 3 h, which progressively decreased from 6 to 9 h post-sepsis induction. Insulin treatment reduced post-sepsis-induced hyperglycemia at 1.5 and 3 h. The mortality rate of CS-only pups (39%) was similar to that of CS + 1 U/kg insulin pups (60%). However, the mortality rate of CS + 5 U/kg insulin pups (82%) was significantly higher than that of CS-only pups. CONCLUSIONS Marked hyperglycemia was induced immediately after post-sepsis induction, and the high-dose insulin treatment increased mortality post-induction. Stress-induced hyperglycemia could therefore be a physiological and protective response for preterm sepsis, and aggressive treatment of this hyperglycemia might be contraindicated.
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Affiliation(s)
- Harunori Miyauchi
- Department of Pediatric Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kazumichi Fujioka
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Saki Okubo
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kosuke Nishida
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Mariko Ashina
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Toshihiko Ikuta
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuichi Okata
- Department of Pediatric Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Kosaku Maeda
- Department of Pediatric Surgery, Kobe Children's Hospital, Kobe, Japan
| | - Kazumoto Iijima
- Department of Pediatrics, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yuko Bitoh
- Department of Pediatric Surgery, Kobe University Graduate School of Medicine, Kobe, Japan
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Effect of Personalized Music Intervention in Mechanically Ventilated Children in the PICU: A Pilot Study. Pediatr Crit Care Med 2020; 21:e8-e14. [PMID: 31652195 DOI: 10.1097/pcc.0000000000002159] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the feasibility of a personalized music intervention with mechanically ventilated patients in the PICU. DESIGN Pilot study with a quasi-experimental design. SETTING Tertiary children's hospital in China with a 40-bed PICU. PATIENTS Children, 1 month to 7 years, with mechanical ventilation were recruited and assigned to music group (n = 25) and control group (n = 25). INTERVENTIONS Children in the music group received their own favorite music and listened for 60 minutes three times a day. The control group receive routine care without music. MEASUREMENTS AND MAIN RESULTS Primary outcome measure was comfort measured with the COMFORT Behavior scale 5 minutes before and after the music. Secondary outcome measures were physiologic variables; heart rate, respiration, blood pressure, oxygen saturation. Mechanical ventilation time, length of stay, and sedation medication were also collected. Qualitative analysis revealed that nurses had a positive attitude in delivering the interventions and identified improvements for the main trial. Children in the music group had lower COMFORT Behavior scores (15.7 vs 17.6; p = 0.011). Children in the music group had better physiologic outcomes; heart rate (140 vs 144; p = 0.039), respiration rate (40 vs 43; p = 0.036), systolic blood pressure (93 vs 95 mm Hg; p = 0.031), oxygen saturation (96% vs 95%; p < 0.001), diastolic blood pressure was not significantly (52 vs 53 mm Hg; p = 0.11). Children in the music group had a shorter ventilation time (148.7 vs 187.6; p = 0.044) and a shorter length of stay, but not significant (11.2 vs 13.8; p = 0.071). Children in the control group had higher total amount of on-demand midazolam (29 vs 33 mg; p = 0.040). CONCLUSIONS Our pilot study indicates that personalized music intervention is feasible and might improve the comfort of children with mechanical ventilation. Further studies are needed to provide conclusive evidence in confirming the effectiveness of music interventions comforting critically ill children in PICUs.
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Hajian P, Shabani M, Khanlarzadeh E, Nikooseresht M. The Impact of Preoperative Fasting Duration on Blood Glucose and Hemodynamics in Children. J Diabetes Res 2020; 2020:6725152. [PMID: 32904566 PMCID: PMC7456475 DOI: 10.1155/2020/6725152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/14/2020] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Prolonged preoperative fasting is one of the concerns of pediatricians and anesthesiologists in pediatric surgery. The aim of this study was to assess the impact of preoperative fasting duration on blood glucose and hemodynamics in children. METHODS This cross-sectional study was conducted on 50 children who were between the ages of 3 and 12 years in Besat Hospital, Hamedan, Iran. The time of the last solid and liquid meal taken by child were recorded based on interview with the parents. The first blood glucose test was obtained in the operation room, and the second test was performed 20 minutes after induction of anesthesia by glucometer. Systolic blood pressure (SBP), mean arterial pressure (MAP), and heart rate (HR) were recorded before anesthesia induction and in five-minute intervals in the first 20 minutes of surgery. RESULTS The mean age of the children was 6.63 (SD 1.85) years. Mean blood glucose 20 minutes after surgery was 101.17 (SD 92) mg/dl, which was significantly higher than the baseline values (87.66 (SD 11.84) mg/dl) (P < 0.001). The comparison of mean blood glucose level between groups of fasting with different duration for solids (<12 hours and >12 hours) and for liquids (<6 hours and >6 hours) revealed no significant difference in either groups (P > 0.05). No significant correlation was observed between blood glucose level at the induction of anesthesia with weight and age (P > 0.05). There was a significantly negative correlation between duration of fasting for liquids and SBP (P > 0.05). CONCLUSION Prolonged preoperative fasting cannot affect blood glucose in children; however, maybe it has impact on systolic blood pressure.
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Affiliation(s)
- Pouran Hajian
- Department of Anesthesiology, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Minoo Shabani
- Student Research Committee, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Elham Khanlarzadeh
- Department of Community Medicine, School of Medicine Health Sciences, Hamadan University of Medical Sciences, Hamadan, Iran
| | - Mahshid Nikooseresht
- Department of Anesthesiology, Besat Hospital, Hamadan University of Medical Sciences, Hamadan, Iran
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Outcomes Associated With Multiple Organ Dysfunction Syndrome in Critically Ill Children With Hyperglycemia. Pediatr Crit Care Med 2019; 20:1147-1156. [PMID: 31688812 PMCID: PMC6895434 DOI: 10.1097/pcc.0000000000002151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVES Patterns and outcomes of multiple organ dysfunction syndrome are unknown in critically ill children with hyperglycemia. We aimed to determine whether tight glycemic control to a lower vs. higher range influenced timing, duration, or resolution of multiple organ dysfunction syndrome as well as characterize the clinical outcomes of subgroups of multiple organ dysfunction syndrome in children enrolled in the Heart And Lung Failure-Pediatric INsulin Titration trial. DESIGN Planned secondary analysis of the multicenter Heart And Lung Failure-Pediatric INsulin Titration trial. SETTING Thirty-five PICUs. PATIENTS Critically ill children with hyperglycemia who received the Heart And Lung Failure-Pediatric INsulin Titration protocol from 2012 to 2016. INTERVENTIONS Randomization to a lower versus higher glucose target group. MEASUREMENTS AND MAIN RESULTS Of 698 patients analyzed, 48 (7%) never developed multiple organ dysfunction syndrome, 549 (79%) had multiple organ dysfunction syndrome without progression, 32 (5%) developed new multiple organ dysfunction syndrome, and 69 (10%) developed progressive multiple organ dysfunction syndrome. Of those whose multiple organ dysfunction syndrome resolved, 192 (34%) experienced recurrent multiple organ dysfunction syndrome. There were no significant differences in the proportion of multiple organ dysfunction syndrome subgroups between Heart And Lung Failure-Pediatric INsulin Titration glucose target groups. However, patients with new or progressive multiple organ dys function syndrome had fewer ICU-free days through day 28 than those without new or progressive multiple organ dysfunction syndrome, and progressive multiple organ dysfunction syndrome patients had fewer ICU-free days than those with new multiple organ dysfunction syndrome: median 25.1 days for never multiple organ dysfunction syndrome, 20.2 days for multiple organ dysfunction syndrome without progression, 18.6 days for new multiple organ dysfunction syndrome, and 0 days for progressive multiple organ dysfunction syndrome (all comparisons p < 0.001). Patients with recurrent multiple organ dysfunction syndrome experienced fewer ICU-free days than those without recurrence (median, 11.2 vs 22.8 d; p < 0.001). CONCLUSIONS Tight glycemic control target range was not associated with differences in the proportion of new, progressive, or recurrent multiple organ dysfunction syndrome. New or progressive multiple organ dysfunction syndrome was associated with poor clinical outcomes, and progressive multiple organ dysfunction syndrome was associated with worse outcomes than new multiple organ dysfunction syndrome. In future studies, new multiple organ dysfunction syndrome and progressive multiple organ dysfunction syndrome may need to be considered separately, as they represent distinct subgroups with different, potentially modifiable risk factors. Patients with recurrent multiple organ dysfunction syndrome represent a newly characterized, high-risk group which warrants attention in future research.
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21
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Guidelines for the Management of Pediatric Severe Traumatic Brain Injury, Third Edition: Update of the Brain Trauma Foundation Guidelines. Pediatr Crit Care Med 2019; 20:S1-S82. [PMID: 30829890 DOI: 10.1097/pcc.0000000000001735] [Citation(s) in RCA: 164] [Impact Index Per Article: 32.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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22
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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.
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Affiliation(s)
| | - Huda Marzouk
- Department of Pediatrics, Cairo University - Cairo, Egypt
| | - Riham El-Sayed
- Department of Clinical and Chemical Pathology, Cairo University - Cairo; Egypt
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Tumwebaze A, Kiboneka E, Mugalu J, Kikabi EM, Tumwine JK. Prevalence and outcome of stress hyperglycaemia among severely malnourished children admitted to Mulago referral and teaching hospital in Kampala, Uganda. BMC Nutr 2018; 4:49. [PMID: 32153910 PMCID: PMC7050710 DOI: 10.1186/s40795-018-0258-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/29/2018] [Indexed: 01/19/2023] Open
Abstract
Background Stress hyperglycaemia is a transient increase in blood glucose level during stressful events and is common in critically ill children. Several studies have demonstrated increased risk of mortality in these children. There is paucity of information on this subject in sub Saharan Africa.The aim of this study was to describe the prevalence, outcome and factors associated with stress hyperglycaemia among children with severe acute malnutrition (SAM) admitted to the Mwanamugimu nutrition unit of Mulago hospital in Uganda. Methods This study was conducted from August 2015 to March 2016 at the Mwanamugimu nutrition unit of Mulago hospital among severely malnourished children aged 1 to 60 months. Random blood sugar levels were measured. Stress hyperglycaemia was considered as a random blood sugar > 150 mg/dl. The final outcome was ascertained at death or discharge. Statistical analysis was done using the Chi square test and logistic regression. Results Two hundred and thirty-five children were enrolled of whom 50% were girls. The median age was 5.1 months (range 1-60 months). Stress hyperglycaemia was present in 16.6% of the 235 participants. Several factors were significantly associated with stress hyperglycaemia at bivariate analysis; but on logistic regression, only presence of oral sores was associated with stress hyperglycaemia: (Odds ratio 2.61; 95% CI 1.02-6.65).Mortality was higher among children with stress hyperglycaemia (56.4%) compared to (12.8%) in the non-hyperglycaemic group: OR 8.75; 95% CI 4.09-18.70). Conclusion The prevalence of stress hyperglycaemia was 16.6% and was associated with high mortality. It is important to monitor blood glucose levels of severely malnourished children. Hitherto, the main concern among severely malnourished children has been hypoglycaemia. Innovative ways of preventing and managing stress hyperglycaemia among these children are urgently needed.
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Affiliation(s)
- Anita Tumwebaze
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Elizabeth Kiboneka
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Jamir Mugalu
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Edward M Kikabi
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - James K Tumwine
- Department of Paediatrics and Child Health, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
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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.
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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
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Tight glycemic control in critically ill pediatric patients: a meta-analysis and systematic review of randomized controlled trials. Pediatr Res 2018; 84:22-27. [PMID: 29795449 DOI: 10.1038/s41390-018-0002-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 11/02/2017] [Accepted: 11/19/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND There still are controversies in the impact of tight glycemic control (TGC) in critically ill children. The aim of this study was to assess the benefits and risks of TGC compared with conventional glycemic control (CGC) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) by using data retrieved from randomized controlled trials (RCTs). METHOD EMBASE, CNKI, PubMed, and the Cochrane Database were searched for RCTs comparing TGC with CGC in critically ill children in PICU. RESULT The meta-analysis included five RCTs representing 3933 patients and compared TGC with CGC. Our result revealed that TGC did not reduce the 30-day mortality rates (OR 0.99, 95% CI 0.74-1.32, P = 0.95) and was not associated with decreasing health care-associated infections (OR 0.80, 95% CI 0.64-1.00, P = 0.05) compared with CGC, but significantly increased the incidence of hypoglycemia (OR 6.37, 95% CI 4.41-9.21, P < 0.001). CONCLUSION Tight glycemic control was not associated with reducing the 30-day mortality rates and acquired infections compared with CGC in critically ill children. Significant increase of the incidence of hypoglycemia was revealed in TGC group. The conclusion should be interpreted with caution for the methodological heterogeneity among trials.
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26
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Thabet Mahmoud A, Tawfik MAM, Abd El Naby SA, Abo El Fotoh WMM, Saleh NY, Abd El Hady NMS. Neurophysiological study of critical illness polyneuropathy and myopathy in mechanically ventilated children; additional aspects in paediatric critical illness comorbidities. Eur J Neurol 2018; 25:991-e76. [PMID: 29604150 DOI: 10.1111/ene.13649] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 03/27/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Critical illness polyneuropathy and myopathy (CIP/CIM) is being increasingly recognized as a significant clinical problem in critically ill children especially if they have spent long periods in the intensive care unit. So the aim was to determine the frequency of CIP/CIM amongst mechanically ventilated children and to analyse the associated risk factors and drawbacks frequently encountered in this cohort. METHODS The study included 105 patients admitted to the paediatric intensive care unit who underwent mechanical ventilation for ≥7 days. These patients were screened daily for awakening. Patients with severe muscle weakness on day 7 post-awakening underwent nerve conduction studies and electromyography. Accordingly, the patients were classified as CIP/CIM patients if they had abnormal neurophysiology studies or control patients if normal neurophysiology studies were obtained. Their clinical and laboratory profiles had been recorded as well. RESULTS Overall, of 105 patients who achieved satisfactory awakening, 34 patients (32.4%) developed CIP/CIM mostly of the axonal polyneuropathy pattern (27.6%) whilst 71 control patients (67.6%) showed normal electrophysiological studies. The mean duration of mechanical ventilation was significantly longer in patients with CIP/CIM compared to control patients (P = 0.001). The study also revealed that 62.1% of our CIP/CIM patients failed weaning trials and finally died. CIP/CIM was significantly associated with decreased platelets, elevated liver enzymes and prolonged prothrombin time. Acidosis, low serum calcium and albumin levels and higher blood glucose were also found to be more significant in CIP/CIM patients compared to control patients. CONCLUSION Critically ill children frequently develop CIP/CIM, mostly of axonal polyneuropathy pattern, which compromises rehabilitation and recovery and is associated with a number of comorbidities.
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Affiliation(s)
- A Thabet Mahmoud
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - M A M Tawfik
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - S A Abd El Naby
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - W M M Abo El Fotoh
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - N Y Saleh
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
| | - N M S Abd El Hady
- Faculty of Medicine, Menoufia University Hospitals, Shebin El-Kom, Egypt
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Zhao Y, Wu Y, Xiang B. Tight glycemic control in critically ill pediatric patients: a meta-analysis and systematic review of randomized controlled trials. Pediatr Res 2018; 83:930-935. [PMID: 29244792 DOI: 10.1038/pr.2017.310] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Accepted: 11/19/2017] [Indexed: 02/05/2023]
Abstract
BackgroundThere still are controversies in the impact of tight glycemic control (TGC) in critically ill children. The aim of this study was to assess the benefits and risks of TGC compared with conventional glycemic control (CGC) in critically ill pediatric patients admitted to the pediatric intensive care unit (PICU) by using the data retrieved from randomized controlled trials (RCTs).MethodsEMBASE, CNKI, PubMed, and the Cochrane Database were searched for RCTs comparing TGC with CGC in critically ill children in PICU.ResultsThe meta-analysis included 5 RCTs representing 3,933 patients that compared TGC with CGC. Our result revealed that TGC did not reduce 30-day mortality rates (odds ratio (OR) 0.99, 95% confidence interval (CI) 0.74-1.32, P=0.95) and was not associated with decreasing health care-associated infections (OR 0.80, 95% CI 0.64-1.00, P=0.05) compared with CGC, but significantly increased the incidence of hypoglycemia (OR 6.37, 95% CI 4.41-9.21, P<0.001).ConclusionTight glycemic control was not associated with reducing 30-day mortality rates and acquired infections compared with CGC in critically ill children. Significant increase of incidence of hypoglycemia was revealed in TGC group. The conclusion should be interpreted with caution for the methodological heterogeneity among trials.
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Affiliation(s)
- Yiyang Zhao
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Yang Wu
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Bo Xiang
- Department of Pediatric Surgery, Sichuan University West China Hospital, Chengdu, Sichuan, China
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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.
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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
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Uleanya ND, Aniwada EC, Nwokoye IC, Ndu IK, Eke CB. Relationship between Glycemic Levels and Treatment Outcome among Critically Ill Children admitted into Emergency Room in Enugu. BMC Pediatr 2017; 17:126. [PMID: 28511644 PMCID: PMC5434620 DOI: 10.1186/s12887-017-0879-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 05/08/2017] [Indexed: 01/08/2023] Open
Abstract
Background Critically ill children are those in need of immediate attention on arrival to an emergency room. The importance of glycemic level measurement as well as maintaining the patency of the airway, effective breathing and circulation cannot be overemphasied. It has been highlighted that the peak hyperglycemia and hypoglycemia predict poor prognosis, longer lengths of hospital stay and higher mortality. The study aims to assess the relationship between glycemic level and treatment outcomes as well as length of hospital stay. Methods Analytical cross sectional method was used to study critically ill children aged ≥1 month to ≤10 years admitted into the Children Emergency Room of Enugu State University Teaching Hospital, Enugu. Their admission blood glucose was done. Interviewer administered questionnaire was used to collect information including sociodemographics, duration of hospitalization and outcome of treatment. Data was analysed using SPSS version 20. Chi square, logistic regressions and Kruskal Wallis tests were done as appropriate. Results A total of 300 patients were recruited. One hundred and seventeen (39%) had hyperglycemia, 62 (20.7%) patients had hypoglycaemia and 121 (40.3%) had euglycemia. Two hundred and fifty two (84%) were discharged while 48 (16%) died. There was significant association between glycemic levels and treatment outcome (p = < 0.001). Among the 48 who died, 12 (25.0%) had euglycemia, 21 (43.75%) had hypoglycaemia while 15 (31.25%) had hyperglycemia. On multivariate analysis, there was statistically significant association between hypoglycaemia and mortality (p = < 0.001). Unadjusted, those children with hypoglycaemia at presentation were about 4.7 times (UOR = 0.21, 95% Cl: 0.08–0.38) and adjusted, about 5 times (AOR = 0.20, 95% CI: 0.09–0.47) less likely to survive compared with those with euglycemia. Although not statistically significant, those with hyperglycemia were about 1.3 times less likely to survive compared with euglycemic children, adjusted and unadjusted (UOR = 0.75, 95% Cl: 0.33–1.68). Conclusion While both hypo- and hyperglycemia are associated with mortality, hypoglycaemia had a greater effect than hyperglycemia. Glycemic levels significantly affects treatment outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12887-017-0879-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
| | - Elias Chikee Aniwada
- Department of Community Medicine, University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria
| | | | - Ikenna Kingsley Ndu
- Department of Pediatrics, Enugu State University Teaching Hospital, Enugu, Nigeria
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Hirshberg EL, Lanspa MJ, Wilson EL, Sward KA, Jephson A, Larsen GY, Morris AH. A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages. Diabetes Technol Ther 2017; 19:188-193. [PMID: 28248127 PMCID: PMC5359657 DOI: 10.1089/dia.2016.0423] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Computer clinical decision support (CDS) systems are uncommon in the pediatric intensive care unit (PICU), despite evidence suggesting they improve outcomes in adult ICUs. We reasoned that a bedside CDS protocol for intravenous insulin titration, eProtocol-insulin, would be feasible and safe in critically ill children. METHODS We retrospectively reviewed data from non-diabetic children admitted to the PICU with blood glucose (BG) ≥140 mg/dL who were managed with intravenous insulin by either unaided clinician titration or eProtocol-insulin. Primary outcomes were BG measurements in target range (80-110 mg/dL) and severe hypoglycemia (BG ≤40 mg/dL); secondary outcomes were 60-day mortality and PICU length of stay. We assessed bedside nurse satisfaction with the eProtocol-insulin protocol by using a 5-point Likert scale and measured clinician compliance with eProtocol-insulin recommendations. RESULTS Over 5 years, 69 children were titrated with eProtocol-insulin versus 104 by unaided clinicians. eProtocol-insulin achieved target range more frequently than clinician titration (41% vs. 32%, P < 0.001). Severe hypoglycemia was uncommon in both groups (4.3% of patients in eProtocol-insulin, 8.7% in clinician titration, P = 0.37). There were no differences in mean time to BG target or median BG between the groups. Mortality was 23% in both groups. Clinician compliance with eProtocol-insulin recommendations was 89%. Nurses believed that eProtocol-insulin was easy to understand and safer than clinician titration. CONCLUSIONS eProtocol-insulin is safe for titration of intravenous insulin in critically ill children. Clinical research protocols and quality improvement initiatives aimed at optimizing BG control should utilize detailed computer protocols that enable replicable clinician decisions.
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Affiliation(s)
- Eliotte L. Hirshberg
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, Utah
| | - Michael J. Lanspa
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah
| | - Emily L. Wilson
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Center for Humanizing Critical Care, Intermountain Medical Center, Murray, Utah
| | - Katherine A. Sward
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
- University of Utah School of Nursing, Salt Lake City, Utah
| | - Al Jephson
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
| | - Gitte Y. Larsen
- Pediatric Critical Care, University of Utah School of Medicine, Salt Lake City, Utah
| | - Alan H. Morris
- Pulmonary and Critical Care Division, Intermountain Medical Center, Murray, Utah
- Pulmonary and Critical Care Medicine, University of Utah School of Medicine, Salt Lake City, Utah
- Department of Biomedical Informatics, University of Utah School of Medicine, Salt Lake City, Utah
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"Clamping" Down on Insulin to Modulate the Three-Legged Stool of Hormones, Inflammation, and Metabolism in Critical Illness! Pediatr Crit Care Med 2017; 18:93-95. [PMID: 28060161 DOI: 10.1097/pcc.0000000000001012] [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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Marano M, Lonati D, Locatelli CA, Pisani M. Letter in response to: “Hyperglycemia is a risk factor for high-grade envenomations after European viper bites ( Vipera spp.) in children”. Clin Toxicol (Phila) 2016; 54:539. [DOI: 10.3109/15563650.2016.1166374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Marco Marano
- Pediatric Intensive Care Unit, IRCCS “Bambino Gesù” Children Hospital, Piazza Sant'Onofrio, 4, Rome, Italy
| | - Davide Lonati
- Poison Control Centre and National Toxicology Information Centre, Toxicology Unit, IRCCS Maugeri Foundation Hospital and University of Pavia, via Maugeri, 10, Pavia, 27100, Italy
| | - Carlo Alessandro Locatelli
- Poison Control Centre and National Toxicology Information Centre, Toxicology Unit, IRCCS Maugeri Foundation Hospital and University of Pavia, via Maugeri, 10, Pavia, 27100, Italy
| | - Mara Pisani
- Emergency Department, IRCCS “Bambino Gesù” Children Hospital, Piazza Sant'Onofrio, 4, Rome, Italy
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Grimaud M, de Lonlay P, Dupic L, Arnoux JB, Brassier A, Hubert P, Lesage F, Oualha M. High glucose intake and glycaemic level in critically ill neonates with inherited metabolic disorders of intoxication. Eur J Pediatr 2016; 175:849-58. [PMID: 27023793 DOI: 10.1007/s00431-016-2717-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 03/15/2016] [Accepted: 03/18/2016] [Indexed: 10/22/2022]
Abstract
UNLABELLED To investigate glycaemic levels in critically ill neonates with inherited metabolic disorders of intoxication. Thirty-nine neonates with a median age of 7 days (0-24) were retrospectively included (urea cycle disorders (n = 18), maple syrup disease (n = 13), organic acidemias (n = 8)). Twenty-seven neonates were intubated, 21 were haemodialysed and 6 died. During the first 3 days, median total and peak blood glucose (BG) levels were 7.1 mmol/L (0.9-50) and 10 mmol/L (5.1-50), respectively. The median glucose intake rate was 11 mg/kg/min (2.7-15.9). Fifteen and 23 neonates exhibited severe hyperglycaemia (≥2 BG levels >12 mmol/L) and mild hyperglycaemia (≥2 BG levels >7 and ≤12 mmol/L), respectively. Glycaemic levels and number of hyperglycaemic neonates decreased over the first 3 days (p < 0.001) while total glucose intake rate was stable (p = 0.11). Enteral route of glucose intake was associated with a lower number of hyperglycaemic neonates (p = 0.04) and glycaemic level (p = 0.02). CONCLUSION Hyperglycaemia is common in critically ill neonates receiving high glucose intake with inherited metabolic disorders of intoxication. Physicians should decrease the rate of total glucose intake and begin enteral feeding as quickly as possible in cases of persistent hyperglycaemia. WHAT IS KNOWN • The risk of hyperglycaemia in the acute phase of critical illness is high. What is New: • Hyperglycaemia is common in the initial management of critically ill neonates with inherited metabolic disorders of intoxication receiving high glucose intake.
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Affiliation(s)
- Marion Grimaud
- Pediatric Intensive Care Unit, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, 149, Rue de Sèvres, 75743, Paris, Cedex 15, France
| | - Pascale de Lonlay
- Pediatric Metabolic Diseases Department, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, Paris, France
| | - Laurent Dupic
- Pediatric Intensive Care Unit, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, 149, Rue de Sèvres, 75743, Paris, Cedex 15, France
| | - Jean-Baptiste Arnoux
- Pediatric Metabolic Diseases Department, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, Paris, France
| | - Anais Brassier
- Pediatric Metabolic Diseases Department, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, Paris, France
| | - Philippe Hubert
- Pediatric Intensive Care Unit, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, 149, Rue de Sèvres, 75743, Paris, Cedex 15, France
| | - Fabrice Lesage
- Pediatric Intensive Care Unit, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, 149, Rue de Sèvres, 75743, Paris, Cedex 15, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, Necker-Enfants-Malades Hospital, APHP, Paris-Descartes University, 149, Rue de Sèvres, 75743, Paris, Cedex 15, France.
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Wilson B, Typpo K. Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:108. [PMID: 27790606 PMCID: PMC5061746 DOI: 10.3389/fped.2016.00108] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Accepted: 09/20/2016] [Indexed: 12/18/2022] Open
Abstract
Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.
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Affiliation(s)
- Bryan Wilson
- Department of Emergency Medicine, University of Arizona College of Medicine , Tucson, AZ , USA
| | - Katri Typpo
- Department of Pediatrics, Steele Children's Research Center, University of Arizona College of Medicine , Tucson, AZ , USA
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de Grauw AM, Mul D, van Noesel MM, Buddingh EP. Stress hyperglycaemia as a result of a catecholamine producing tumour in an infant. BMJ Case Rep 2015; 2015:bcr-2014-209091. [PMID: 26341160 DOI: 10.1136/bcr-2014-209091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Hyperglycaemia commonly occurs in children presenting at the emergency department. In the absence of diabetic symptoms, this stress-related hyperglycaemia is considered a benign condition. We present a malignant cause of hyperglycaemia in an 11-month-old girl with concomitant symptoms of a neuroendocrine malignancy. One month earlier, she had undergone an episode of stress-related hyperglycaemia concurrent with fever during an upper respiratory tract infection. Current glucose level was 234 mg/dL (13 mmol/L) and the glycosylated haemoglobin level was 44 mmol/mol (6.2%) without metabolic acidosis. We observed periods of hyperglycaemia, sweating, flushing, hypertension and tachypnoea. Urinalysis showed high amounts of catecholamine intermediates. Abdominal ultrasound revealed a mass originating in the right adrenal gland. Histology confirmed the diagnosis of neuroblastoma. Hyperglycaemia in this patient was the first presenting symptom of a metabolically active neuroblastoma.
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Affiliation(s)
- Anne Mariëtte de Grauw
- Department of Pediatrics, HAGAziekenhuis/Juliana Children's Hospital, The Hague, The Netherlands
| | - Dick Mul
- Diabeter, National Centre for Pediatric and Adolescent Diabetes Care and Research, Rotterdam, The Netherlands
| | - Max M van Noesel
- Department of Pediatric Oncology/Hematology, Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Emilie P Buddingh
- Department of Pediatric Infectious Diseases and Immunology, Sophia Children's Hospital, Rotterdam, The Netherlands
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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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Tight Glucose Control With Insulin Following Pediatric Cardiac Surgery: Still "Muscling" on in Search of Answers! Pediatr Crit Care Med 2015; 16:587-8. [PMID: 26154902 DOI: 10.1097/pcc.0000000000000459] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
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Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg 2015; 150:498-504.e1. [PMID: 26190660 DOI: 10.1016/j.jtcvs.2015.06.028] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 06/10/2015] [Accepted: 06/14/2015] [Indexed: 11/22/2022]
Abstract
OBJECTIVES Hyperglycemia is common after pediatric cardiopulmonary bypass (CPB) surgery and is attributed to a state of insulin resistance. We examined the role of CPB-induced inflammation on postoperative plasma glucose, insulin, and the glucose-to-insulin ratio, which was used as a marker of insulin resistance; a decrease in the ratio reflects increased resistance. METHODS We conducted an ancillary study on a previously published randomized trial of children undergoing CPB surgery. Serial blood glucose, insulin, and cytokines were drawn after CPB and at selected intervals for up to 48 hours after surgery. The primary outcome was plasma insulin levels and glucose-to-insulin ratio. Glucose delivery and feeding status were monitored for potential modifying effects. RESULTS The 299 children studied were predominantly male (55%) with a median age of 2.7 (interquartile range [IQR]: 0.5-6.5) years, and weight of 12.6 (IQR: 6.4-10.8) kg. Operations had a median Society of Thoracic Surgery-European Association for Cardio-Thoracic Surgery complexity score of 1 (IQR: 1-2) and CPB time of 82 (IQR: 58-122) minutes. Hyperglycemia occurred in 85% of subjects; odds of hyperglycemia peaked at 6 hours after CPB. Plasma glucose was associated with increased insulin and a lower glucose-to-insulin ratio. Increased interleukin (IL)-6 concentrations were associated with increased glucose (estimate [EST]: 0.55 (±0.13) mmol/L; P < .001) and insulin (EST: 1.14 (±0.12) μmol/L; P < .001) in linear regression adjusted for repeated measures. Paradoxically, increased cytokines were associated with an increased glucose-to-insulin ratio (EST: 0.21 (±0.03) mmol/μmol; P < .001). CONCLUSIONS Hyperglycemia after pediatric CPB surgery is associated with hyperinsulinemia, which may reflect insulin resistance in some patients. Inflammation induced by CPB may play a causative role in insulin resistance.
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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.
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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
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Role of AMPK α in skeletal muscle glycometabolism regulation and adaptation in relation to sepsis. BIOMED RESEARCH INTERNATIONAL 2014; 2014:390760. [PMID: 25097857 PMCID: PMC4100375 DOI: 10.1155/2014/390760] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 06/16/2014] [Indexed: 12/19/2022]
Abstract
Background. AMP-activated protein kinase (AMPK) and the translocation of glucose transporter 4 (GLUT4) protein always involve disturbance of carbohydrate metabolism. Objective. To determine whether the change of blood glucose in the early stage of septic rat is associated with the alteration of AMPKα protein expression and GLUT4 protein translocation expression. Methods. Animal models of sepsis were induced by tail vein injection of LPS in Wistar rats. The dynamic values of blood glucose within 2 hours after injection of LPS were observed. AMPKα protein and GLUT4 protein translocation in different tissues (such as soleus muscle and extensor digitorum longus) were assessed by western blot.
Results. Blood glucose levels appeared to rise at 0.5 h after injection of LPS, arrived the peak value at 1 h, then fell at 1.5 h and 2 h Animals in LPS group experienced the increase of phos-AMPKα protein and GLUT4 protein translocation expression in soleus muscle and extensor digitorum longus. Conclusion. The dynamic change of blood glucose, represented in a form of initiative increase and subsequent decrease in the early stage of sepsis, may be related to glycometabolism disorder in the skeletal muscle, coming down to enhancement of GLUT4 translocation expression promoted by activation of AMPKα.
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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.
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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
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Abstract
PURPOSE OF REVIEW Hyperglycemia is a significant problem for children in the ICU. Use of tight glycemic control (TGC) to manage hyperglycemia remains controversial, especially given the potential risk of insulin-induced hypoglycemia. This review will address the latest evidence regarding TGC in critically ill children. RECENT FINDINGS Two randomized controlled trials (RCT) involving primarily postoperative cardiac surgery patients demonstrated the feasibility and safety of TGC in pediatric patients. The trials, however, had discrepant results with regards to the benefit of TGC. There is also uncertainty about the generalizability of these results to nonpostoperative cardiac patients. There is only one published study addressing the long-term safety of TGC in children. In this study, hypoglycemia was not associated with adverse effects on neurocognitive development. In contrast, articles from adult studies demonstrate increased risk of death with hypoglycemia. SUMMARY Although the clinical benefit of TGC in critically ill children is still unclear, TGC can be done safely in this population.
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