Relationship between Glycemic Levels and Treatment Outcome among Critically Ill Children admitted into Emergency Room in Enugu

Treatment Outcome and Associated Factors among Type 1 Diabetic Children Admitted with DKA in Bahir Dar City Public Referral Hospital, Northwest, Ethiopia: A Cross-sectional Study

Background. Outcomes that should be measured during diabetic ketoacidosis management is crucial. However, data associated to this was limited in Ethiopia. Methods. A cross-sectional study was conducted among children with diabetic keto acidosis between 2016 and 2021.Data were stored in Epi-data version 4.6 and exported into STATA 14.0 software for analysis. The association between independent variables and length of hospital stay was assessed using binary logistic regression. Finally, variables with P-value <.05 were considered statistically significant. Result. Median length of hospital stay was 8 ± 6.2 days. Majority of patients (97.5%) improved and discharged. Factors that affected longer hospital stay were Residence(aOR = 4.31;95% CI = 1.25-14.80),family history of diabetes (aOR = 0.12; 95% CI = 0.02-0.64), glycemia at admission (aOR = 1.01; 95% CI = 1.00-1.02),insulin skipping (aOR = 0.08; 95% CI = 0.01-0.98), abdominal pain (aOR = 4.28; 95% CI = 1.11-15.52) and time in which the patient get out of diabetic ketoacidosis(aOR = 6.39; 95% CI = 1.09-37.50). Conclusion. Majority of patients showed improvement and discharged to homes after a long hospital stay. Majority of patients resolved from diabetic ketoacidosis between 24 and 48 hours.

Prospective cohort study of referred Malawian children and their survival by hypoxaemia and hypoglycaemia status

Objective

To investigate survival in children referred from primary care in Malawi, with a focus on hypoglycaemia and hypoxaemia progression.

Methods

The study involved a prospective cohort of children aged 12 years or under referred from primary health-care facilities in Mchinji district, Malawi in 2019 and 2020. Peripheral blood oxygen saturation (SpO₂) and blood glucose were measured at recruitment and on arrival at a subsequent health-care facility (i.e. four hospitals and 14 primary health-care facilities). Children were followed up 2 weeks after discharge or their last clinical visit. The primary study outcome was the case fatality ratio at 2 weeks. Associations between SpO₂ and blood glucose levels and death were evaluated using Cox proportional hazards models and the treatment effect of hospitalization was assessed using propensity score matching.

Findings

Of 826 children recruited, 784 (94.9%) completed follow-up. At presentation, hypoxaemia was moderate (SpO₂: 90-93%) in 13.1% (108/826) and severe (SpO₂: < 90%) in 8.6% (71/826) and hypoglycaemia was moderate (blood glucose: 2.5-4.0 mmol/L) in 9.0% (74/826) and severe (blood glucose: < 2.5 mmol/L) in 2.3% (19/826). The case fatality ratio was 3.7% (29/784) overall but 26.3% (5/19) in severely hypoglycaemic children and 12.7% (9/71) in severely hypoxaemic children. Neither moderate hypoglycaemia nor moderate hypoxaemia was associated with mortality.

Conclusion

Presumptive pre-referral glucose treatment and better management of hypoglycaemia could reduce the high case fatality ratio observed in children with severe hypoglycaemia. The morbidity and mortality burden of severe hypoxaemia was high; ways of improving hypoxaemia identification and management are needed.

Association between Stress Hyperglycemia and Adverse Outcomes in Children Visiting the Pediatric Emergency Department

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.

Effect of hyperglycemia on all-cause mortality from pediatric brain injury: A systematic review and meta-analysis

BACKGROUND

This study aimed to assess the effect of hyperglycemia on all-cause mortality in pediatric patients with brain injury, based on currently available evidence.

METHODS

We systematically searched the PubMed, Embase, and Cochrane Library databases with the keywords "hyperglycemia", "brain injury", and "pediatrics". The retrieved records were screened by title, abstract, and full-text to include original articles assessing the effects of hyperglycemia on pediatric brain injury. The extracted data were assessed by a fixed-effects model. The risk of bias in the eligible studies was evaluated with the Newcastle-Ottawa Scale. Publication bias was visually examined with a funnel plot. Begg and Egger tests, respectively, were used to identify small-study effects. Sensitivity analysis was performed to evaluate the robustness of the original effect size.

RESULTS

Nine observational studies were identified from 1439 primary hits. A total of 970 pediatric patients, including 304 with hyperglycemia and brain injury, were included for meta-analysis. Hyperglycemia was strongly associated with a higher risk of all-cause mortality in pediatric patients (odds ratio = 11.60, 95% confidence interval [CI] 7.88-17.08; I = 0%). The overall quality of eligible studies was low, but the funnel plot indicated no publication bias.

CONCLUSIONS

Hyperglycemia is significantly associated with high all-cause mortality in pediatric patients with brain injury. However, the relationship should be confirmed by larger-scale observational studies and randomized controlled trials.

Effect on mortality of increasing the cutoff blood glucose concentration for initiating hypoglycaemia treatment in severely sick children aged 1 month to 5 years in Malawi (SugarFACT): a pragmatic, randomised controlled trial

BACKGROUND

Low blood glucose concentrations are common in sick children who present to hospital in low-resource settings and are associated with increased mortality. The cutoff blood glucose concentration for the diagnosis and treatment of hypoglycaemia currently recommended by WHO (2·5 mmol/L) is not evidence-based. We aimed to assess whether increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely ill children at presentation to hospital improves mortality outcomes.

METHODS

We did a pragmatic, randomised controlled trial at two referral hospitals in Malawi. Severely ill children aged 1 month to 5 years presenting to the emergency department with a capillary blood glucose concentration of between 2·5 mmol/L (3·0 mmol/L in severely malnourished children) and 5·0 mmol/L were randomly assigned (1:1) by a computer-generated randomisation sequence, stratified by study site and severe malnutrition, to receive either an immediate intravenous bolus of 10% dextrose at 5 mL/kg followed by a 24-h maintenance infusion of 10% dextrose at 100 mL/kg for the first 10 kg of bodyweight, 50 mL/kg for the next 10 kg, and 20 mL/kg for each subsequent kg of bodyweight (intervention group) or observation for a minimum of 60 min and standard care (control group). Participants and study personnel were not masked to treatment allocation. The primary outcome was all-cause in-hospital mortality, assessed on an intention-to-treat basis. Safety was also assessed in the intention-to-treat population. The study is registered with ClinicalTrials.gov, NCT02989675.

FINDINGS

Between Dec 5, 2016, and Jan 22, 2019, 10 947 children were screened, of whom 332 were randomly assigned, and 322 were included in the final analysis (n=162 in the control group and n=160 in the intervention group). The study was terminated after an interim analysis at 24% enrolment indicated futility. The median age of participants was 2·3 years (IQR 1·4-3·2), 65 (45%) were female, and the baseline characteristics of participants were similar between the two groups. The number of in-hospital deaths from any cause was 26 (16%) in the control group and 24 (15%) in the intervention group, with an absolute mortality difference of 1·0% (95% CI -6·9 to 9·0). Serious adverse events, including hypoglycaemia, hyperglycaemia, convulsions, reduced consciousness, and death, were reported in 47 (29%) children in the control group and 39 (24%) children in the intervention group.

INTERPRETATION

Increasing the cutoff blood glucose concentration for hypoglycaemia treatment in severely sick children in Malawi from 2·5 mmol/L to 5·0 mmol/L did not reduce all-cause in-hospital mortality. Our findings do not support changing the cutoff for dextrose administration, and further research on the optimal management of severely ill children who present to the emergency department with low blood glucose concentrations is warranted.

FUNDING

Swedish Research Council and Stockholm Country Council.

Risk Factors for Mortality in Severely Ill Children Admitted to a Tertiary Referral Hospital in Malawi

In low-resource settings, many children are severely ill at arrival to hospital. The risk factors for mortality among such ill children are not well-known. Understanding which of these patients are at the highest risk could assist in the allocation of limited resources to where they are most needed. A cohort study of severely ill children treated in the resuscitation room of the pediatric emergency department at Queen Elizabeth Central Hospital in Malawi was conducted over a 6-month period in 2017. Data on signs and symptoms, vital signs, blood glucose levels, and nutritional status were collected and linked with in-hospital mortality data. The factors associated with in-hospital mortality were analyzed using multivariable logistic regression. Data for 1,359 patients were analyzed and 118 (8.7%) patients died. The following factors were associated with mortality: presence of any severely deranged vital sign, unadjusted odds ratio (UOR) 2.6 (95% CI 1.7–4.0) and adjusted odds ratio (AOR) 3.2 (95% CI 2.0–5.0); severe dehydration, UOR 2.6 (1.4–5.1) and AOR 2.8 (1.3–6.0); hypoglycemia glycemia (< 5 mmol/L), UOR 3.6 (2.2–5.8) and AOR 2.7 (1.6–4.7); and severe acute malnutrition, UOR 5.8 (3.5–9.6) and AOR 5.7 (3.3–10.0). This study suggests that among severely sick children, increased attention should be given to those with hypo/low glycemia, deranged vital signs, malnutrition, and severe dehydration to avert mortality among these high-risk patients.

Emergency department risk factors for serious clinical deterioration in a paediatric hospital in Peru

AIM

Identification of critically ill children upon presentation to the emergency department (ED) is challenging, especially when resources are limited. The objective of this study was to identify ED risk factors associated with serious clinical deterioration (SCD) during hospitalisation in a resource-limited setting.

METHODS

A retrospective case-control study of children less than 18 years of age presenting to the ED in a large, freestanding children's hospital in Peru was performed. Cases had SCD during the first 7 days of hospitalisation whereas controls did not. Information collected during initial ED evaluation was used to identify risk factors for SCD.

RESULTS

A total of 120 cases and 974 controls were included. In univariate analysis, young age, residence outside Lima, evaluation at another facility prior to ED presentation, congenital malformations, abnormal neurologic baseline, co-morbidities and a prior paediatric intensive care unit admission were associated with SCD. In multivariate analysis, age < 12 months, residence outside Lima and evaluation at another facility prior to ED presentation remained associated with SCD. In addition, comatose neurological status, hypoxaemia, tachycardia, tachypnoea and temperature were also associated with SCD.

CONCLUSIONS

Many risk factors for SCD during hospitalisation can be identified upon presentation to the ED. Using these factors to adjust monitoring during and after the ED stay has the potential to decrease SCD events. Further studies are needed to determine whether this holds true in other resource-limited settings.