Short-Term Adverse Outcomes Associated With Hypoglycemia in Critically Ill Children

Short-Term Adverse Outcomes Associated With Hypoglycemia in Critically Ill Children

by Faustino, Edward Vincent S et al: Critical Care Medicine: May 2019 - Volume 47 - Issue 5 - p 706–714

Objectives: Previous studies report worse short-term outcomes with hypoglycemia in critically ill children. These studies relied on intermittent blood glucose measurements, which may have introduced detection bias. We analyzed data from the Heart And Lung Failure-Pediatric INsulin Titration trial to determine the association of hypoglycemia with adverse short-term outcomes in critically ill children.

Design: Nested case-control study.

Setting: Thirty-five PICUs. A computerized algorithm that guided the timing of blood glucose measurements and titration of insulin infusion, continuous glucose monitors, and standardized glucose infusion rates were used to minimize hypoglycemia.

Patients: Nondiabetic children with cardiovascular and/or respiratory failure and hyperglycemia. Cases were children with any hypoglycemia (blood glucose < 60 mg/dL), whereas controls were children without hypoglycemia. Each case was matched with up to four unique controls according to age group, study day, and severity of illness.

Interventions: None.

Measurements and Main Results: A total of 112 (16.0%) of 698 children who received the Heart And Lung Failure-Pediatric INsulin Titration protocol developed hypoglycemia, including 25 (3.6%) who developed severe hypoglycemia (blood glucose < 40 mg/dL). Of these, 110 cases were matched to 427 controls. Hypoglycemia was associated with fewer ICU-free days (median, 15.3 vs 20.2 d; p = 0.04) and fewer hospital-free days (0 vs 7 d; p = 0.01) through day 28. Ventilator-free days through day 28 and mortality at 28 and 90 days did not differ between groups. More children with insulin-induced versus noninsulin-induced hypoglycemia had zero ICU-free days (35.8% vs 20.9%; p = 0.008). Outcomes did not differ between children with severe versus nonsevere hypoglycemia or those with recurrent versus isolated hypoglycemia.

Conclusions: When a computerized algorithm, continuous glucose monitors and standardized glucose infusion rates were used to manage hyperglycemia in critically ill children with cardiovascular and/or respiratory failure, severe hypoglycemia (blood glucose < 40 mg/dL) was uncommon, but any hypoglycemia (blood glucose < 60 mg/dL) remained common and was associated with worse short-term outcomes.

Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients

Severe and multiple hypoglycemic episodes are associated with increased risk of death in ICU patients. Critical Care 2015, 19: 153


Kalfon, P., et al.


http://ccforum.com/content/pdf/s13054-015-0851-7.pdf


Using a randomized controlled trial comparing tight glucose control with a computerized decision-support systems and conventional protocols (post hoc analysis), we tested the hypothesis that hypoglycemia is associated with a poor outcome, even when controlling for initial severity. We looked for moderate (2.2-3.3 mmol/l) and severe (<2.2 mmol/l) hypoglycemia, multiple hypoglycemic events (n ≥ 3), and the other main components of glycemic control (mean blood glucose level and blood glucose coefficient of variation (CV)). The primary end-point was 90-day mortality. We used both a multivariable analysis taking into account only variables observed at admission and a multivariable matching process (greedy matching algorithm, caliper width of 10−5 digit with no replacement). Results: A total of 2,601 patients were analyzed and divided into three groups: no hypoglycemia (n = 1,474), moderate hypoglycemia (n = 874, 34%), and severe hypoglycemia (n = 253, 10%). Patients with moderate or severe hypoglycemia had a poorer prognosis as shown by a higher mortality rate (36% and 54% respectively, vs. 28%) and decreased number of treatment-free days. In the multivariable analysis, severe (OR 1.50, 95% CI 1.36-1.56, P = 0.043) and multiple hypoglycemic events (OR 1.76, 95% CI 1.31-3.37, P < 0.001) were significantly associated with mortality whereas blood glucose CV was not. Using multivariable matching, patients with severe (53 vs. 35%, P < 0.001), moderate (33 vs. 27%, P = 0.029), and multiple hypoglycemic events (46 vs. 32%, P < 0.001), had a higher 90-day mortality. Conclusion: In a large cohort of ICU patients, severe hypoglycemia and multiple hypoglycemic events were associated with increased 90-day mortality.

Tight glycemic control in the ICU

Tight glycemic control in the ICU - is the earth flat? Critical Care 2014, 18: 159

Steil, G.M. and Agus, M.S.D.

http://ccforum.com/content/18/3/159

Tight glycemic control in the ICU has been shown to reduce mortality in some but not all prospective randomized control trials. Confounding the interpretation of these studies are differences in how the control was achieved and underlying incidence of hypoglycemia, which can be expected to be affected by the introduction of continuous glucose monitoring (CGM). In this issue of Critical Care, a consensus panel provides a list of the research priorities they believe are needed for CGM to become routine practice in the ICU. We reflect on these recommendations and consider the implications for using CGM today.

Hypoglycemia in the critically ill: how low is too low?

Hypoglycemia in the critically ill: how low is too low? Mayo clinic proceedings, March 2010, Vol. 85(3), p. 215-216.

Krinsley, J.S.

http://www.mayoclinicproceedings.com/content/85/3/215.full

Tight glycemic control in critically ill patients became a therapeutic paradigm after the 2001 publication of a landmark single-center interventional trial in Leuven, Belgium, (ie, “Leuven 1”) that targeted euglycemia in a population of mechanically ventilated patients in a surgical intensive care unit (ICU).