Early change in blood glucose concentration is an indicator of mortality in critically ill children

Glycemic Variability Is Independently Associated With Poor Prognosis in Five Pediatric ICU Centers in Southwest China

Background

Glucose variability (GV) is a common complication of dysglycemia in critically ill patients. However, there are few studies on the role of GV in the prognosis of pediatric patients, and there is no consensus on the appropriate method for GV measurement. The objective of this study was to determine the “optimal” index of GV in non-diabetic critically ill children in a prospective multicenter cohort observational study. Also, we aimed to confirm the potential association between GV and unfavorable outcomes and whether this association persists after controlling for hypoglycemia or hyperglycemia.

Materials and Methods

Blood glucose values were recorded for the first 72 h and were used to calculate the GV for each participant. Four different metrics [SD, glycemic lability index (GLI), mean absolute glucose (MAG), and absolute change of percentage (ACACP)] were considered and compared to identify the “best” GV index associated with poor prognosis in non-diabetic critically ill children. Among the four metrics, the SD was most commonly used in previous studies, while GLI- and MAG-integrated temporal information, that is the rate and magnitude of change and the time interval between glucose measurements. The fourth metric, the average consecutive ACACP, was introduced in our study, which can be used in real-time clinical decisions. The primary outcome of this study was the 28-day mortality. The receiver operating characteristic (ROC) curve analysis was conducted to compare the predictive power of different metrics of GV for the primary outcome. The GV index with the largest area under ROC curve (AUC) was chosen for subsequent multivariate analyses. Multivariate Cox regression analysis was performed to identify the potential predictors of the outcome. To compare the contribution in 28-day mortality prognosis between glycemic variability and hyper- or hypoglycemia, performance metrics were calculated, which included AUC, net reclassification improvement (NRI), and integrated discrimination improvement (IDI).

Results

Among 780 participants, 12.4% (n = 97) died within 28 days after admission to the pediatric intensive care unit (PICU). Statistically significant differences were found between survivors and non-survivors in terms of four GV metrics (SD, GLI, MAG, and ACACP), in which MAG (AUC: 0.762, 95% CI: 0.705–0.819, p < 0.001) achieved the largest AUC and showed a strong independent association with ICU mortality. Subsequent addition of MAG to the multivariate Cox model for hyperglycemia resulted in further quantitative evolution of the model statistics (AUC = 0.651–0.681, p = 0.001; IDI: 0.017, p = 0.044; NRI: 0.224, p = 0.186). The impact of hyperglycemia (adjusted hazard ratio [aHR]: 1.419, 95% CI: 0.815–2.471, p = 0.216) on outcome was attenuated and no longer statistically relevant after adjustment for MAG (aHR: 2.455, 95% CI: 1.411–4.270, p = 0.001).

Conclusions

GV is strongly associated with poor prognosis independent of mean glucose level, demonstrating more predictive power compared with hypoglycemia and hyperglycemia after adjusting for confounding factors. GV metrics that contain information, such as time and rate of change, are the focus of future research; thus, the MAG may be a good choice. The findings of this study emphasize the crucial role of GVs in children in the PICU. Clinicians should pay more attention to GV for clinical glucose management.

A Study of Mortality in Cardiac Patients in a Pediatric Intensive Care Unit

OBJECTIVE

One of the major causes of mortality in the pediatric intensive care unit (PICU) is heart disease. This study aimed to determine the causes of mortality in children with pre-existing cardiac abnormalities who were admitted into the PICU.

METHODS

Data were collected through patient profile assessment and outcome and heart diseases affecting prognosis were analyzed. Medical records of children were reviewed retrospectively. The updated Pediatric Index of Mortality 2 (PIM2) scores were used. Exploratory data analysis was performed using descriptive measures. Kolmogorov-Smirnov tests were used to test the normality of data distribution.

RESULTS

Out of 566 admissions into PICU, 76 (13.4%) had cardiac abnormalities. Median and range of PICU stay were 5.50 and 417.88 days. The mean PIM2 score on admission was found to be 31.05. The most common admission was due to atrioventricular septal defect (AVSD) (15.7%), cardiomyopathy (13.1%), ventricular septal defect (VSD) (11.8%), tetralogy of Fallot (10.5%) and others (48.9%). There were multiple cardiac anomalies in 3.9% of patients. The most important cause of cardiac mortality in PICU was septic shock (26.0%) followed by cardiogenic shock (20.6%), and cardiac failure (13.7%). The nosocomial infection rate of cardiac patients in PICU was 10.5%.

CONCLUSIONS

Our study reconfirmed that the PIM2 score is a good indicator of cardiac diseases. Infections, nosocomial infections, pneumonia, and septic shock were the leading causes of mortality in cardiac patients. Better infection control in the PICU may have a significant impact on decreasing mortality rates.

Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.

Are platelet volume indices related to mortality in hospitalized children on mechanical ventilation?

Objectives

To investigate platelet volume indices and in-hospital mortality in children on mechanical ventilation.

Methods

This retrospective study included children aged <16 years on mechanical ventilation, and compared parameters, measured on admission, between survivors and non-survivors. Dynamic platelet volume indices over the first 7 days were visualized. Independent risk factors of mortality were identified using multivariate logistic regression analysis.

Results

Out of 2 319 children aged 28 days–3 years, serum albumin (odds ratio [OR] 0.9, 95% confidence interval [CI] 0.85, 0.96), bilirubin (OR 1.01, 95% CI 1.0, 1.77), and lactic acid (OR 1.22, 95% CI 1.05, 1.38) levels were associated with mortality. Out of 2 415 children aged > 3 years, procalcitonin (OR 1.01, 95% CI 1.0, 1.01) and lactic acid (OR 1.22, 95% CI 1.09, 1.35) were associated with mortality. Platelet volume indices on admission were not independently associated with mortality in either group. Mean platelet volume (MPV) and platelet distribution width (PDW) showed different trends in non-survivors versus survivors over 1 week in both age groups.

Conclusions

Platelet volume indices may be associated with mortality in critically ill children receiving mechanical ventilation.

Analgosedation in paediatric severe traumatic brain injury (TBI): practice, pitfalls and possibilities

Analgosedation is a fundamental part of traumatic brain injury (TBI) treatment guidelines, encompassing both first and second tier supportive strategies. Worldwide analgosedation practices continue to be heterogeneous due to the low level of evidence in treatment guidelines (level III) and the choice of analgosedative drugs is made by the treating clinician. Current practice is thus empirical and may result in unfavourable (often hemodynamic) side effects. This article presents an overview of current analgosedation practices in the paediatric intensive care unit (PICU) and addresses pitfalls both in the short and long term. We discuss innovative (pre-)clinical research that can provide the framework for initiatives to improve our pharmacological understanding of analgesic and sedative drugs used in paediatric severe TBI and ultimately facilitate steps towards evidence-based and precision pharmacotherapy in this vulnerable patient group.

Optimal nutrition in the paediatric ICU

PURPOSE OF REVIEW

This article describes the current best available evidence on optimal nutrition in the paediatric intensive care based on different levels of outcome, which can be divided in surrogate and hard clinical outcome parameters.

RECENT FINDINGS

Undernutrition is associated with increased morbidity and mortality, whereas in specific cohorts of critically ill children, such as those with burn injury, obesity is associated with more complications, longer length of stay, and decreased likelihood of survival. There is a relation with adequacy of delivery of enteral nutrition and the amount of protein on length of hospital stay, neurological status, and mortality. Studies relating organ function, other than skin healing after thermal injury, with the nutritional status are scarce. There is also a scarcity of data concerning long-term follow-up and health economics.

SUMMARY

Until now, there are no randomized controlled trials which have investigated a causal relation between different feeding regimens on the nutritional status and short and long-term outcome. As a result current optimal nutritional strategies are based on small trials with surrogate outcome parameters. Prospective randomized studies are needed with nutritional and/or metabolic interventions to come to an optimal feeding strategy for critically ill children.

Targeting Glycemic Control After Pediatric Cardiac Surgery: The Influence of Age on Insulin Requirement

OBJECTIVE

Factors influencing the development of hyperglycemia and pattern of insulin requirement in children undergoing cardiac surgery are poorly understood. This study investigated the impact of age on the pattern of hyperglycemia and insulin requirement in children after cardiac surgery.

DESIGN

Cohort study, based on a prospectively collected dataset for patients enrolled into the Control of Hyperglycemia in Pediatric Intensive Care trial.

SETTING

A 24-bedded multidisciplinary PICU.

PATIENTS

Children randomized to the tight glycemic control arm (target blood glucose, 4-7 mmol/L [72-126 mg/dL]) of the Control of Hyperglycemia in Pediatric Intensive Care trial following cardiac surgery. Children were categorized into four age groups (neonate, 1-30 d; infant, 31-365 d; young child, 1-5 yr; older child, 5-16 yr) for analyses of patterns of hyperglycemia and insulin requirement over the 12-hour period following initiation of insulin.

INTERVENTIONS

Insulin titration was performed based on blood glucose value and rate of change of blood glucose using an algorithm developed for the Control of Hyperglycemia in Pediatric Intensive Care trial.

MEASUREMENTS AND MAIN RESULTS

Of 92 children, 72 children (78%) randomized to the tight glycemic control group developed hyperglycemia (blood glucose, > 7 mmol/L [126 mg/dL]) and received insulin. Older age was associated with higher blood glucose and a higher insulin dose per kilogram over the first 3 hours of the study period (p ≤ 0.02). Cumulative insulin dose was significantly higher in older children (median, 1.3 U/kg [range, 0.2-5.75]) compared with other age groups (neonate, 0.37 [0.05-2.2]; infant, 0.45 [0.05-2.2]; young child, 0.35 [0.05-0.81]) (p = 0.004). Age group, rather than body mass index, carbohydrate intake, or cardiac surgery variables, was the only variable (coefficient: 1.14 ± 0.3; p < 0.001) associated with cumulative insulin dose on multivariate analysis.

CONCLUSIONS

When tight glycemic control is targeted in children who have undergone cardiac surgery, children in the older child age group (5-16 yr) require insulin at significantly higher doses. Further study is needed to understand the mechanisms involved.

U-shaped relationship between early blood glucose and mortality in critically ill children

BACKGROUND

The aims of this study are to evaluate the relationship between early blood glucose concentrations and mortality and to define a 'safe range' of blood glucose concentrations during the first 24 h after pediatric intensive care unit (PICU) admission with the lowest risk of mortality. We further determine whether associations exist between PICU mortality and early hyperglycemia and hypoglycemia occurring within 24 h of PICU admission, even after adjusting for illness severity assessed by the pediatric risk of mortality III (PRISM III) score.

METHODS

This retrospective cohort study included patients admitted to PICU between July 2008 and June 2011 in a tertiary teaching hospital. Both the initial admission glucose values and the mean glucose values over the first 24 h after PICU admission were analyzed.

RESULTS

Of the 1349 children with at least one blood glucose value taken during the first 24 h after admission, 129 died during PICU stay. When analyzing both the initial admission and mean glucose values during the first 24 h after admission, the mortality rate was compared among children with glucose concentrations ≤ 65, 65-90, 90-110, 110-140, 140-200, and >200 mg/dL (≤ 3.6, 3.6-5.0, 5.0-6.1, 6.1-7.8, 7.8-11.1, and >11.1 mmol/L). Children with glucose concentrations ≤ 65 mg/dL (3.6 mmol/L) and >200 mg/dL (11.1 mmol/L) had significantly higher mortality rates, indicating a U-shaped relationship between glucose concentrations and mortality. Blood glucose concentrations of 110-140 mg/dL (6.1-7.8 mmol/L), followed by 90-110 mg/dL (5.0-6.1 mmol/L), were associated with the lowest risk of mortality, suggesting that a 'safe range' for blood glucose concentrations during the first 24 h after admission in critically ill children exists between 90 and 140 mg/dL (5.0 and 7.8 mmol/L). The odds ratios of early hyperglycemia (>140 mg/dL [7.8 mmol/L]) and hypoglycemia (≤ 65 mg/dL [3.6 mmol/L]) being associated with increased risk of mortality were 4.13 and 15.13, respectively, compared to those with mean glucose concentrations of 110-140 mg/dL (6.1-7.8 mmol/L) (p <0.001). The association remained significant after adjusting for PRISM III scores (p <0.001).

CONCLUSIONS

There was a U-shaped relationship between early blood glucose concentrations and PICU mortality in critically ill children. Both early hyperglycemia and hypoglycemia were associated with mortality, even after adjusting for illness severity.