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

• Published in: Critical care medicine Vol. 47; no. 5; pp. 706 - 714
• Main Authors: Faustino, Edward Vincent S., Hirshberg, Eliotte L., Asaro, Lisa A., Biagas, Katherine V., Pinto, Neethi, Srinivasan, Vijay, Bagdure, Dayanand N., Steil, Garry M., Coughlin-Wells, Kerry, Wypij, David, Nadkarni, Vinay M., Agus, Michael S. D.
• Format: Journal Article
• Language: English
• Published: United States by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc 01-05-2019; Copyright by by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc
• Subjects: Adolescent; Algorithms; Blood Glucose - metabolism; Case-Control Studies; Child; Child, Preschool; Critical Illness - therapy; Female; Heart Failure - therapy; Humans; Hyperglycemia - drug therapy; Hypoglycemic Agents - administration & dosage; Intensive Care Units, Pediatric; Male; Organ Dysfunction Scores; Respiratory Insufficiency - therapy
• ISSN: 0090-3493; 1530-0293
• DOI: 10.1097/CCM.0000000000003699

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.