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research letters

Indian Pediatr 2009;46: 809-810

Day 1 Blood Glucose and Outcome in Critically Ill Children


Rakesh Lodha, Tsultem D Bhutia, SK Kabra and Anu Thukral

Department of Pediatrics, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India.
Email: [email protected]

 

Abstract

We analyzed the association between the day 1 glucose values in 209 children admitted to the PICU and the outcome (mortality). 58 (27.7%) children had hyperglycemia while 18 (8.6%) children had hypoglycemia, on day 1 after admission. Hypoglycemia was associated with higher mortality. This is contrary to the prevalent view supporting the association of hyperglycemia with poor outcome in the critically ill children.

Key words: Blood glucose, Child, Critically ill, Outcome.

Hyperglycemia during critical illness is a fairly common observation; the prevalence ranging from 15% to 86%(1-4). Studies have suggested that hyperglycemia in critically ill children is associated with increased mortality and length of stay(1-4). Some studies have documented hypoglycemia in approximately 10% children(3,4). We undertook a retrospective analysis of data of children admitted to our PICU to evaluate association between abnormalities in blood glucose in first 24 hrs of admission with mortality. Hyperglycemia was defined as blood glucose >126 mg/dL while hypoglycemia was defined as blood glucose <60 mg/dL(1).

Data for 209 (134 boys) children aged more than 1 month age were analyzed. 48.8% of our patients were underweight (weight for age £2 SD) and 46% had wasting (weight for height £2 SD). In 37.2%, the primary indication of admission was severe sepsis/septic shock; respiratory distress requiring ventilation accounted for the second largest category (25.6%). 70 children died. 58 (27.7%) children had hyperglycemia, while 18 (8.6%) children had hypoglycemia on Day 1 of admission. Table I shows the characteristics of the 3 groups based on the blood glucose values on day 1. This suggests that hypoglycemia is an important determinant of mortality in critically ill children. On controlling for the severity of illness using PRISM or PIM2, the association was no longer significant (P=0.68 and P=0.23, respectively).

TABLE I



Characteristics of Study Subjects 
  Hypoglycemia
(n = 18)
Normoglycemia
(n = 133)
Hyperglycemia
(n = 58)
P value
 
Boys 11 83 40 0.66
Age (months), median (95% CI) 14 (4, 36) 18 (11,  27.9) 24 (14, 46.7) 0.74
Infection at admission 13 (72.2%) 97 (72.9%) 42 (72.4%) 0.99
PRISM, median (95% CI) 25.5 (17.8, 40.9) 14 (12.7, 15) 19 (16, 22) 0.34
Probability of death using PIM2 score, median (95% CI) 32.2% (8, 78.4) 8% (7, 9.4%) 13% (8, 26.6) 0.89
PICU stay (days), median (95% CI) 2 (1, 11) 4 (3, 5) 3 (3, 5) 0.32
Survival 6 (33.3%) 97 (72.9%) 36 (62.1%) 0.003

Our observations suggest an association of hypoglycemia with mortality while there was no such association between hyperglycemia and mortality (P=0.13), which is at variance with most published pediatric studies. Our results are similar to those reported by Klein, et al.(5). They observed that controlling for disease severity, hyperglycemia within 24 hours of PICU admission was not independently associated with increased mechanical ventilation time, length of stay, or mortality(5), though they used a cut off of 200 mg/dL for defining hyperglycemia. Our study patients differ from those in other studies in that we did not have post-surgical patients, while in others they constituted a major proportion. Moreover, a considerable number of children had associated malnutrition. The findings reported here should serve as a caution to the prevalent view supporting the association of hyperglycemia with poor outcome in the PICU.

References

1. Srinivasan V, Spinella PC, Drott HR, Roth CL, Helfaer MA, Nadkarni V. Association of timing, duration, and intensity of hyperglycemia with intensive care unit mortality in critically ill children. Pediatr Crit Care Med 2004; 5: 329-336.

2. Faustino EV, Apkon M. Persistent hyperglycemia in critically ill children. J Pediatr 2005; 146: 30-34.

3. Wintergerst KA, Buckingham B, Gandred L, Wong BJ, Kach S, Wilson DM. Association of hypoglycemia, hyperglycemia and glucose variability with morbidity and death in pediatric intensive care unit. Pediatrics 2006; 118: 173-179.

4. Hirshberg E, Larsen G, Duker VD. Alteration in glucose homeostasis in pediatric intensive care unit. Pediatr Crit Care Med 2008; 9: 361-366.

5. Klein GW, Hojak JM, Schmeidler J, Rappaport R. Hyperglycemia and outcome in pediatric intensive care unit. J Pediatr 2008; 153: 379-384.
 

 

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