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

BMC Pediatrics

Xing Feng³  Jian Wang⁴  Xiaozhong Li²  Jian Pan⁴  Xueqin Wang²  Mengxia Li²  Zhenjiang Bai¹  Yanhong Li⁴ 

[1] Pediatric Intensive Care Unit, Suzhou, China;Department of Nephrology, Suzhou, China;Department of Neonatology, Children’s Hospital of Soochow University, Suzhou, 215003, China;Institute of Pediatric Research, Suzhou, China

关键词: Pediatric risk of mortality III;    Pediatric;    Mortality;    Intensive care;    Hypoglycemia;    Hyperglycemia;    Glucose;    Critically ill children;   

Others  :  1221253
DOI  :  10.1186/s12887-015-0403-y

 received in 2014-06-05, accepted in 2015-07-08,  发布年份 2015

【 摘 要 】

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.

【 授权许可】

   
2015 Li et al.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

【 参考文献 】

• [1]Polito A, Thiagarajan RR, Laussen PC, Gauvreau K, Agus MS, Scheurer MA et al.. Association between intraoperative and early postoperative glucose levels and adverse outcomes after complex congenital heart surgery. Circulation. 2008; 118:2235-42.
• [2]Hirshberg E, Larsen G, Van Duker H. Alterations in glucose homeostasis in the pediatric intensive care unit: Hyperglycemia and glucose variability are associated with increased mortality and morbidity. Pediatr Crit Care Med. 2008; 9:361-6.
• [3]Kyle UG, Coss Bu JA, Kennedy CE, Jefferson LS. Organ dysfunction is associated with hyperglycemia in critically ill children. Intensive Care Med. 2010; 36:312-20.
• [4]Macrae D, Grieve R, Allen E, Sadique Z, Morris K, Pappachan J et al.. A randomized trial of hyperglycemic control in pediatric intensive care. N Engl J Med. 2014; 370:107-18.
• [5]Krinsley JS, Schultz MJ, Spronk PE, Harmsen RE, van Braam HF, van der Sluijs JP et al.. Mild hypoglycemia is independently associated with increased mortality in the critically ill. Crit Care. 2011; 15:R173. BioMed Central Full Text
• [6]Bagshaw SM, Bellomo R, Jacka MJ, Egi M, Hart GK, George C. The impact of early hypoglycemia and blood glucose variability on outcome in critical illness. Crit Care. 2009; 13:R91. BioMed Central Full Text
• [7]Goyal A, Mehta SR, Diaz R, Gerstein HC, Afzal R, Xavier D et al.. Differential clinical outcomes associated with hypoglycemia and hyperglycemia in acute myocardial infarction. Circulation. 2009; 120:2429-37.
• [8]Faustino EV, Apkon M. Persistent hyperglycemia in critically ill children. J Pediatr. 2005; 146:30-4.
• [9]Yates AR, Dyke PC, Taeed R, Hoffman TM, Hayes J, Feltes TF et al.. Hyperglycemia is a marker for poor outcome in the postoperative pediatric cardiac patient. Pediatr Crit Care Med. 2006; 7:351-5.
• [10]Capes SE, Hunt D, Malmberg K, Gerstein HC. Stress hyperglycaemia and increased risk of death after myocardial infarction in patients with and without diabetes: a systematic overview. Lancet. 2000; 355:773-8.
• [11]Tasker RC. Pediatric critical care, glycemic control, and hypoglycemia: what is the real target? JAMA. 2012; 308:1687-8.
• [12]Agus MS. Tight glycemic control in children--is the target in sight? N Engl J Med. 2014; 370:168-9.
• [13]Ognibene KL, Vawdrey DK, Biagas KV. The association of age, illness severity, and glycemic status in a pediatric intensive care unit. Pediatr Crit Care Med. 2011; 12:e386-90.
• [14]Macrae D, Pappachan J, Grieve R, Parslow R, Nadel S, Schindler M et al.. Control of hyperglycaemia in paediatric intensive care (CHiP): study protocol. BMC Pediatr. 2010; 10:5. BioMed Central Full Text
• [15]Siegelaar SE, Hermanides J, Oudemans-van Straaten HM, van der Voort PH, Bosman RJ, Zandstra DF et al.. Mean glucose during ICU admission is related to mortality by a U-shaped curve in surgical and medical patients: a retrospective cohort study. Crit Care. 2010; 14:R224. BioMed Central Full Text
• [16]Wintergerst KA, Buckingham B, Gandrud L, Wong BJ, Kache S, Wilson DM. Association of hypoglycemia, hyperglycemia, and glucose variability with morbidity and death in the pediatric intensive care unit. Pediatrics. 2006; 118:173-9.
• [17]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; 5:329-36.
• [18]Yung M, Wilkins B, Norton L, Slater A. Glucose control, organ failure, and mortality in pediatric intensive care. Pediatr Crit Care Med. 2008; 9:147-52.
• [19]Wintergerst KA, Foster MB, Sullivan JE, Woods CR. Association of hyperglycemia, glucocorticoids, and insulin use with morbidity and mortality in the pediatric intensive care unit. J Diabetes Sci Technol. 2012; 6:5-14.
• [20]Faustino EV, Bogue CW. Relationship between hypoglycemia and mortality in critically ill children. Pediatr Crit Care Med. 2010; 11:690-8.
• [21]Bhutia TD, Lodha R, Kabra SK. Abnormalities in glucose homeostasis in critically ill children. Pediatr Crit Care Med. 2013; 14:e16-25.
• [22]Faustino EV, Hirshberg EL, Bogue CW. Hypoglycemia in critically ill children. J Diabetes Sci Technol. 2012; 6:48-57.
• [23]Branco RG, Garcia PC, Piva JP, Casartelli CH, Seibel V, Tasker RC. Glucose level and risk of mortality in pediatric septic shock. Pediatr Crit Care Med. 2005; 6:470-2.
• [24]Nayak PP, Davies P, Narendran P, Laker S, Gao F, Gough SC et al.. Early change in blood glucose concentration is an indicator of mortality in critically ill children. Intensive Care Med. 2013; 39:123-8.
• [25]Klein GW, Hojsak JM, Schmeidler J, Rapaport R. Hyperglycemia and outcome in the pediatric intensive care unit. J Pediatr. 2008; 153:379-84.
• [26]Guidelines for developing admission and discharge policies for the pediatric intensive care unit. American Academy of Pediatrics. Committee on Hospital Care and Section of Critical Care. Society of Critical Care Medicine. Pediatric Section Admission Criteria Task Force. Pediatrics. 1999;103:840-2.
• [27]Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med. 1996; 24:743-52.
• [28]Tan GH, Tan TH, Goh DY, Yap HK. Risk factors for predicting mortality in a paediatric intensive care unit. Ann Acad Med Singapore. 1998; 27:813-8.
• [29]Bai Z, Zhu X, Li M, Hua J, Li Y, Pan J et al.. Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatr. 2014; 14:83. BioMed Central Full Text
• [30]Gunst J, Van den Berghe G. Blood glucose control in the intensive care unit: benefits and risks. Semin Dial. 2010; 23:157-62.
• [31]Finfer S, Liu B, Chittock DR, Norton R, Myburgh JA, McArthur C et al.. Hypoglycemia and risk of death in critically ill patients. N Engl J Med. 2012; 367:1108-18.
• [32]Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. Jama. 2008; 300:933-44.
• [33]Hirshberg E, Lacroix J, Sward K, Willson D, Morris AH. Blood glucose control in critically ill adults and children: a survey on stated practice. Chest. 2008; 133:1328-35.
• [34]Karon BS, Gandhi GY, Nuttall GA, Bryant SC, Schaff HV, McMahon MM et al.. Accuracy of roche accu-chek inform whole blood capillary, arterial, and venous glucose values in patients receiving intensive intravenous insulin therapy after cardiac surgery. Am J Clin Pathol. 2007; 127:919-26.