Baseline insulin/glucose ratio as a marker for the clinical course of hyperglycemic critically ill children treated with insulin.

OBJECTIVE: The objective of this study was to investigate the relations of baseline insulin/glucose ratio to the clinical course of critically ill children. Such information will provide insight into the pathophysiologic mechanisms leading to hyperglycemia and will optimize preventive and therapeutic measures for hyperglycemia in critically ill children. METHODS: Sixty-four consecutively admitted critically ill children with hyperglycemia, defined as a blood glucose level higher than 8 mmol/L (>145 mg/dL) and treated with insulin according to a glucose-control protocol, were included. Demographic data and clinical and laboratory parameters were collected. Insulin sensitivity was investigated by calculating the ratio of insulin to the blood glucose level just before the start of insulin administration. Results are expressed as median (range). RESULTS: Sixty-four children (24 girls) 7.0 y of age (0.3-16.9 y) with various diagnoses were included. A hyperinsulinemic response, indicated by an increased insulin/glucose ratio (>18 pmol/mmol), was seen in 55% of children. The durations of insulin therapy, mechanical ventilation, and pediatric intensive care unit length of stay in children with a hyperinsulinemic response were longer than in children with a hypoinsulinemic response. CONCLUSION: Hyper- and hypoinsulinemic responses play a role in the occurrence of hyperglycemia in critically ill children. Each is associated with a particular clinical course after the initiation of insulin therapy. It would be worthwhile to further investigate if the insulinemic response to hyperglycemia, determined by the insulin/glucose ratio in combination with the type of organ dysfunction, could be used in clinical practice to determine the need for insulin therapy.

Management of hyperglycemia in the pediatric intensive care unit; implementation of a glucose control protocol.

OBJECTIVE: To evaluate a stepwise nurse-driven glucose control protocol for the treatment of hyperglycemia in critically ill pediatric patients. SETTING: Academic pediatric intensive care unit. DESIGN: Prospective observational study. PATIENTS: A total of 50 consecutively admitted critically ill children with hyperglycemia >8 mmol/L (>145 mg/dL) were included and treated according to the glucose control protocol. MEASUREMENTS AND MAIN RESULTS: Demographic data and clinical parameters were collected and different steps in the protocol were evaluated. Data were expressed as medians with interquartile ranges. Fifty children (28 boys), aged 3.5 yrs (range, 1.2 -9.3 yrs) were treated in 18 mos. Forty-two children had multiple organ failure. Eight children died. Insulin treatment was initiated 4 hrs after the first episode of hyperglycemia was documented (median blood glucose, 11.4 mmol/L, [207 mg/dL] [9.7-14.5 mmol/L, 176-264 mg/dL]). Blood glucose was <8 mmol/L (<145 mg/dL) within 12 hrs of initiating insulin therapy in 47 (94%) of 50 children (median, 5 hrs). Duration of treatment was 34 hrs (17-72 hrs) and the maximum insulin dose ranged between 20 and 200 mIU/kg/hr (median, 70 mIU/kg/hr). Episodes of severe hypoglycemia <2.2 mmol/L (<47 mg/dL) did not occur. CONCLUSION: The use of a stepwise nurse-driven glucose control protocol resulted in normoglycemia within 12 hrs for 94% of the children involved. Episodes of severe hypoglycemia did not occur. We conclude that the glucose control protocol is effective in treating hyperglycemia in critically ill children. Further studies are necessary to assess safety before the protocol could also be implemented in other pediatric intensive care units.