Glucose control, organ failure, and mortality in pediatric intensive care

Abstract

Objective: In ventilated children, to determine the prevalence of hyperglycemia, establish whether it is associated with organ failure, and document glycemic control practices in Australasian pediatric intensive care units (PICUs). Design: Prospective inception cohort study. Setting: All nine specialist PICUs in Australia and New Zealand. Patients: Children ventilated >12 hrs excluding those with diabetic ketoacidosis, on home ventilation, undergoing active cardiopulmonary resuscitation on admission, or with do-not-resuscitate orders. Interventions: None. Measurements and Main Results: All blood glucose measurements for up to 14 days, clinical and laboratory values needed to calculate Paediatric Logistic Organ Dysfunction (PELOD) scores, and insulin use were recorded in 409 patients. Fifty percent of glucose measurements were >6.1 mmol/L, with 89% of patients having peak values >6.1 mmol/L. The median time to peak blood glucose was 7 hrs. Hyperglycemia was defined by area under the glucose-time curve >6.1 mmol/L above the sample median. Thirteen percent of hyperglycemic subjects died vs. 3% of nonhyperglycemic subjects. There was an independent association between hyperglycemia and a PELOD score ≥10 (odds ratio 3.41, 95% confidence interval 1.91-6.10) and death (odds ratio 3.31, 95% confidence interval 1.26-7.7). Early hyperglycemia, defined using only glucose data in the first 48 hrs, was also associated with these outcomes but not with PELOD ≥10 after day 2 or with worsening PELOD after day 1. Five percent of patients received insulin. Conclusions: Hyperglycemia is common in PICUs, occurs early, and is independently associated with organ failure and death. However, early hyperglycemia is not associated with later or worsening organ failure. Australasian PICUs seldom use insulin.