Glucose control in severely thermally injured pediatric patients: what glucose range should be the target?

Abstract

Objective: To determine which glucose levels are associated with improved morbidity and mortality in thermally injured patients.

Summary background data: Tight euglycemic control was rapidly implemented in intensive care units around the world, but there is increasing evidence that tight euglycemic control is associated with detrimental outcomes. Currently, no study exists that indicates which glucose range should be targeted.

Methods: Two-hundred and eight severely burned pediatric patients with burns over 30% of their total body surface area were included in this trial. Several statistical models were used to determine the daily average and 6 AM glucose target that were associated with improved morbidity and mortality. Patients were then divided into good glucose controlled and poor glucose controlled patients and demographics, clinical outcomes, infection, sepsis, inflammatory, and hypermetabolic responses were determined.

Results: Statistical modeling showed that hyperglycemia is a strong predictor of adverse hospital outcome and that daily 6 am glucose level of 130 mg/dL and daily average glucose levels of 140 mg/dL are associated with improved morbidity and mortality postburn. When patients were divided into good glucose control and poor glucose control, we found that patients with glucose levels of 130 mg/dL exert attenuated hypermetabolic and inflammatory responses, as well as significantly lower incidence of infections, sepsis, and mortality compared with patients with poor glucose control, P < 0.05.

Conclusions: Given the controversy over glucose range, glucose target, and risks and detrimental outcomes associated with hypoglycemia we suggest that in severely burned patient's blood glucose of 130 mg/dL should be targeted.

Trial registration: ClinicalTrials.gov NCT00673309.

Figure 1

Kaplan-Meier survival curve. There were no deaths in the group with good glucose control. *Significant difference between poor vs. good, p<0.05.

Figure 2

(A) Daily 6 a.m. glucose. Patients with good glucose control had significantly lower level compared to patients with poor glucose control. (B) Daily maximum glucose levels. Good glucose controlled patients have significantly lower peak levels of glucose compared to poor glucose controlled patients. (C) There is no difference between good and poor glucose controlled patients for daily minimum glucose levels. (D) Daily insulin administration. * Significant difference between good glucose control vs. poor glucose control, p<0.05.

Figure 3

Patients with good glucose control had a significantly attenuated hypermetabolic response at various time points when compared to poor glucose controlled patients. * Significant difference between good glucose control vs. poor glucose control, p<0.05.

Figure 4

Good glucose control significantly decreased the following cytokines: IFN-γ (A), IL-10 (B), IL-7 (C), IL-8 (D), IL-5 (E), IL-6 (F), and MCP-1 (G).Good glucose control attenuated 1-anti trypsin (H), significantly decreased CRP (I), as well as haptoglobin (J), while it significantly increased transferring (K). Good glucose control improved organ function as indicated by improved serum organ function markers ALT (L), AST (M), bilirubin (N), total protein (O), BUN (P), and creatinin (Q). Data presented as mean±SEM. * Significant difference between control vs. propranolol at each corresponding time point, p<0.05.