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Permissive glycemic target may safely reduce hypoglycemia incidence in critically ill children, study suggests

Wednesday, October 22 2008 | Comments

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What's This? Setting a more permissive glycemic target of 90 to 140 mg/dL for children who have undergone surgical repair of congenital heart defects reduces the incidence of hypoglycemia without increasing the mortality rate, researchers discovered.

A retrospective chart review was performed for 177 patients who underwent a total of 211 surgeries at a single tertiary care children's hospital in Texas.

Patients were identified as having euglycemia (60-125 mg/dL), mild hyperglycemia (126-139 mg/dL), moderate hyperglycemia (140-179 mg/dL), or severe hyperglycemia (>=180 mg/dL). Overall, hyperglycemia (>125 mg/dL) occurred after 98% of surgeries, and a measurement >200 mg/dL occurred after 78% of surgeries.

Fifteen patients died before discharge, including 5 of 54 patients who underwent surgery during the neonatal period.

During the first day after surgery, mortality rates were not significantly different between the euglycemia (10%), mild hyperglycemia (16.67%), moderate hyperglycemia (4.88%), severe hyperglycemia (3.7%), and permissive target groups (11.54%; P=.287).

However, median glucose measurements from days 2 through 5 post-surgery showed significantly higher mortality rates in the moderate hyperglycemia group (38.8%) and the severe hyperglycemia group (58.3%) versus the euglycemia group (6.02%) and the permissive target group (4.69%). Mortality rates in the euglycemia group and the permissive target groups were not significantly different.

The severe hyperglycemia group also had a significantly higher morbidity rate than did the euglycemia group and the permissive target group, based on median glucose measurements from days 2 through 5.

During the 5 days after surgery, 45 patients experienced hypoglycemia (defined as a glucose level <60 mg/dL), which was associated with an increased mortality rate. Hypoglycemia was significantly more common in the euglycemia group (31.8%) than it was in the permissive target group (17.8%).

"As strict glycemic control strategies invariably begin to permeate into pediatric critical care practice, we must clearly understand the risks and benefits of such strategies and realize that a definitive study showing the benefits of strict glycemic control in the pediatric population is still lacking," the researchers wrote.

"By identifying a more permissive glycemic target (90–140 mg/dL, 5–7.7 mmol/L) that is associated not only with a low mortality rate, comparable to that of the euglycemic group, but also with a lower likelihood of undesirable hypoglycemia, we may now have a safer range for the prospective evaluation of glycemic control strategies for critically ill children," they concluded.

These findings were published online Sept. 8 ahead of print in the journal Pediatrics by Ulate KP, et al.

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