Background Hyperglycemia after traumatic brain injury (TBI) is associated with poor outcome. This study examined the incidence and risk factors for perioperative hyperglycemia in children with TBI. Methods A retrospective cohort study of children ≤ 13 years who underwent urgent or emergent craniotomy for TBI at Harborview Medical Center (level I Adult and Pediatric Trauma Center) between 1994 and 2004 was performed. Preoperative (Emergency department to general anesthesia start), intraoperative (during general anesthesia), and immediate postoperative (first 24 hours after surgery) glucose values for each patient were retrieved. The incidence of hyperglycemia (glucose ≥ 200 mg/dL) and hypoglycemia (glucose < 60 mg/dL) was determined. Persistent hyperglycemia was defined as hyperglycemia during any 2/3 (preoperative, intraoperative and immediate postoperative) study periods whereas transient hyperglycemia was defined as hyperglycemia during any one study period. Multivariate logistic regression analysis was used to determine the independent predictors of perioperative hyperglycemia. Data are presented as AOR (95% CI) and p < 0.05 reflects significance. Results At-least one serum glucose value was recorded during each study period: preoperative (86 [82%]), intraoperative (94 [89%]), and postoperative (101 [97%]. Sixty four percent of children had less than one glucose recorded per anesthetic hour. Forty-seven (45%) children had hyperglycemia during at least one study period. Transient hyperglycemia occurred in 29 (28%) and persistent hyperglycemia occurred in 18 (17%) of children. Independent predictors of perioperative hyperglycemia were age < 4 years (AOR [95% CI]; 3.5 [1.2–10.6]), GCS ≤ 8 (AOR 95% CI; 7.2 (2.4–21.5)) and the presence of multiple lesions including SDH (AOR 95% CI; 34.7 [2.3– 525.5]). Six children were treated with insulin, and 2 children had hypoglycemia, unrelated to insulin treatment. Conclusions Perioperative hyperglycemia was common and intraoperative hypoglycemia was not rare but more frequent intraoperative glucose sampling may be needed to better determine the incidence of hypo and hyperglycemia during the perioperative period. Age < 4 years, severe TBI and the presence of multiple lesions including SDH were risk factors for perioperative hyperglycemia.
Management of pain in critically ill patients can be very difficult. In the attempt to provide comfort with adequate levels of opioids and sedatives, respiratory depression and cardiovascular instability may become difficult to control in patients with labile hemodynamics and poor cardiopulmonary reserve. The use of medications like ketamine, an anesthetic agent that in subanesthetic doses has been reported to be effective in preventing opioidinduced tolerance and to have analgesic properties, may be of help, especially in patients who develop tolerance, leading to rapidly escalating doses of opioids and sedatives. The case report presented here shows how a very low dose of ketamine can be helpful for the management of pain and sedation in critically ill patients, especially when they are ready to be weaned from mechanical ventilation, and very high doses of opiods and sedatives do not permit it.
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