A protocolized approach to identify and manage hyperglycemia in a pediatric critical care unit*

Preissig, Catherine; Hansen, Inger Lise Skog; Roerig, Pei-Ling; Rigby, Mark R.

doi:10.1097/pcc.0b013e31818d36cb

Cited by 67 publications

(54 citation statements)

References 32 publications

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“…24,27,48,49 In the PICU, several studies have successfully demonstrated the use of insulin-glucose control protocols without significantly increasing the rate of hypoglycemia. 50,51 In a 2008 study by Preissig and colleagues 51 , the overall rate of severe hypoglycemia (<40 mg/dl) was 4% in those receiving insulin for CIH. 51 The rate of less severe hypoglycemia (<60 mg/dl) was actually found to be higher in patients who did not receive insulin (7%) versus those who did (6.7%).…”

Section: Discussionmentioning

confidence: 99%

“…50,51 In a 2008 study by Preissig and colleagues 51 , the overall rate of severe hypoglycemia (<40 mg/dl) was 4% in those receiving insulin for CIH. 51 The rate of less severe hypoglycemia (<60 mg/dl) was actually found to be higher in patients who did not receive insulin (7%) versus those who did (6.7%). This risk, though, is clearly protocol-dependent as demonstrated by a 25% hypoglycemia rate (<40 mg/dl) reported by Vlasselaers and colleagues 52 in children treated with intensive management versus conventional therapy (1%).…”

Section: Discussionmentioning

confidence: 99%

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Association of Hyperglycemia, Glucocorticoids, and Insulin Use with Morbidity and Mortality in the Pediatric Intensive Care Unit

Wintergerst

Foster

Sullivan

et al. 2012

J Diabetes Sci Technol

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Background: Studies of pediatric intensive care unit (PICU) patients have shown a significant association of morbidity and mortality with hyperglycemia. We retrospectively evaluated the degree of hyperglycemia as well as its correlation with glucocorticoid and insulin use and assessed its association with hospital length of stay (LOS) and mortality. This study preceded the initiation of a standard glycemic control protocol. Methods: We examined medical records at Kosair Children's Hospital for all PICU admissions from 2008 of patients without diabetes mellitus. Critical illness hyperglycemia (CIH) was defined by having three or more peak glucose values greater than thresholds of 110, 140, 180, and 200 mg/dl. These patients were evaluated for glucocorticoid, insulin use, and outcome measures. Results: We evaluated the eligible 1173 admissions, where 10.5% of these patients reached the highest threshold (200 mg/dl) of CIH. Glucocorticoids were used in 43% of these patients, with dexamethasone being the most common (58%). There was a significant correlation between glucocorticoids and higher peak glucose values, where 81% of the patients who were above the 200 mg/dl cutoff level were treated with glucocorticoids. Only 36.8% in that group were also treated with insulin. Patients at the 200 mg/dl cutoff had the highest median PICU and total hospital length of stays (4 and 10 days, respectfully). Mortality was associated with increasing glucose levels, reaching 18.7% among patients above the 200 mg/dl cutoff. Conclusion: Hyperglycemia was prevalent in the PICU and was associated with increased morbidity, as characterized by increased LOS and increased mortality. Glucocorticoid use was prevalent among patients exhibiting hyperglycemia. Insulin use was uncommon.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Association of Hyperglycemia, Glucocorticoids, and Insulin Use with Morbidity and Mortality in the Pediatric Intensive Care Unit

Wintergerst

Foster

Sullivan

et al. 2012

J Diabetes Sci Technol

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“…[14][15][16] To optimize BG control, investigators have implemented bedside paper protocols or guidelines for intravenous insulin titration in the pediatric ICU (PICU). [17][18][19] However, CDS protocol use in the PICU is not widely accepted. [20][21][22] Clinicians express concern about both the introduction of unseen risk and alienation from bedside decision making.…”

mentioning

confidence: 99%

A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages

Lanspa

Wilson

Sward

et al. 2017

Diabetes Technology & Therapeutics

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Background: Computer clinical decision support (CDS) systems are uncommon in the pediatric intensive care unit (PICU), despite evidence suggesting they improve outcomes in adult ICUs. We reasoned that a bedside CDS protocol for intravenous insulin titration, eProtocol-insulin, would be feasible and safe in critically ill children. Methods: We retrospectively reviewed data from non-diabetic children admitted to the PICU with blood glucose (BG) ‡140 mg/dL who were managed with intravenous insulin by either unaided clinician titration or eProtocol-insulin. Primary outcomes were BG measurements in target range (80-110 mg/dL) and severe hypoglycemia (BG £40 mg/dL); secondary outcomes were 60-day mortality and PICU length of stay. We assessed bedside nurse satisfaction with the eProtocol-insulin protocol by using a 5-point Likert scale and measured clinician compliance with eProtocol-insulin recommendations. Results: Over 5 years, 69 children were titrated with eProtocol-insulin versus 104 by unaided clinicians. eProtocol-insulin achieved target range more frequently than clinician titration (41% vs. 32%, P < 0.001). Severe hypoglycemia was uncommon in both groups (4.3% of patients in eProtocol-insulin, 8.7% in clinician titration, P = 0.37). There were no differences in mean time to BG target or median BG between the groups. Mortality was 23% in both groups. Clinician compliance with eProtocol-insulin recommendations was 89%. Nurses believed that eProtocol-insulin was easy to understand and safer than clinician titration. Conclusions: eProtocol-insulin is safe for titration of intravenous insulin in critically ill children. Clinical research protocols and quality improvement initiatives aimed at optimizing BG control should utilize detailed computer protocols that enable replicable clinician decisions.

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“…5,6 Studies have revealed the association between MODS with hyperglycemia in children requiring intensive care and mortality, 10,11 while insulin therapy decreases mortality rate and length of stay. 12,13 A study in America revealed that children requiring intensive care with blood sugar higher than 140 mg/dL as a criteria of hyperglycemia had a positive predictive value of 51% and a negative predictive value of 94%, and was set up as the foundation of insulin therapy in children. 12,14 The purpose of this study was to determine the association between MODS in children requiring intensive care and hyperglycemia.…”

mentioning

confidence: 99%

“…12,13 A study in America revealed that children requiring intensive care with blood sugar higher than 140 mg/dL as a criteria of hyperglycemia had a positive predictive value of 51% and a negative predictive value of 94%, and was set up as the foundation of insulin therapy in children. 12,14 The purpose of this study was to determine the association between MODS in children requiring intensive care and hyperglycemia. The secondary purpose of this study was to prove that a blood sugar level of > 140 mg/dL can be applied as a value of hyperglycemia due to MODS.…”

mentioning

confidence: 99%

Multiple organ dysfunction syndrome associated with hyperglycemia in children requiring intensive care

Halim

Suparyatha

Arimbawa

et al. 2015

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A protocolized approach to identify and manage hyperglycemia in a pediatric critical care unit*

Abstract: Hyperglycemia is prevalent in pediatric intensive care units and may be effectively identified and managed using a protocolized approach.

Cited by 67 publications

References 32 publications

Association of Hyperglycemia, Glucocorticoids, and Insulin Use with Morbidity and Mortality in the Pediatric Intensive Care Unit

Association of Hyperglycemia, Glucocorticoids, and Insulin Use with Morbidity and Mortality in the Pediatric Intensive Care Unit

A Pediatric Intensive Care Unit Bedside Computer Clinical Decision Support Protocol for Hyperglycemia Is Feasible, Safe and Offers Advantages

Multiple organ dysfunction syndrome associated with hyperglycemia in children requiring intensive care

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