Incidence and Risk Factors for Perioperative Hyperglycemia in Children with Traumatic Brain Injury

Abstract

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.

Intraoperative Secondary Insults During Orthopedic Surgery in Traumatic Brain Injury

“…25,26 In addition, surgical intervention leads to fluid shifts and blood loss. Secondary insults during craniotomy for TBI have been reported, 9,10,27–32 and as evidenced by our data here, secondary insults are also common during orthopedic surgery in patients with TBI and may contribute to worse outcomes. Therefore, anesthesiologists can potentially contribute to improving TBI outcomes by reducing the burden of secondary insults during craniotomy as well as extracranial surgery.…”

“…3–8 Although previous studies have examined secondary insults in the pre-hospital period, during transportation to a tertiary care center, in the emergency department and in the intensive care setting, 3–8 data on intraoperative secondary insults are limited. 9,10 Moreover, patients with TBI frequently have associated orthopedic injuries requiring surgical intervention and data on secondary insults during orthopedic surgery in TBI and their impact on neurological outcomes are sparse and old. 11–14 …”

“…Given the advances in anesthetic and intraoperative management in general, and the modification of clinical care guidelines for TBI management (such as change in the recommended cerebral perfusion pressure {CPP} goal to 50–70 mmHg), 17 it is important to quantify the current burden of intraoperative secondary insults and examine their impact. We have previously reported on intraoperative secondary insults during craniotomy for TBI 9,10 but secondary insults in other surgical settings were not examined. The primary aim of this retrospective study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery within 2 weeks of moderate-severe TBI.…”

Association of increased morbidity with the occurrence of hyperglycemia in the immediate postoperative period after elective pediatric neurosurgery

“…We observed that approximately 10% of patients had at least 1 blood glucose reading of 150 mg/dl or higher dur- 17 studied a retrospective cohort of children under 13 years of age who presented with a head trauma and underwent emergency neurosurgery. They found blood glucose levels of 200 mg/ dl or higher in 32% of the patients during the intraoperative period.…”

Hyperglycemia Is Associated With Intracranial Injury in Children Younger Than 3 Years of Age

“…10Y14 One study found that 82% of neurosurgical pediatric patients with TBI had hyperglycemia preoperatively. 10 We have observed that infants admitted to our pediatric intensive care unit (PICU) with TBI often have hyperglycemic on initial presentation. We hypothesized that elevated serum glucose could be a sensitive marker for the presence of intracranial injury in infants who presented to the ED with a variety of symptoms.…”