Safe and Effective Use of a Glycemic Control Protocol for Neonates in a Cardiac ICU*
1 Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA. 2 Section of Pediatric Critical Care, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN. 3 Pharmacy Department, Children's Healthcare of Atlanta, Atlanta, Georgia.Pediatric Critical Care Medicine (Impact Factor: 2.34). 02/2013; 14(3). DOI: 10.1097/PCC.0b013e31827200de
OBJECTIVE:: To investigate the safety and efficacy of a hyperglycemia protocol in neonates with critical cardiac illness. Neonates are often regarded as high risk for hypoglycemia while receiving continuous insulin infusions and thus have been excluded from some clinical trials. DESIGN:: A retrospective review. SETTING:: A pediatric cardiac ICU in a tertiary academic center. INTERVENTIONS:: Neonates with critical cardiac illness who developed hyperglycemia were placed on an insulin-hyperglycemia protocol at the attending physician's discretion. Insulin infusions were titrated based on frequent blood glucose monitoring. MEASUREMENTS:: Critical illness hyperglycemia was defined as a blood glucose > 140 mg/dL. Hypoglycemia was defined as moderate (≤ 60 mg/dL) or severe (≤ 40 mg/dL). Initiating blood glucose, lowest blood glucose during insulin infusion, doses of insulin, duration of insulin, and time to blood glucose < 140 mg/dL were evaluated. MAIN RESULTS:: A total of 44 patients were placed on the protocol between January 2009 and October 2011. The majority of insulin infusions were initiated in the early postoperative period (33 of 44, 75%). Moderate hypoglycemia occurred in two patients (4.5%), with blood glucose levels of 49 and 53 mg/dL. No episodes of severe hypoglycemia occurred. A total of 345 discrete blood glucose levels were analyzed; two of these being < 60 mg/dL (0.58%). Mean blood glucose prior to starting insulin was 252 ± 45 mg/dL and time until euglycemia was 6.1 ± 3.9 hrs. The mean duration of insulin infusion was 24.6 ± 38.7 hrs, mean peak dose was 0.10 ± 0.05 units/kg/hr, and mean insulin dose was 0.06 ± 0.02 units/kg/hr. For postoperative patients, mean time after bypass until onset of hyperglycemia was 2.2 ± 2.6 hrs. CONCLUSIONS:: A glycemic control protocol can safely and effectively be applied to neonates with critical cardiac disease. Neonates with critical cardiac illness should be included in clinical trials evaluating the benefits of glycemic control.
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ABSTRACT: Although once considered a benign consequence to the stress of severe illness or injury, a significant body of evidence compiled over the past decade shows that hyperglycemia in critically ill patients is associated with poor outcomes. In both adults and pediatric studies, there is a strong association with hyperglycemia with higher morbidity and mortality, and in some prospective studies, controlling hyperglycemia improves outcomes. These data have resulted in a number of national and international consensus statements and guidelines recommending active glycemic control - though primarily directed at the critically ill or injured adult. Due to the lack of pediatric-specific data, it has been unclear how pediatric intensivists should incorporate glycemic control into their practice. During the past decade data from both retrospective and prospective studies have also shown significant associations between hypoglycemia and dysglycemia (i.e., glycemic variability) and poor outcomes. From the current data, it appears that both hyper- and hypoglycemia occurs in patients who have higher illness severities and require more organ support measures. A number of pediatric-specific protocols have been developed and published which suggest that approaches to identify and manage hyperglycemia in critically ill children can be effectively and safely implemented, and interestingly in many cases hypoglycemic rates are less than that which occurs spontaneously. Although most pediatric practitioners support active glycemic control in certain subsets of patients, it is unclear how widespread standardized, consistent glycemic management has been incorporated into practice. Prospective trials have yielded disparate outcome findings regarding glycemic control in the pediatric ICU. Data from ongoing and completed studies will hopefully yield more definitive data on whether pediatric practitioners should regularly practice glycemic control, and what patient populations might benefit from this practice. This chapter reviews the existing data on hyperglycemia, hypoglycemia and dysglycemia, and will hopefully assist how pediatric practitioners synthesize these data into practice.
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ABSTRACT: Objective: To investigate the effectivity of pentoxifylline (PTX) and immunoglobulin M (IgM)-enriched intravenous immunoglobulin (IVIG) therapy in the treatment of neonatal sepsis (NS), alone or in combination. Study design: This was a prospective, double-blind, controlled study. Newborns with suspicion of sepsis were enrolled in the study. The patients were separated into four groups according to treatment protocol: Group 1 = placebo, Group 2 = pentoxifylline, Group 3 = IgM-enriched IVIG, and Group 4 = pentoxifylline + IgM-enriched IVIG. Blood samples were taken for C-reactive protein, interleukin-6, neutrophil CD64 expression, and tumor necrosis factor-alfa measurements immediately before treatment (1st day), and measurements were repeated on the 2nd and 4th days of the therapy. Results: A total of 204 patients, 51 in each group, were recruited into the study. There were no significant differences for symptoms of sepsis among groups, except lethargy. No significant differences were observed among the groups according to laboratory data. Overall mortality rate was 8.8%. The rates of morbidities and mortality among study groups were similar. Conclusion: PTX and IgM-enriched IVIG therapies, either alone or in combination, did not reduce the rates of morbidities and mortality in NS.
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