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Relationship between hyperglycemia and outcome in children with severe traumatic brain injury
Rebecca L Smith1, John C Lin, P David Adelson
1Department of Critical Care Medicine, Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA. smithr3@upmc.edu
Insights
Hyperglycemia after the first 48 hours of severe traumatic brain injury in children is linked to worse outcomes. This suggests a connection between high blood sugar and injury severity, but further research is needed.
Area of Science:
- Pediatric critical care
- Neurotrauma research
- Endocrinology
Background:
- Severe traumatic brain injury (TBI) in children presents significant management challenges.
- Glycemic control is a critical factor in patient outcomes following critical illness and injury.
- The specific impact of hyperglycemia on pediatric TBI outcomes requires further elucidation.
Purpose of the Study:
- To investigate the association between hyperglycemia and clinical outcomes in pediatric patients with severe traumatic brain injury.
- To analyze the relationship between different levels of blood glucose and patient outcomes.
Main Methods:
- Retrospective analysis of a prospectively collected Pediatric Neurotrauma Registry (1999-2004).
- Inclusion criteria: children with severe TBI (Glasgow Coma Scale ≤ 8) and standard TBI protocol management.
- Blood glucose levels were monitored, and outcomes were assessed, with analysis of early (0-48 hours) and late (49-168 hours) periods post-injury.
Main Results:
- In the late period (49-168 hours post-injury), elevated mean serum glucose concentrations were significantly associated with unfavorable outcomes (p = .02).
- Children experiencing severe hyperglycemia (blood glucose >200 mg/dL) in the late period showed a decreased incidence of good outcomes (33.3%) compared to those with normal or mild hyperglycemia.
- This association between hyperglycemia and poor outcome persisted after adjusting for injury severity, age, and insulin use, although the link with severe hyperglycemia lost statistical significance after insulin adjustment.
Conclusions:
- Hyperglycemia occurring beyond 48 hours after severe traumatic brain injury in children is associated with poorer outcomes.
- Both mean glucose levels and episodic severe hyperglycemia correlate with adverse outcomes.
- Prospective studies are necessary to determine if interventions targeting serum glucose concentration can improve outcomes in pediatric TBI.
Objective:
To determine the relationship between hyperglycemia and outcome in infants and children after severe traumatic brain injury.
Design:
Retrospective review of a prospectively collected Pediatric Neurotrauma Registry.
Setting And Patients:
Children admitted after severe traumatic brain injury (postresuscitation Glasgow Coma Scale ≤ 8) were studied (1999-2004). A subset of children (n = 28) were concurrently enrolled in a randomized, controlled clinical trial of early hypothermia for neuroprotection.
Interventions:
Demographic data, serum glucose concentrations, and outcome assessments were collected.
Methods And Main Results:
Children (n = 57) were treated with a standard traumatic brain injury protocol. Exogenous glucose was withheld for 48 hrs after injury unless hypoglycemia was observed (blood glucose <70 mg/dL). Early (first 48 hrs) and Late (49-168 hrs) time periods were defined and mean blood glucose concentrations were calculated. Additionally, children were categorized based on peak blood glucose concentrations during each time period (normal, blood glucose <150 mg/dL; mild hyperglycemia, blood glucose ≤ 200 mg/dL; severe hyperglycemia, blood glucose >200 mg/dL). In the Late period, an association between elevated mean serum glucose concentration and outcome was observed (133.5 ± 5.6 mg/dL in the unfavorable group vs. 115.4 ± 4.1 mg/dL in favorable group, p = .02). This association continued to be significant after correcting for injury severity, age, and exposure to insulin (p = .03). Similarly, in the Late period, children within the severe hyperglycemia group had decreased incidence of good outcome compared to children within the other glycemic groups (% good outcome: normal, 61.9%; mild hyperglycemia, 73.7%; severe hyperglycemia, 33.3%; p = .05). However, when adjusted for exposure to insulin, this relationship was no longer statistically significant.
Conclusions:
In children with severe traumatic brain injury, hyperglycemia beyond the initial 48 hrs is associated with poor outcome. This relationship was observed in both our analysis of mean blood glucose concentrations as well as among the patients with episodic severe hyperglycemia. This observation suggests a relationship between hyperglycemia and outcome from traumatic brain injury. However, only a prospective study can answer the important question of whether manipulating serum glucose concentration can improve outcome after traumatic brain injury in children.
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