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Published on: June 11, 2012
Safe and effective use of a glycemic control protocol for neonates in a cardiac ICU
Camden L Hebson1, Nikhil K Chanani, Mark R Rigby
1Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine/Children's Healthcare of Atlanta, Atlanta, GA, USA. chebson@emory.edu
Insights
A hyperglycemia protocol safely managed blood glucose in critically ill neonates with heart conditions. This suggests neonates with critical cardiac illness can be included in clinical trials for glycemic control.
Area of Science:
- Pediatric Cardiology
- Neonatal Intensive Care
- Endocrinology
Background:
- Neonates with critical cardiac illness are at high risk for hypoglycemia during insulin infusions.
- Previous clinical trials have excluded these neonates due to hypoglycemia concerns.
Purpose of the Study:
- To assess the safety and efficacy of a hyperglycemia management protocol in neonates with critical cardiac illness.
- To determine if neonates with critical cardiac conditions can be safely included in glycemic control studies.
Main Methods:
- Retrospective review of 44 neonates with critical cardiac illness and hyperglycemia.
- Insulin infusions were initiated and titrated based on blood glucose monitoring.
- Moderate hypoglycemia defined as blood glucose ≤ 60 mg/dL; severe hypoglycemia as ≤ 40 mg/dL.
Main Results:
- Two patients (4.5%) experienced moderate hypoglycemia; no severe hypoglycemia occurred.
- Mean time to euglycemia was 6.1 hours, with a mean insulin dose of 0.06 units/kg/hour.
- The protocol was initiated primarily in the early postoperative period (75% of cases).
Conclusions:
- A glycemic control protocol is safe and effective for neonates with critical cardiac disease.
- Neonates with critical cardiac illness should be included in future clinical trials on glycemic control benefits.
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 less than 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 greater than 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 greater than 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 hours. The mean duration of insulin infusion was 24.6 ± 38.7 hours, mean peak dose was 0.10 ± 0.05 units/kg/hour, and mean insulin dose was 0.06 ± 0.02 units/kg/hour. For postoperative patients, mean time after bypass until onset of hyperglycemia was 2.2 ± 2.6 hours.
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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