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Impact of stress-induced diabetes on outcomes in severely burned children
Celeste C Finnerty1, Arham Ali2, Josef McLean2
1Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX; Sealy Center for Molecular Medicine, University of Texas Medical Branch, Galveston, TX.
Insights
In pediatric burn patients, insulin therapy to control hyperglycemia increased mortality and resting energy expenditure, despite improving bone and muscle health. The no-insulin group experienced reduced hospital stays and no deaths, suggesting a need for new glucose-lowering strategies.
Area of Science:
- Pediatric critical care
- Metabolic response to injury
- Burn management
Background:
- Post-burn hyperglycemia is linked to severe complications, including graft failure, organ failure, and death.
- Current management uses strict or less-stringent insulin protocols to maintain target serum glucose levels.
- The effectiveness and safety of insulin in pediatric burn patients require further investigation.
Purpose of the Study:
- To compare morbidity and mortality in pediatric patients with massive burns randomized to receive sliding scale insulin versus no insulin.
- To evaluate the impact of insulin therapy on glucose levels, infections, metabolic parameters, and physical outcomes.
Main Methods:
- Randomized controlled trial involving pediatric patients (0-18 years) with burns covering ≥30% total body surface area.
- Two groups: sliding scale insulin (n=145) and no insulin (n=98).
- Assessed endpoints included glucose levels, infections, resting energy expenditure, body composition, muscle strength, and inflammatory markers.
Main Results:
- Insulin therapy significantly altered daily glucose levels but did not prevent hyperglycemia within 6 days post-burn.
- Patients receiving insulin showed increased resting energy expenditure and improved bone mineral content and muscle strength.
- Conversely, insulin administration was associated with increased mortality and hypoglycemic episodes; no deaths occurred in the non-insulin group.
Conclusions:
- Burn-induced hyperglycemia occurs in a subset of severely burned children.
- While insulin improved bone mineral content and muscle strength, it increased resting energy expenditure, hypoglycemia, and mortality.
- The findings suggest that current insulin protocols may not be optimal and new glucose-lowering strategies are needed for pediatric burn patients.
Background:
Post-burn hyperglycemia leads to graft failure, multiple organ failure, and death. A hyperinsulinemic-euglycemic clamp is used to keep serum glucose between 60 and 110 mg/dL. Because of frequent hypoglycemic episodes, a less-stringent sliding scale insulin protocol is used to maintain serum glucose levels between 80 and 160 mg/dL after elevations >180 mg/dL.
Study Design:
We randomized pediatric patients with massive burns into 2 groups, patients receiving sliding scale insulin to lower blood glucose levels (n = 145) and those receiving no insulin (n = 98), to determine the differences in morbidity and mortality. Patients 0 to 18 years old with burns covering ≥ 30% of the total body surface area and not randomized to receive anabolic agents were included in this study. End points included glucose levels, infections, resting energy expenditure, lean body mass, bone mineral content, fat mass, muscle strength, and serum inflammatory cytokines, hormones, and liver enzymes.
Results:
Maximal glucose levels occurred within 6 days of burn injury. Blood glucose levels were age dependent, with older children requiring more insulin (p < 0.05). Daily maximum and daily minimum, but not 6 am, glucose levels were significantly different based on treatment group (p < 0.05). Insulin significantly increased resting energy expenditure and improved bone mineral content (p < 0.05). Each additional wound infection increased incidence of hyperglycemia (p = 0.004). There was no mortality in patients not receiving insulin, only in patients who received insulin (p < 0.004). Muscle strength was increased in patients receiving insulin (p < 0.05).
Conclusions:
Burn-induced hyperglycemia develops in a subset of severely burned children. Length of stay was reduced in the no insulin group, and there were no deaths in this group. Administration of insulin positively impacted bone mineral content and muscle strength, but increased resting energy expenditure, hypoglycemic episodes, and mortality. New glucose-lowering strategies might be needed.
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