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Tight Glycemic Control in Critically Ill Children.

Michael S D Agus1, David Wypij1, Eliotte L Hirshberg1

  • 1From the Division of Medicine Critical Care (M.S.D.A., J.L.A., G.M.S.) and the Department of Cardiology (D.W., L.A.A.), Boston Children's Hospital and Harvard Medical School, Boston; the Division of Pediatric Critical Care, University of Utah Medical School, Primary Children's Hospital, Salt Lake City, and Intermountain Medical Center, Murray - both in Utah (E.L.H.); Children's Hospital of Philadelphia (V.S., V.M.N.) and the Perelman School of Medicine (V.S., M.A.Q.C., V.M.N.) and the School of Nursing (M.A.Q.C.), University of Pennsylvania - all in Philadelphia; Yale School of Medicine, New Haven, CT (E.V.F.); and Children's Medical Center Dallas and the University of Texas Southwestern Medical School, Dallas (P.M.L.).

The New England Journal of Medicine
|January 25, 2017
PubMed
Summary

Tight glycemic control in critically ill children without cardiac surgery did not improve intensive care unit (ICU)-free days. This approach was associated with increased infections and severe hypoglycemia, suggesting it may cause harm.

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Area of Science:

  • Pediatric Critical Care Medicine
  • Endocrinology
  • Clinical Trials

Background:

  • Previous studies showed no benefit of tight glycemic control in critically ill adults and children post-cardiac surgery.
  • Limited data exists on glycemic control in critically ill children not undergoing cardiac surgery.

Purpose of the Study:

  • To investigate the efficacy and safety of tight glycemic control versus a higher target range in critically ill children with hyperglycemia who have not undergone cardiac surgery.

Main Methods:

  • A 35-center randomized trial assigned critically ill children with hyperglycemia to a lower (80-110 mg/dL) or higher (150-180 mg/dL) glycemic control target.
  • Continuous glucose monitoring and explicit insulin adjustment protocols were used.
  • The primary outcome was intensive care unit (ICU)-free days to day 28.

Main Results:

  • The trial was stopped early due to low likelihood of benefit and potential harm.
  • No significant difference in median ICU-free days was observed between the lower-target and higher-target groups (19.4 days vs. 19.4 days).
  • The lower-target group had higher rates of healthcare-associated infections (3.4% vs. 1.1%) and severe hypoglycemia (5.2% vs. 2.0%).

Conclusions:

  • Tight glycemic control targeting 80-110 mg/dL offers no benefit and may increase harm in critically ill children with hyperglycemia compared to a higher target of 150-180 mg/dL.
  • The findings suggest that a less stringent glycemic control strategy is appropriate for this patient population.