Does tight glycemic control improve outcomes in pediatric patients undergoing surgery and/or those with critical illness?

Abstract

This literature review examines the current evidence regarding the potential usefulness of tight glycemic control in pediatric surgical patients. In adults, fluctuations in glucose levels and/or prolonged hyperglycemia have been shown to be associated with poor outcomes with respect to morbidity and mortality. This review begins by summarizing the findings of key papers in adult patients and continues by investigating whether or not similar results have been seen in pediatric patients by performing a comprehensive literature review using Medline (OVID). A database search using the OVID interface and including the search terms (exp glucose) AND (exp surgery) AND (exp Paediatric/pediatric) AND (exp Hypoglycaemia/hypoglycemia) AND (exp Hyperglycaemia/hyperglycemia) yielded a total of 150+ papers, of which 24 fulfilled our criteria. We isolated papers utilizing pediatric patients who were hospitalized due to illness and/or surgery. Our review highlights several difficulties encountered in addressing this potentially useful clinical intervention. An absence of scientifically robust and randomized trials and the existence of several small-powered trials yielding conflicting results mean we cannot recommend tight glycemic control in these patients. Differences in study design and disagreements concerning the crucial stage of surgery where hyperglycemia becomes important are compounded by an over-reliance on the discretion of clinicians in the absence of well described treatment protocols. Closer inspection of key papers in adult patients identified fundamental discrepancies between exact definitions of both hyperglycemia and hypoglycemia. This lack of consensus, along with a fear of inducing iatrogenic hypoglycemia in pediatric patients, has resulted in professional bodies advising against this form of intervention. In conclusion, we cannot recommend use of tight glycemic control in pediatric surgical patients due to unclear glucose definitions, unclear thresholds for treatment, and the unknown long-term effects of iatrogenic hypoglycemia on the developing body and brain.

Adjusted tight control blood glucose management in diabetic patients undergoing on pump coronary artery bypass graft. A randomized clinical trial

“…Tight control of blood glucose is a method for reduced of hyperglycemia side effects [8]. This method can lead to hypoglycemia; that may be associated with neurological damage [9,10].…”

Perioperative care of children and young people with diabetes

“…The risks of both inducing hypoglycaemia and the deleterious effects of hypoglycaemia on the developing brain are potentially greater. 4…”

Blood Glucose Control in Critically Ill Children: A Survey Study on Approaches of Pediatricians Working in Pediatric Intensive Care Units in Turkey

“…Kısa süreli bile olsa hiperglisemi, bağışıklık yanıtının değişik aşamalarında bozulmaya yol açarak kompleman fiksasyonunu, makrofaj işlevlerini, granülosit kemotaksisini ve yapışmayı, fagositozu, bakterisidal aktiviteyi olumsuz etkilemektedir. [2][3][4][5][6] Stres yanıtı sonucu gelişen sitokin ve insülin karşıtı hormonların (kortizol, adrenalin, noradrenalin, glukagon, büyüme hormonu) artışı insülin reseptör direnci ve insülin bağımlı hücre kanallarının işlev kaybına yol açmaktadır. Bu durum karaciğer, kas ve yağ dokusunda glukoneogenez, lipoliz ve proteolize neden olmaktadır.…”