Glycemic control and insulin therapy in sepsis and critical illness

Abstract

Objetivo: Revisar a literatura sobre a fisiopatologia de hiperglicemia e controle glicêmico em crianças e adultos com sepse e doença crítica. Fontes de dados:Pesquisa não sistemática da literatura médica através da base de dados MEDLINE usando os termos hiperglicemia, controle glicêmico, terapia insulínica intensiva, sepse e terapia intensiva. Os artigos foram selecionados de acordo com sua relevância, conforme a opinião dos autores. Síntese dos dados:A hiperglicemia é freqüente em crianças com doenças críticas e está associada a desfecho negativo. Em adultos, não há um consenso sobre a eficácia e segurança do controle glicêmico. Descrevemos os possíveis mecanismos envolvidos em toxicidade da glicose e os efeitos benéficos do controle glicêmico. Estudos iniciais demonstraram que o uso de insulina para atingir controle glicêmico reduziu a morbimortalidade em terapia intensiva em adultos; no entanto, estudos recentes não confirmaram esses achados. É importante destacar que o controle glicêmico está evidentemente associado a aumento da incidência de hipoglicemia. A eficácia do controle glicêmico ainda não foi estudada em crianças criticamente doentes. Conclusão:O controle glicêmico é uma nova opção terapêutica em terapia intensiva. Evidências conflitantes em adultos significam que, antes de aplicar esta abordagem em pediatria, é necessário avaliá-la em ensaio clínico.J Pediatr (Rio J). 2007;83(5 Supl):S128-136: Hiperglicemia, controle glicêmico, nível de glicose, terapia insulínica, terapia intensiva, pediatria.Objective: To review the literature about the pathophysiology of hyperglycemia and glycemic control in children and adults with sepsis and critical illness.Sources: Non-systematic survey of the medical literature using MEDLINE and terms hyperglycemia, glycemic control, intensive insulin therapy, sepsis and intensive care. Articles were selected according to their relevance based on the authors' opinion. Summary of the findings:Hyperglycemia is frequent in critically ill children and it is associated with worsened outcome. In adults, there is no consensus on the efficacy and safety of glycemic control. We describe the possible mechanisms involved in glucose toxicity and the beneficial effects of glycemic control. Initial studies showed that use of insulin to achieve glycemic control reduced morbidity and mortality in adult intensive care; however, recent studies have failed to confirm these findings. Importantly, it is evident that glycemic control is associated with increased incidence of hypoglycemia. The efficacy of glycemic control has not yet been studied in critically ill children. Conclusion:Glycemic control is a novel therapeutic option in critical care. Conflicting evidence in adults means that before we apply this approach to pediatrics it will need to be assessed in clinical trial.J Pediatr (Rio J). 2007;83(5 Suppl):S128-136: Hyperglycemia, glycemic control, glucose level, insulin therapy, intensive care, pediatric. IntroduçãoO metabolismo de carboidratos é essencial para a sobrevivência. A escasse...

Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock, 2012

“…An RCT of strict glycemic control compared to moderate control using insulin in a pediatric ICU population found a reduction in mortality with an increase in hypoglycemia. Insulin therapy should only be conducted with frequent glucose monitoring in view of the risks for hypoglycemia which can be greater in newborns and children due to a) relative lack of glycogen stores and muscle mass for gluconeogenesis, and b) the heterogeneity of the population with some excreting no endogenous insulin and others demonstrating high insulin levels and insulin resistance [622][623][624][625][626][627][628].…”

Glucose metabolism in children: influence of age, fasting, and infectious diseases

“…Insulin resistance is defined as the relative inability of insulin to increase glucose uptake and utilization and/or to suppress glucose production [147] and typically presents with hyperglycemia despite "normal" or increased insulin levels [148], although during infections, seemingly low insulin levels have been reported [149]. During illness, these alterations in glucose metabolism may differ in children compared with adults [150]. For instance, in children with meningococcal sepsis and shock, hyperglycemia and inadequate low insulin levels were found, which are compatible with an insufficient insulin response [151,152], whereas in children with meningococcal sepsis without shock, insulin resistance was found [151].…”

Glycemic Status and its Effect in Neonatal Sepsis in a Tertiary Care Hospital

“…These hormonal changes (also known as the counterregulatory response) and an increase in proinflammatory cytokines, i.e-interleukin (IL-1, IL-6), and tumor necrosis factor (TNF)-alpha, are important factors leading to hyperglycemia. 8 A high or low blood glucose level may have a significant effect on the outcomes in patients of neonatal sepsis. A recent study in Pakistan found that those patients of neonatal sepsis with altered glucose level had higher mortality.…”