Reducing glucose infusion safely prevents hyperglycemia in post-surgical children

Verbruggen, Sascha; Betue, Carlijn T.I. de; Schierbeek, Henk; Chacko, Shaji; Adrichem, L.N.A. van; Verhoeven, Jennifer; Goudoever, Johannes B. van; Joosten, Koen

doi:10.1016/j.clnu.2011.05.011

Cited by 21 publications

(15 citation statements)

References 52 publications

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“…Furthermore, reduced glucose intake resulted in decreased blood glucose concentrations and not in hypoglycemia or increased protein catabolism. However, in contrast with our hypothesis and our previous study in healthy children undergoing elective craniofacial surgery, the glycemic target (4.0 to 6.0 mmol/L) was not achieved with reduced glucose intake [39]. In addition, it resulted in increased EGP due to increased glycogenolysis.…”

Section: Discussioncontrasting

confidence: 92%

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Does a reduced glucose intake prevent hyperglycemia in children early after cardiac surgery? a randomized controlled crossover study

et al. 2012

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IntroductionHyperglycemia in children after cardiac surgery can be treated with intensive insulin therapy, but hypoglycemia is a potential serious side effect. The aim of this study was to investigate the effects of reducing glucose intake below standard intakes to prevent hyperglycemia, on blood glucose concentrations, glucose kinetics and protein catabolism in children after cardiac surgery with cardiopulmonary bypass (CPB).MethodsSubjects received a 4-hour low glucose (LG; 2.5 mg/kg per minute) and a 4-hour standard glucose (SG; 5.0 mg/kg per minute) infusion in a randomized blinded crossover setting. Simultaneously, an 8-hour stable isotope tracer protocol was conducted to determine glucose and leucine kinetics. Data are presented as mean ± SD or median (IQR); comparison was made by paired samples t test.ResultsEleven subjects (age 5.1 (20.2) months) were studied 9.5 ± 1.9 hours post-cardiac surgery. Blood glucose concentrations were lower during LG than SG (LG 7.3 ± 0.7 vs. SG 9.3 ± 1.8 mmol/L; P < 0.01), although the glycemic target (4.0-6.0 mmol/L) was not achieved. No hypoglycemic events occurred. Endogenous glucose production was higher during LG than SG (LG 2.9 ± 0.8 vs. SG 1.5 ± 1.1 mg/kg per minute; P = 0.02), due to increased glycogenolysis (LG 1.0 ± 0.6 vs. SG 0.0 ± 1.0 mg/kg per minute; P < 0.05). Leucine balance, indicating protein balance, was negative but not affected by glucose intake (LG -54.8 ± 14.6 vs. SG -58.8 ± 16.7 μmol/kg per hour; P = 0.57).ConclusionsCurrently recommended glucose intakes aggravated hyperglycemia in children early after cardiac surgery with CPB. Reduced glucose intake decreased blood glucose concentrations without causing hypoglycemia or affecting protein catabolism, but increased glycogenolysis.Trial registrationDutch trial register NTR2079.

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Section: Discussioncontrasting

confidence: 92%

“…Under steady-state conditions, total glucose rate of appearance is equal to the rate of disappearance [37], the latter of which reflects glucose utilization. Rates of EGP, glucose clearance, glycogenolysis, and gluconeogenesis were calculated as previously described [21,39,40]. …”

Section: Methodsmentioning

confidence: 99%

Does a reduced glucose intake prevent hyperglycemia in children early after cardiac surgery? a randomized controlled crossover study

et al. 2012

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“…While normal infants and children may have substantially higher glucose turnover rates than adults, 81 limited data from critically ill children suggest that glucose infusion rates (GIR) less than 5 mg/kg/min may be optimal for glucose utilization from PN. 82,83 Further, BG concentrations may not accurately reflect glucose turnover and utilization. 82 The practice of cycling PN may also be associated with development of SH, most likely due to impaired insulin secretion.…”

Section: Prolonged Immobility and Stress Hyperglycemiamentioning

confidence: 99%

Stress Hyperglycemia in Pediatric Critical Illness: The Intensive Care Unit Adds to the Stress!

Srinivasan

2012

J Diabetes Sci Technol

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Abbreviations: (BG), blood glucose, (CBP) cardiopulmonary bypass, (EN) enteral nutrition, (ECLS) extracorporeal life support, (FFA) free fatty acids, (GIR) glucose infusion rate, (GLUT) glucose transporter protein, (GH) growth hormone, (IGF-1) insulin-like growth factor-1, (ICU) intensive care unit, (IL-1) interleukin-1, (IL-6) interleukin-6, (PN) parenteral nutrition, (ROS) reactive oxygen species, (RRT) renal replacement therapy, (SH) stress hyperglycemia, (TGC) tight glucose control, (TNF-α) tumor necrosis factor-α

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“…It is therefore thought that parenteral nutrition creates a significantly higher blood glucose level which causes cellular glucose overload and oxidative injury in cells that do not require insulin for glucose uptake 7. Another small study recommended a reduction in glucose infusion as opposed to the aggressive use of insulin 15. Gandhi et al quantified the risk of intraoperative glucose and adverse events by formulating a continuous scale whereby every 20 mg/dL increase in blood glucose above 100 mg/dL was associated with a 34% increase in the likelihood of an adverse event 16…”

Section: Intensive Insulin Therapy In Adult Patientsmentioning

confidence: 99%

“…Interestingly, the survey showed that clinicians tend to undertreat due to a fear of inducing iatrogenic hypoglycemia. This was especially the case with the pediatric intensivists because of the unknown long-term effects of hypoglycemia 15,20. As documented in recently published correspondence, opinion still differs on what are considered “correct” blood glucose levels to aim for 20.…”

Section: Standards Of Carementioning

confidence: 99%

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

Forbes¹,

Anders²

2013

IJGM

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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.

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Reducing glucose infusion safely prevents hyperglycemia in post-surgical children

Cited by 21 publications

References 52 publications

Does a reduced glucose intake prevent hyperglycemia in children early after cardiac surgery? a randomized controlled crossover study

Does a reduced glucose intake prevent hyperglycemia in children early after cardiac surgery? a randomized controlled crossover study

Stress Hyperglycemia in Pediatric Critical Illness: The Intensive Care Unit Adds to the Stress!

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

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