Tight Glycemic Control Leads to More Hypoglycemia in the Pediatric ICU Population

Question

Does tight control of hyperglycemia improve outcomes in the pediatric intensive care unit?

Bottom line

Tight glycemic control does not increase the number of days alive and free from mechanical ventilation for pediatric patients in the intensive care unit (ICU), but does increase the risk of severe hypoglycemia. Children in the ICU for reasons other than cardiac surgery and were treated with tight control had lower overall healthcare costs and reduced lengths of stay. However, these benefits must be weighed against the increased risk of hypoglycemia.

Reference

Macrae D, Grieve R, Allen E, et al, for the CHiP Investigators. A randomized trial of hyperglycemic control in pediatric intensive care. N Engl J Med 2014;370(2):107-118. (LOE: 1b)

Allocation

(Concealed)

Design

Randomized controlled trial (nonblinded)

Setting

Inpatient (ICU only)

Synopsis

Using concealed allocation, these investigators randomized 1369 patients in the pediatric ICU to receive either tight glycemic control with a target blood glucose of 72 mg/dL to 126 mg/dL (4 – 7 mmol/L) or conventional glycemic control with a target of less than 216 mg/dL (12 mmol/L). Eligible patients were aged between 36 weeks and 16 years. They required mechanical ventilation and vasoactive drugs for an anticipated 12 hours following an injury or major surgery or to treat a critical illness. Children with diabetes were excluded. Analysis was by intention to treat. Baseline characteristics of the 2 groups were similar, and 60% of the patients in the total cohort had undergone cardiac surgery. There was no significant difference detected between the 2 groups for the primary outcome – the number of days alive and free from mechanical ventilation at 30 days. As expected, patients in the tight control group were more likely to have multiple severe hypoglycemic episodes (7.3% vs 1.5%; odds ratio = 5.27; 95% CI, 2.65-10.48). Although major clinical outcomes did not improve, there were some benefits associated with tight control, including reduced costs and reduced lengths of stay in the subgroup of patients who had not undergone cardiac surgery, as well as decreased need for renal replacement therapy in the overall group.

Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.

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