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Abstract and Introduction
Abstract
Introduction: Hyperglycemia is common in critically ill patients and is associated with increased morbidity and mortality. Strict glycemic control improves outcomes in some adult populations and may have similar effects in children. While glycemic control has become standard care in adults, little is known regarding hyperglycemia management strategies used by pediatric critical care practitioners. We sought to assess both the beliefs and practice habits regarding glycemic control in pediatric intensive care units (ICUs) in the United States (US).
Methods: We surveyed 30 US pediatric ICUs from January to May 2009. Surveys were conducted by phone between the investigators and participating centers and consisted of a 22-point questionnaire devised to assess physician perceptions and center-specific management strategies regarding glycemic control.
Results: ICUs included a cross section of centers throughout the US. Fourteen out of 30 centers believe all critically ill hyperglycemic adults should be treated, while 3/30 believe all critically ill children should be treated. Twenty-nine of 30 believe some subsets of adults with hyperglycemia should be treated, while 20/30 believe some subsets of children should receive glycemic control. A total of 70%, 73%, 80%, 27%, and 40% of centers believe hyperglycemia adversely affects outcomes in cardiac, trauma, traumatic brain injury, general medical, and general surgical pediatric patients, respectively. However, only six centers use a standard, uniform approach to treat hyperglycemia at their institution. Sixty percent of centers believe hypoglycemia is more dangerous than hyperglycemia. Seventy percent listed fear of management-induced hypoglycemia as a barrier to glycemic control at their center.
Conclusions: Considerable disparity exists between physician beliefs and actual practice habits regarding glycemic control among pediatric practitioners, with few centers reporting the use of any consistent standard approach to screening and management. Physicians wishing to practice glycemic control in their critically ill pediatric patients may want to consider adopting center-wide uniform approaches to improve safety and efficacy of treatment.
Introduction
Hyperglycemia in critically ill patients occurs frequently, is associated with increased morbidity and mortality, and studies in adults suggest that tight glycemic control with insulin may improve outcomes. Questions regarding safety and efficacy of this therapy, extent of outcome improvement, goal blood glucose (BG) range, and target patient population for treatment are of significant debate. However, despite these unresolved issues several medical advisory committees recommend glycemic control as standard care in adults.
Studies regarding hyperglycemia and glycemic control in pediatrics are limited. Those available demonstrate that high BG is prevalent and independently associated with increased morbidity and mortality. To date, a single randomized controlled trial to assess whether glycemic control improves outcomes in pediatric critical illness has been published. In this study, although tight glycemic control reduced morbidity and mortality, approximately 25% of patients receiving this management developed severe hypoglycemia. Despite strong data favoring treatment and official recommendations to practice glycemic control in critically ill adults, there are no definitive studies or guidelines to help steer the practice in pediatric critical care.
Recent studies indicate that hyperglycemia is a significant concern among physicians caring for critically ill children and suggest that glycemic management is routinely performed. Our group developed and published a protocol to identify and manage hyperglycemia in critically ill children and adopted this practice as routine care in our pediatric intensive care unit (ICU). From current literature, however, it is difficult to discern the breadth and extent of actual glycemic control efforts adopted by other pediatric centers. To better determine how physician attitudes towards glycemic control translate to actual practice we conducted a survey to assess the beliefs and practice habits regarding glycemic control in a cross section of pediatric ICUs in the United States.
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