Critically ill infants and children often develop hyperglycaemia (abnormally high blood sugar), which is associated with mortality and secondary infections. Intensive insulin therapy in these children to reduce blood sugar to normal levels reduces the mortality rate, the infection rate and the length of intensive care stay. These are the conclusions of authors of an Article published Online First and in an upcoming edition of The Lancet, written by Professor Greet Van den Berghe, University Hospital Gasthuisberg and Catholic University Leuven, Belgium, and colleagues.
Prior to this study, it was unknown what the effect would be of lowering blood glucose levels in these hyperglycaemic children to age-adjusted normal ranges. This randomised controlled trial studied 700 critically ill patients — 317 infants aged under one year and 383 children aged 1-16 years. The children were randomly assigned to receive either intensive insulin treatment to reduce their blood glucose level to the normal level for their age (349 patients), or to insulin treatment only if their hyperglycaemia reached critically high levels (conventional group: 351 patients).
The researchers found that mean blood glucose concentrations were lower in the intensive group than the conventional group. More patients in the intensive group experienced hypoglycaemia — meaning their blood sugar levels dropped to abnormally low levels. But, despite this, mortality was lower in the intensive group (3%) versus the conventional group (6%); and intensive care stay was also shorter for the intensive group (5.5 days) versus the conventional group (6.1 days).
The authors conclude: "Targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome of patients in paediatric intensive care units. The effect on long-term survival, morbidity, and neurocognitive development needs to be investigated."
In an accompanying Comment, Dr Mitchell M. Levy, Brown University and Rhode Island Hospital, Providence, RI, USA, and Dr Andrew Rhodes, St George's Healthcare NHS Trust, London, UK, say: "Clinicians must take into account several factors, including the nature of the intensive-care population in their institution and the incidence of hypoglycaemia with local insulin protocols when determining what glucose target is most appropriate for their critically ill patients. Perhaps the results of ongoing large-scale trials will provide greater clarity for this clinical dilemma."
Professor Greet Van den Berghe, University Hospital Gasthuisberg and Catholic University Leuven, Belgium T) +32-16-34 40 21 / +32-16-34 40 13 E) greet.vandenberghe@med.kuleuven.be
Dr Mitchell M. Levy, Brown University and Rhode Island Hospital, Providence, RI, USA T) +1 401 444 2776 E) Mitchell_levy@brown.edu
For full Article and Comment see: http://press.thelancet.com/paediatricinsulin.pdf
Journal
The Lancet