Question: Insulin for hyperglycaemic PICU patients?

Should paediatric critically ill patients receive insulin therapy to maintain strict normoglycaemia?

Blood sugar monitorJoseph, a 4 year old boy with septic shock, lactic acidosis and multi-organ failure has been admitted to the paediatric intensive care unit. Mechanical ventilation, vaso-active support, and renal replacement therapy (CVVHD) are initiated. His serum glucose level is 10.5 mmol/l. The senior consultant decides to order insulin therapy in order to maintain strict normoglycaemia, but the junior fellow argues that there is no evidence that strict normoglycaemia improves outcome in critically ill children.

… but there is evidence from adults that this is the case. Should we always wait for information to be replicated in children- with the lower incidence of problems, increased difficulty with study organisation and relatively low financial input – before we act? Or should we just follow physiology and adult data?

Report by

D. G. Markhorst (dg.markhorst@vumc.nl), M. van Heerde, M. C. J. Kneyber
Paediatric intensivists
Paediatric intensive care unit, Vrije Universiteit medical center, Amsterdam The Netherlands

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  • L J Solomon

    The initial enthusiasm for tight glycaemic control in adults came from van den Berg’s study based on a population of predominantly post op cardiac patients. A follow-up study by the same group in a population of medical adult patients showed no clear benefit for tight glycaemic control, and could suggest potential harm due to such a strategy. So the data suggest that benefit from tight glycaemic control is context dependent, and may not be generalizable to sepsis / MODS in children, though the potential for reversing the hyperglycaemic stress response seems appealing…
    The consequences of overshoot hypoglycaemia in childen remain a valid concern …