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Clinical Equipoise Regarding Glycemic Control: A Survey of Pediatric Intensivist Perceptions*

Hirshberg, Eliotte L. MD1,2; Sward, Katherine A. PhD3; Faustino, Edward Vincent S. MD4; Nadkarni, Vinay M. MD5; Agus, Michael S. D. MD6; Morris, Alan H. MD2; Lacroix, Jacques MD7

Pediatric Critical Care Medicine: February 2013 - Volume 14 - Issue 2 - p 123–129
doi: 10.1097/PCC.0b013e31826049b3
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Objectives: To assess the willingness of pediatric intensivists to conduct a pediatric trial of blood glucose control, and to determine if self-reported practices were influenced by adult-specific data over the past 4 yrs. This was a follow-up to our previous 2005 survey.

Design: Electronic survey comprising a 30-item questionnaire.

Setting: North American PICUs that were members of, or connected to, the Pediatric Acute Lung Injury and Sepsis Network (n = 96 targeted institutions).

Participants: North American pediatric intensivists (n = 209).

Interventions: None.

Methods: We conducted a survey of North American PICUs using a Web-based questionnaire. Invitations were sent to 96 institutions in 37 states/provinces.

Results: Response rate was 68% (141/209). The median definitions of hyperglycemia (150 mg/dL) and hypoglycemia (≤60 mg/dL) were similar to our 2005 survey results. Self-reported practice patterns remain variable. Although 75% of clinician respondents denied a change in clinical practice based on the published literature, the preferred blood glucose target range increased from 80–110 mg/dL in 2005 to 90–140 mg/dL in 2009. Intensivists who preferred a blood glucose target of 80–110 mg/dL decreased from 43% to 6% (p < 0.001). Many respondents (45%) indicated that the acceptable severe hypoglycemia rate (% patients) for a protocol was ≤2.5%. The majority (93%) indicated they would be willing to enroll patients in a pediatric trial of blood glucose control.

Conclusions: Pediatric intensivists report that they control blood glucose with insulin in critically ill children and do not necessarily adopt adult-specific data or a single uniform blood glucose target. The published evidence does not adequately address PICU clinicians concerns. Unanswered questions and persistent variation in practice suggest a need for a multicenter clinical trial of blood glucose control in critically ill children.

1 Department of Pediatrics, University of Utah, Primary Children’s Medical Center, Intermountain Medical Center, Murray, UT.

2 Department of Internal Medicine, University of Utah, Primary Children’s Medical Center, Intermountain Medical Center, Murray, UT.

3 Departments of Bioinformatics and Nursing, University of Utah, Primary Children's Medical Center, Intermountain Medical Center, Murray, UT.

4 Department of Pediatrics, Yale University School of Medicine, New Haven, CT.

5 Department of Pediatrics, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA.

6 Department of Pediatrics, Harvard Medical School, Children’s Hospital Boston, Boston, MA.

7 Department of Pediatrics. Division of Pediatric Intensive Care, Sainte-Justine Hospital and Université de Montréal, Montréal, QC, Canada.

*See also p. 221.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (http://journals.lww.com/pccmjournal).

Financial support for use of SurveyMonkey (http://www.surveymonkey.com) was obtained from Ellie Hirshberg’s institutional department funds from Intermountain Medical Center.

Drs. Nadkarni and Agus are currently receiving money from the NIH –NHLBI subsection for Heart and Lung Failure – Pediatric Insulin Titration Trial (NHLBI UO1 2010–2015) The remaining authors have not disclosed any potential conflicts of interest.

For information regarding this article, E-mail: ellie.hirshberg@hsc.utah.edu

©2013The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies