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Relationship between hyperglycemia and outcome in children with severe traumatic brain injury

Smith, Rebecca L. MD; Lin, John C. MD; Adelson, P. David MD; Kochanek, Patrick M. MD, FCCM; Fink, Ericka L. MD; Wisniewski, Stephen R. PhD; Bayir, Hülya MD; Tyler-Kabara, Elizabeth C. MD, PhD; Clark, Robert S. B. MD; Brown, S. Danielle RN, MS; Bell, Michael J. MD

Pediatric Critical Care Medicine: January 2012 - Volume 13 - Issue 1 - p 85–91
doi: 10.1097/PCC.0b013e3182192c30
Neurocritical Care

Objective: To determine the relationship between hyperglycemia and outcome in infants and children after severe traumatic brain injury.

Design: Retrospective review of a prospectively collected Pediatric Neurotrauma Registry.

Setting and Patients: Children admitted after severe traumatic brain injury (postresuscitation Glasgow Coma Scale ≤8) were studied (1999–2004). A subset of children (n = 28) were concurrently enrolled in a randomized, controlled clinical trial of early hypothermia for neuroprotection.

Interventions: Demographic data, serum glucose concentrations, and outcome assessments were collected.

Methods and Main Results: Children (n = 57) were treated with a standard traumatic brain injury protocol. Exogenous glucose was withheld for 48 hrs after injury unless hypoglycemia was observed (blood glucose <70 mg/dL). Early (first 48 hrs) and Late (49–168 hrs) time periods were defined and mean blood glucose concentrations were calculated. Additionally, children were categorized based on peak blood glucose concentrations during each time period (normal, blood glucose <150 mg/dL; mild hyperglycemia, blood glucose ≤200 mg/dL; severe hyperglycemia, blood glucose >200 mg/dL). In the Late period, an association between elevated mean serum glucose concentration and outcome was observed (133.5 ± 5.6 mg/dL in the unfavorable group vs. 115.4 ± 4.1 mg/dL in favorable group, p = .02). This association continued to be significant after correcting for injury severity, age, and exposure to insulin (p = .03). Similarly, in the Late period, children within the severe hyperglycemia group had decreased incidence of good outcome compared to children within the other glycemic groups (% good outcome: normal, 61.9%; mild hyperglycemia, 73.7%; severe hyperglycemia, 33.3%; p = .05). However, when adjusted for exposure to insulin, this relationship was no longer statistically significant.

Conclusions: In children with severe traumatic brain injury, hyperglycemia beyond the initial 48 hrs is associated with poor outcome. This relationship was observed in both our analysis of mean blood glucose concentrations as well as among the patients with episodic severe hyperglycemia. This observation suggests a relationship between hyperglycemia and outcome from traumatic brain injury. However, only a prospective study can answer the important question of whether manipulating serum glucose concentration can improve outcome after traumatic brain injury in children.

From the Departments of Critical Care Medicine (RLS, PMK, ELF, HB, RSC, MJB), Neurological Surgery (ECT, MJB), and Epidemiology and Biostatistics (SW), and the Safar Center for Resuscitation Research (RSL, PMK, ELF, HB, RSC, MJB), University of Pittsburgh, Pittsburgh, PA; and the Department of Pediatrics (JCL), Wilford Hall, San Antonio, TX; and Department of Neurological Surgery (PDA, SDB), Phoenix Children's Hospital, Phoenix, AZ.

Supported, in part, by a grant from NIH (T32 HD040686) to Dr. Smith.

Dr. Adelson is employed with Phoenix Children's Hospital; has consulted for Traumtec, Inc; received honoraria/speaking fees from Cyberonics; and received grant support from the NIH. The remaining authors have not disclosed any potential conflicts of interest.

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©2012The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies