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Safe and Effective Use of a Glycemic Control Protocol for Neonates in a Cardiac ICU*

Hebson, Camden L. MD1; Chanani, Nikhil K. MD1; Rigby, Mark R. MD2; Wolf, Michael J. MD1; Deshpande, Shriprasad R. MD1; Montegna, Leticia M. PharmD3; Maher, Kevin O. MD1

Pediatric Critical Care Medicine: March 2013 - Volume 14 - Issue 3 - p 284–289
doi: 10.1097/PCC.0b013e31827200de
Cardiac Intensive Care

Objective: To investigate the safety and efficacy of a hyperglycemia protocol in neonates with critical cardiac illness. Neonates are often regarded as high risk for hypoglycemia while receiving continuous insulin infusions and thus have been excluded from some clinical trials.

Design: A retrospective review.

Setting: A pediatric cardiac ICU in a tertiary academic center.

Interventions: Neonates with critical cardiac illness who developed hyperglycemia were placed on an insulin-hyperglycemia protocol at the attending physician’s discretion. Insulin infusions were titrated based on frequent blood glucose monitoring.

Measurements: Critical illness hyperglycemia was defined as a blood glucose less than 140 mg/dL. Hypoglycemia was defined as moderate (≤ 60 mg/dL) or severe (≤ 40 mg/dL). Initiating blood glucose, lowest blood glucose during insulin infusion, doses of insulin, duration of insulin, and time to blood glucose greater than 140 mg/dL were evaluated.

Main Results: A total of 44 patients were placed on the protocol between January 2009 and October 2011. The majority of insulin infusions were initiated in the early postoperative period (33 of 44, 75%). Moderate hypoglycemia occurred in two patients (4.5%), with blood glucose levels of 49 and 53 mg/dL. No episodes of severe hypoglycemia occurred. A total of 345 discrete blood glucose levels were analyzed; two of these being greater than 60 mg/dL (0.58%). Mean blood glucose prior to starting insulin was 252 ± 45 mg/dL and time until euglycemia was 6.1 ± 3.9 hours. The mean duration of insulin infusion was 24.6 ± 38.7 hours, mean peak dose was 0.10 ± 0.05 units/kg/hour, and mean insulin dose was 0.06 ± 0.02 units/kg/hour. For postoperative patients, mean time after bypass until onset of hyperglycemia was 2.2 ± 2.6 hours.

Conclusions: A glycemic control protocol can safely and effectively be applied to neonates with critical cardiac disease. Neonates with critical cardiac illness should be included in clinical trials evaluating the benefits of glycemic control.

1Division of Pediatric Cardiology, Department of Pediatrics, Emory University School of Medicine/Children’s Healthcare of Atlanta, Atlanta, GA.

2Section of Pediatric Critical Care, Indiana University School of Medicine/Riley Hospital for Children, Indianapolis, IN.

3Pharmacy Department, Children’s Healthcare of Atlanta, Atlanta, Georgia.

*See also p. 328.

Dr. Chanani receives funding from the National Institutes of Health (NIH). The remaining authors have not disclosed any potential conflict of interest.

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