Glucose control in severely thermally injured pediatric patients: what glucose range should be the target?
Marc G Jeschke, Robert Kraft, Fatemeh Emdad, Gabriela A Kulp, Felicia N Williams, David N Herndon, Marc G Jeschke, Robert Kraft, Fatemeh Emdad, Gabriela A Kulp, Felicia N Williams, David N Herndon
Abstract
Objective: To determine which glucose levels are associated with improved morbidity and mortality in thermally injured patients.
Summary background data: Tight euglycemic control was rapidly implemented in intensive care units around the world, but there is increasing evidence that tight euglycemic control is associated with detrimental outcomes. Currently, no study exists that indicates which glucose range should be targeted.
Methods: Two-hundred and eight severely burned pediatric patients with burns over 30% of their total body surface area were included in this trial. Several statistical models were used to determine the daily average and 6 AM glucose target that were associated with improved morbidity and mortality. Patients were then divided into good glucose controlled and poor glucose controlled patients and demographics, clinical outcomes, infection, sepsis, inflammatory, and hypermetabolic responses were determined.
Results: Statistical modeling showed that hyperglycemia is a strong predictor of adverse hospital outcome and that daily 6 am glucose level of 130 mg/dL and daily average glucose levels of 140 mg/dL are associated with improved morbidity and mortality postburn. When patients were divided into good glucose control and poor glucose control, we found that patients with glucose levels of 130 mg/dL exert attenuated hypermetabolic and inflammatory responses, as well as significantly lower incidence of infections, sepsis, and mortality compared with patients with poor glucose control, P < 0.05.
Conclusions: Given the controversy over glucose range, glucose target, and risks and detrimental outcomes associated with hypoglycemia we suggest that in severely burned patient's blood glucose of 130 mg/dL should be targeted.
Trial registration: ClinicalTrials.gov NCT00673309.
Figures
![Figure 1](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3864004/bin/nihms253049f1.jpg)
Figure 2
(A) Daily 6 a.m. glucose.…
Figure 2
(A) Daily 6 a.m. glucose. Patients with good glucose control had significantly lower…
Figure 3
Patients with good glucose control…
Figure 3
Patients with good glucose control had a significantly attenuated hypermetabolic response at various…
Figure 4
Good glucose control significantly decreased…
Figure 4
Good glucose control significantly decreased the following cytokines: IFN-γ (A), IL-10 (B), IL-7…
- What is the optimal blood glucose range to improve morbidity and mortality in surgical patients?Hanazaki K, Munekage M, Okabayashi T. Hanazaki K, et al. Ann Surg. 2011 Oct;254(4):671-2; author reply 672-3. doi: 10.1097/SLA.0b013e318230681b. Ann Surg. 2011. PMID: 21946223 No abstract available.
- Impact of stress-induced diabetes on outcomes in severely burned children.Finnerty CC, Ali A, McLean J, Benjamin N, Clayton RP, Andersen CR, Mlcak RP, Suman OE, Meyer W, Herndon DN. Finnerty CC, et al. J Am Coll Surg. 2014 Apr;218(4):783-95. doi: 10.1016/j.jamcollsurg.2014.01.038. Epub 2014 Jan 24. J Am Coll Surg. 2014. PMID: 24655871 Free PMC article. Clinical Trial.
- Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial.Jeschke MG, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, Herndon DN. Jeschke MG, et al. Am J Respir Crit Care Med. 2010 Aug 1;182(3):351-9. doi: 10.1164/rccm.201002-0190OC. Epub 2010 Apr 15. Am J Respir Crit Care Med. 2010. PMID: 20395554 Free PMC article. Clinical Trial.
- Retinol binding protein: marker for insulin resistance and inflammation postburn?Kraft R, Herndon DN, Kulp GA, Mecott GA, Trentzsch H, Jeschke MG. Kraft R, et al. JPEN J Parenter Enteral Nutr. 2011 Nov;35(6):695-703. doi: 10.1177/0148607111413901. JPEN J Parenter Enteral Nutr. 2011. PMID: 22042048 Free PMC article.
- Clinical Impact of Accurate Point-of-Care Glucose Monitoring for Tight Glycemic Control in Severely Burned Children.Tran NK, Godwin ZR, Steele AN, Wolf SE, Palmieri TL. Tran NK, et al. Pediatr Crit Care Med. 2016 Sep;17(9):e406-12. doi: 10.1097/PCC.0000000000000877. Pediatr Crit Care Med. 2016. PMID: 27472251 Free PMC article.
- Blood glucose control in the trauma patient.Eakins J. Eakins J. J Diabetes Sci Technol. 2009 Nov 1;3(6):1373-6. doi: 10.1177/193229680900300617. J Diabetes Sci Technol. 2009. PMID: 20144391 Free PMC article. Review.
- Expert consensus on the glycemic management of critically ill patients.Wu Z, Liu J, Zhang D, Kang K, Zuo X, Xu Q, Pan A, Fang W, Liu F, Shang Y, Yin H, Hu J, Liu J, Fu J, Zhang W, Zong Y, Shao M, Zhao F, Meng M, Mao Y, Li Y, Chen D. Wu Z, et al. J Intensive Med. 2022 Jul 8;2(3):131-145. doi: 10.1016/j.jointm.2022.06.001. eCollection 2022 Jul. J Intensive Med. 2022. PMID: 36789019 Free PMC article. No abstract available.
- Chronic Critical Illness and PICS Nutritional Strategies.Rosenthal MD, Vanzant EL, Moore FA. Rosenthal MD, et al. J Clin Med. 2021 May 25;10(11):2294. doi: 10.3390/jcm10112294. J Clin Med. 2021. PMID: 34070395 Free PMC article. Review.
- Evaluation of the use of sitagliptin for insulin resistance in burn patients.Pruskowski KA, Shields BA, Ainsworth CR, Cancio LC. Pruskowski KA, et al. Int J Burns Trauma. 2020 Oct 15;10(5):237-245. eCollection 2020. Int J Burns Trauma. 2020. PMID: 33224612 Free PMC article.
- Exploration and Development of PPAR Modulators in Health and Disease: An Update of Clinical Evidence.Cheng HS, Tan WR, Low ZS, Marvalim C, Lee JYH, Tan NS. Cheng HS, et al. Int J Mol Sci. 2019 Oct 11;20(20):5055. doi: 10.3390/ijms20205055. Int J Mol Sci. 2019. PMID: 31614690 Free PMC article. Review.
- Non-Diabetic Hyperglycemia in the Pediatric Age: Why, How, and When to Treat?Fattorusso V, Nugnes R, Casertano A, Valerio G, Mozzillo E, Franzese A. Fattorusso V, et al. Curr Diab Rep. 2018 Oct 29;18(12):140. doi: 10.1007/s11892-018-1115-0. Curr Diab Rep. 2018. PMID: 30370431 Review.
- Randomized Controlled Trial
- Research Support, N.I.H., Extramural
- Research Support, Non-U.S. Gov't
- Blood Glucose / metabolism*
- Burns / blood*
- Burns / complications
- Burns / mortality
- Calorimetry, Indirect
- Child
- Chromatography, High Pressure Liquid
- Female
- Humans
- Hyperglycemia / blood*
- Hyperglycemia / etiology
- Hyperglycemia / mortality
- Hypoglycemia / blood*
- Hypoglycemia / etiology
- Hypoglycemia / mortality
- Insulin Resistance
- Intensive Care Units / standards
- Male
- Models, Statistical
- Nephelometry and Turbidimetry
- Predictive Value of Tests
- Blood Glucose
- ClinicalTrials.gov/NCT00673309
- Full Text Sources
- Medical
NCBI Literature Resources
The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
![Figure 2](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3864004/bin/nihms253049f2.jpg)
Figure 3
Patients with good glucose control…
Figure 3
Patients with good glucose control had a significantly attenuated hypermetabolic response at various…
Figure 4
Good glucose control significantly decreased…
Figure 4
Good glucose control significantly decreased the following cytokines: IFN-γ (A), IL-10 (B), IL-7…
- What is the optimal blood glucose range to improve morbidity and mortality in surgical patients?Hanazaki K, Munekage M, Okabayashi T. Hanazaki K, et al. Ann Surg. 2011 Oct;254(4):671-2; author reply 672-3. doi: 10.1097/SLA.0b013e318230681b. Ann Surg. 2011. PMID: 21946223 No abstract available.
- Impact of stress-induced diabetes on outcomes in severely burned children.Finnerty CC, Ali A, McLean J, Benjamin N, Clayton RP, Andersen CR, Mlcak RP, Suman OE, Meyer W, Herndon DN. Finnerty CC, et al. J Am Coll Surg. 2014 Apr;218(4):783-95. doi: 10.1016/j.jamcollsurg.2014.01.038. Epub 2014 Jan 24. J Am Coll Surg. 2014. PMID: 24655871 Free PMC article. Clinical Trial.
- Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial.Jeschke MG, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, Herndon DN. Jeschke MG, et al. Am J Respir Crit Care Med. 2010 Aug 1;182(3):351-9. doi: 10.1164/rccm.201002-0190OC. Epub 2010 Apr 15. Am J Respir Crit Care Med. 2010. PMID: 20395554 Free PMC article. Clinical Trial.
- Retinol binding protein: marker for insulin resistance and inflammation postburn?Kraft R, Herndon DN, Kulp GA, Mecott GA, Trentzsch H, Jeschke MG. Kraft R, et al. JPEN J Parenter Enteral Nutr. 2011 Nov;35(6):695-703. doi: 10.1177/0148607111413901. JPEN J Parenter Enteral Nutr. 2011. PMID: 22042048 Free PMC article.
- Clinical Impact of Accurate Point-of-Care Glucose Monitoring for Tight Glycemic Control in Severely Burned Children.Tran NK, Godwin ZR, Steele AN, Wolf SE, Palmieri TL. Tran NK, et al. Pediatr Crit Care Med. 2016 Sep;17(9):e406-12. doi: 10.1097/PCC.0000000000000877. Pediatr Crit Care Med. 2016. PMID: 27472251 Free PMC article.
- Blood glucose control in the trauma patient.Eakins J. Eakins J. J Diabetes Sci Technol. 2009 Nov 1;3(6):1373-6. doi: 10.1177/193229680900300617. J Diabetes Sci Technol. 2009. PMID: 20144391 Free PMC article. Review.
- Expert consensus on the glycemic management of critically ill patients.Wu Z, Liu J, Zhang D, Kang K, Zuo X, Xu Q, Pan A, Fang W, Liu F, Shang Y, Yin H, Hu J, Liu J, Fu J, Zhang W, Zong Y, Shao M, Zhao F, Meng M, Mao Y, Li Y, Chen D. Wu Z, et al. J Intensive Med. 2022 Jul 8;2(3):131-145. doi: 10.1016/j.jointm.2022.06.001. eCollection 2022 Jul. J Intensive Med. 2022. PMID: 36789019 Free PMC article. No abstract available.
- Chronic Critical Illness and PICS Nutritional Strategies.Rosenthal MD, Vanzant EL, Moore FA. Rosenthal MD, et al. J Clin Med. 2021 May 25;10(11):2294. doi: 10.3390/jcm10112294. J Clin Med. 2021. PMID: 34070395 Free PMC article. Review.
- Evaluation of the use of sitagliptin for insulin resistance in burn patients.Pruskowski KA, Shields BA, Ainsworth CR, Cancio LC. Pruskowski KA, et al. Int J Burns Trauma. 2020 Oct 15;10(5):237-245. eCollection 2020. Int J Burns Trauma. 2020. PMID: 33224612 Free PMC article.
- Exploration and Development of PPAR Modulators in Health and Disease: An Update of Clinical Evidence.Cheng HS, Tan WR, Low ZS, Marvalim C, Lee JYH, Tan NS. Cheng HS, et al. Int J Mol Sci. 2019 Oct 11;20(20):5055. doi: 10.3390/ijms20205055. Int J Mol Sci. 2019. PMID: 31614690 Free PMC article. Review.
- Non-Diabetic Hyperglycemia in the Pediatric Age: Why, How, and When to Treat?Fattorusso V, Nugnes R, Casertano A, Valerio G, Mozzillo E, Franzese A. Fattorusso V, et al. Curr Diab Rep. 2018 Oct 29;18(12):140. doi: 10.1007/s11892-018-1115-0. Curr Diab Rep. 2018. PMID: 30370431 Review.
- Randomized Controlled Trial
- Research Support, N.I.H., Extramural
- Research Support, Non-U.S. Gov't
- Blood Glucose / metabolism*
- Burns / blood*
- Burns / complications
- Burns / mortality
- Calorimetry, Indirect
- Child
- Chromatography, High Pressure Liquid
- Female
- Humans
- Hyperglycemia / blood*
- Hyperglycemia / etiology
- Hyperglycemia / mortality
- Hypoglycemia / blood*
- Hypoglycemia / etiology
- Hypoglycemia / mortality
- Insulin Resistance
- Intensive Care Units / standards
- Male
- Models, Statistical
- Nephelometry and Turbidimetry
- Predictive Value of Tests
- Blood Glucose
- ClinicalTrials.gov/NCT00673309
- Full Text Sources
- Medical
NCBI Literature Resources
The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.
National Library of Medicine
8600 Rockville Pike
Bethesda, MD 20894
![Figure 3](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3864004/bin/nihms253049f3.jpg)
Figure 4
Good glucose control significantly decreased…
Figure 4
Good glucose control significantly decreased the following cytokines: IFN-γ (A), IL-10 (B), IL-7…
- What is the optimal blood glucose range to improve morbidity and mortality in surgical patients?Hanazaki K, Munekage M, Okabayashi T. Hanazaki K, et al. Ann Surg. 2011 Oct;254(4):671-2; author reply 672-3. doi: 10.1097/SLA.0b013e318230681b. Ann Surg. 2011. PMID: 21946223 No abstract available.
- Impact of stress-induced diabetes on outcomes in severely burned children.Finnerty CC, Ali A, McLean J, Benjamin N, Clayton RP, Andersen CR, Mlcak RP, Suman OE, Meyer W, Herndon DN. Finnerty CC, et al. J Am Coll Surg. 2014 Apr;218(4):783-95. doi: 10.1016/j.jamcollsurg.2014.01.038. Epub 2014 Jan 24. J Am Coll Surg. 2014. PMID: 24655871 Free PMC article. Clinical Trial.
- Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial.Jeschke MG, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, Herndon DN. Jeschke MG, et al. Am J Respir Crit Care Med. 2010 Aug 1;182(3):351-9. doi: 10.1164/rccm.201002-0190OC. Epub 2010 Apr 15. Am J Respir Crit Care Med. 2010. PMID: 20395554 Free PMC article. Clinical Trial.
- Retinol binding protein: marker for insulin resistance and inflammation postburn?Kraft R, Herndon DN, Kulp GA, Mecott GA, Trentzsch H, Jeschke MG. Kraft R, et al. JPEN J Parenter Enteral Nutr. 2011 Nov;35(6):695-703. doi: 10.1177/0148607111413901. JPEN J Parenter Enteral Nutr. 2011. PMID: 22042048 Free PMC article.
- Clinical Impact of Accurate Point-of-Care Glucose Monitoring for Tight Glycemic Control in Severely Burned Children.Tran NK, Godwin ZR, Steele AN, Wolf SE, Palmieri TL. Tran NK, et al. Pediatr Crit Care Med. 2016 Sep;17(9):e406-12. doi: 10.1097/PCC.0000000000000877. Pediatr Crit Care Med. 2016. PMID: 27472251 Free PMC article.
- Blood glucose control in the trauma patient.Eakins J. Eakins J. J Diabetes Sci Technol. 2009 Nov 1;3(6):1373-6. doi: 10.1177/193229680900300617. J Diabetes Sci Technol. 2009. PMID: 20144391 Free PMC article. Review.
- Expert consensus on the glycemic management of critically ill patients.Wu Z, Liu J, Zhang D, Kang K, Zuo X, Xu Q, Pan A, Fang W, Liu F, Shang Y, Yin H, Hu J, Liu J, Fu J, Zhang W, Zong Y, Shao M, Zhao F, Meng M, Mao Y, Li Y, Chen D. Wu Z, et al. J Intensive Med. 2022 Jul 8;2(3):131-145. doi: 10.1016/j.jointm.2022.06.001. eCollection 2022 Jul. J Intensive Med. 2022. PMID: 36789019 Free PMC article. No abstract available.
- Chronic Critical Illness and PICS Nutritional Strategies.Rosenthal MD, Vanzant EL, Moore FA. Rosenthal MD, et al. J Clin Med. 2021 May 25;10(11):2294. doi: 10.3390/jcm10112294. J Clin Med. 2021. PMID: 34070395 Free PMC article. Review.
- Evaluation of the use of sitagliptin for insulin resistance in burn patients.Pruskowski KA, Shields BA, Ainsworth CR, Cancio LC. Pruskowski KA, et al. Int J Burns Trauma. 2020 Oct 15;10(5):237-245. eCollection 2020. Int J Burns Trauma. 2020. PMID: 33224612 Free PMC article.
- Exploration and Development of PPAR Modulators in Health and Disease: An Update of Clinical Evidence.Cheng HS, Tan WR, Low ZS, Marvalim C, Lee JYH, Tan NS. Cheng HS, et al. Int J Mol Sci. 2019 Oct 11;20(20):5055. doi: 10.3390/ijms20205055. Int J Mol Sci. 2019. PMID: 31614690 Free PMC article. Review.
- Non-Diabetic Hyperglycemia in the Pediatric Age: Why, How, and When to Treat?Fattorusso V, Nugnes R, Casertano A, Valerio G, Mozzillo E, Franzese A. Fattorusso V, et al. Curr Diab Rep. 2018 Oct 29;18(12):140. doi: 10.1007/s11892-018-1115-0. Curr Diab Rep. 2018. PMID: 30370431 Review.
- Randomized Controlled Trial
- Research Support, N.I.H., Extramural
- Research Support, Non-U.S. Gov't
- Blood Glucose / metabolism*
- Burns / blood*
- Burns / complications
- Burns / mortality
- Calorimetry, Indirect
- Child
- Chromatography, High Pressure Liquid
- Female
- Humans
- Hyperglycemia / blood*
- Hyperglycemia / etiology
- Hyperglycemia / mortality
- Hypoglycemia / blood*
- Hypoglycemia / etiology
- Hypoglycemia / mortality
- Insulin Resistance
- Intensive Care Units / standards
- Male
- Models, Statistical
- Nephelometry and Turbidimetry
- Predictive Value of Tests
- Blood Glucose
- ClinicalTrials.gov/NCT00673309
- Full Text Sources
- Medical
![Figure 4](https://www.ncbi.nlm.nih.gov/pmc/articles/instance/3864004/bin/nihms253049f4.jpg)
Source: PubMed