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Tight euglycemic control has benefits in severely burned children

Reuters Health • The Doctor's Channel Daily Newscast

NEW YORK (Reuters Health) – Intensive insulin therapy, targeting a blood glucose level of 130 mg/dL, may improve the likelihood of survival for severely burned children, according to results of a randomized study.

Intensive insulin therapy reduced infection and sepsis, dampened acute-phase and inflammatory responses, and improved hepatic and renal function – although it did not lower the mortality rate to a statistically significant effect.

In their report published April 29 in the American Journal of Respiratory and Critical Care Medicine, lead author Dr. Marc G. Jeschke and colleagues from the Shriners Hospitals for Children and University of Texas Medical Branch, Galveston conclude, “Intensive insulin therapy should be implemented in burn ICUs.”

Hyperglycemia is a hallmark of burned patients, the authors note, and its clinical relevance has been shown in several studies, which noted a significantly higher incidence of bacteremia and fungemia, and death, in burn patients with poor glucose control. The current study, they say, is the first randomized controlled trial to evaluate the effects of tight euglycemic control in severely burned patients.

The study involved 186 pediatric patients (up to age 18) with burns over more than 30% of their body: 49 in an intensive insulin treatment group and 137 in a control group. In the control group, the target blood glucose range was 140 to 180 mg/dL. In the intensive therapy group, the target range was 80 to 110 mg/dL.

According to the research team, intensive insulin treatment significantly reduced the incidence of infections and sepsis compared to controls; improved organ function as indicated by serum markers, DENVER2 scores, and ultrasound; alleviated post-burn insulin resistance and the vast catabolic response of the body; and dampened inflammatory and acute-phase responses by decreasing interleukin-6 and acute-phase proteins such as C-reactive protein and complement C3. (The p value for all comparisons was < 0.05). Intensive insulin therapy also significantly alleviated post-burn hepatomegaly but had no effect on cardiac function. At 100 days post-burn, mortality was 4% in the intensive insulin treatment arm and 11% in the control arm (p = 0.14). According to the investigators, daily 6:00 a.m. glucose levels were significantly lower in the intensive insulin treatment group, as were daily average, daily maximum and daily minimum glucose levels. However, the incidence of mild hypoglycemia (blood glucose < 60 mg/dL) and severe hypoglycemia (glucose < 40 mg/dL) was higher with intensive insulin treatment. The control group had 66 episodes of mild hypoglycemia in 24% of patients, but the intensive insulin group had 108 episodes in 43% of patients. Also, the control group had 17 episodes of severe hypoglycemia in 9% of patients, while the intensive therapy group had 23 episodes in 26%. Based on some newer – and as yet unpublished – data, the researchers suggest a blood glucose target range of 130 to 140 mg/dL in severely burned patients. This recommendation comes from their analysis of roughly 300,000 glucose values. They found that burn patients whose 6:00 a.m. glucose levels were at 130 mg/dL for 75% of their acute hospitalization had better outcomes than patients with glucose levels above 140 mg/dL. "Our data showed that the ideal glucose target is around 130-140 mg/dL, and that the glucose curve has a U-form shape, meaning that very low glucose levels are equally as detrimental as very high glucose levels,” Dr. Jeschke and colleagues say. The 130 mg/dL recommended target for severely burned patients supports the results of three other studies in pediatric burn patients, they note. Reference:
Am J Resp Crit Care Med 2010.