Hyperglycaemia in non-diabetic critically ill children - Guideline for management of

Publication: 14/12/2016  --
Last review: 17/12/2019  
Next review: 17/12/2022  
Clinical Guideline
CURRENT 
ID: 4852 
Approved By: Trust Clinical Guidelines Group 
Copyright© Leeds Teaching Hospitals NHS Trust 2019  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Guideline for management of hyperglycaemia in non-diabetic critically ill children

Aims

To improve the diagnosis and management of hyperglycaemia associated with critical illness in children admitted to paediatric intensive care unit.
To maintain glucose levels between 6 to 10 mmol/L.
To prevent complications associated with insulin infusion.

Background

Critically ill children and adults often develop transient hyperglycaemia as part of the stress response. Children who develop hyperglycaemia have less favourable prognosis compared to those who don’t1-3. But recent clinical trials have shown no benefit in targeting tight glycaemic control (4 to 7 mmol/L)4-5. There is significant risk of hypoglycaemia associated with pursuing a tight glucose control6.

Currently, there is no consensus of targeting a specific glucose range in these patients. Based on the risks associated with uncontrolled hyperglycaemia and too low target range, the local consensus is to maintain glucose levels between 6 to 10 mmol/L.

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Diagnosis

In children admitted to PICU, two blood glucose values > 12 mmol/L taken 30 minutes apart.

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Management

  1. Confirm the diagnosis: Has the blood glucose been checked in two different samples drawn 30 minutes apart. Samples drawn from lines infusing TPN will give a falsely high glucose value. Please check glucose levels on an arterial blood sample or on a capillary blood sample if no arterial line insitu.
  2. Check for fluid/TPN administration errors: Is the right fluid/TPN being administered at the right volume.
  3. Contributory drugs: Steroids and immunosuppressant drugs can contribute to the development of hyperglycaemia. It is not usually necessary to modify these medications for transient hyperglycaemia. Discontinuing or altering these medications should always be discussed with PICU consultant and/or relevant sub-specialty teams.
  4. Commence Insulin Infusion: Once the diagnosis of hyperglycaemia is confirmed and administration errors are ruled out, please follow the insulin infusion flow chart.

Insulin infusion should be prepared and administered as per the ‘LTHT Paediatric ICU Administration Guide for Intravenous Soluble Insulin (Actrapid)’

The following guidelines are based on insulin management for control group of ‘Control of hyperglycaemia in Paediatric Intensive Care Trail’4

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Flowchart 1: Starting / re-starting Insulin infusion

Frequency of measuring BG:

Check BG
within 30 mins of starting insulin infusion
within 45 mins of changing insulin infusion rate or stopping insulin infusion
every 1 hour if on steady insulin infusion rate

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Flowchart 2: Management of Insulin infusion

Refer to flowchart 1 every time insulin infusion in re-started.

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Management of Hypoglycaemia:

If BG < 3 mmol/L,

  • Ensure that insulin infusion is turned off
  • Give 10% dextrose 2 ml/kg bolus
  • Increase glucose delivery by increasing either % of glucose or rate of intravenous maintenance fluid. (Fluids with glucose concentration >12.5% should not be run in peripheral venous line)
  • Re-check BG within 30 mins and repeat the above steps until BG > 3 mmol/L
  • All instances of hypoglycaemia (BG < 3 mmol/L) should be reported via Datix incident reporting form.

Provenance

Record: 4852
Objective: To improve the diagnosis and management of hyperglycaemia associated with critical illness in children admitted to paediatric intensive care unit.
To maintain glucose levels between 6 to 10 mmol/L.
To prevent complications associated with insulin infusion.
Clinical condition: Hyperglycaemia
Target patient group: Non-diabetic children admitted to PICU
Target professional group(s): Secondary Care Doctors
Registered Nurses Working in Critical Care
Secondary Care Nurses
Adapted from:

Evidence base

References:

  1. Srinivasan, V., et al., Association of timing, duration, and intensity of hyperglycemia with intensive care unit mortality in critically ill children. Pediatr Crit Care Med, 2004. 5(4): p. 329-36.
  2. Branco, R.G., et al., Glucose level and risk of mortality in pediatric septic shock. Pediatr Crit Care Med, 2005.6(4): p. 470-2.
  3. Faustino, E.V., Apkon, M., Persistent hyperglycemia in critically ill children. J Pediatr, 2005. 146(1): p. 30-4.
  4. Macrae D, Grieve R, Allen E, Sadique Z, Morris K, Pappachan J, Parslow R, Tasker RC, Elbourne D, CHiP Investigators. A randomized trial of hyperglycemic control in pediatric intensive care. N Engl J Med. 2014 Jan 9;370(2):107-18
  5. Agus MS, Steil GM, Wypij D, Costello JM, Laussen PC, Langer M, Alexander JL, Scoppettuolo LA, Pigula FA, Charpie JR, Ohye RG, Gaies MG, SPECS Study Investigators. Tight glycemic control versus standard care after pediatric cardiac surgery. N Engl J Med. 2012 Sep 27;367(13):1208-19.
  6. Vlasselaers, D., et al., Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet, 2009. 373(9663): p. 547-56.

A. Meta-analyses, randomised controlled trials/systematic reviews of RCTs
B. Robust experimental or observational studies
D. Leeds consensus.

Approved By

Trust Clinical Guidelines Group

Document history

LHP version 2.0

Related information

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