Advertisement

Intensive Care Medicine

, 37:1517 | Cite as

Uncertainties in the measurement of blood glucose in paediatric intensive care: implications for clinical trials of tight glycaemic control

  • Helen HillEmail author
  • Paul Baines
  • Paul Barton
  • Paul Newland
  • Dianne Terlouw
  • Mark Turner
Pediatric Original

Abstract

Purpose

In preparation for a tight glycaemic control (TGC) clinical trial we assessed the agreement between methods used to measure blood glucose in critically ill children.

Methods

Service evaluation comparing blood gas and main laboratory analysers with point-of-care (POC) devices PCX, ACCU-Chek and Hemocue.

Results

Two hundred forty-five samples from 157 children measured on 2–4 devices provided 790 values. Marked variation was evident in glucose values between devices, time between tests, sample (whole blood/plasma) and source; 39% of paired values had >20% difference. The decision to start insulin at 7 mmol/L differed depending on the device used for 33% of samples. At low glucose values (<4 mmol/L), differences up to 1.8 mmol/L were evident. The blood gas analyser read lower than all POC models and the laboratory analyser (less risk of undetected hypoglycaemia). An inverse relationship was evident between haematocrit (Hct) and glucose error using POC devices. PCX values for samples with Hct <30% were higher (85%), whereas those for Hct values >38% were lower (66%). Glycolysis occurred during transfer of samples to the laboratory. Using the PCX at the bedside resulted in 0.5 mmol/L mean difference higher than laboratory values; locating the PCX in the laboratory reduced this to 0.2 mmol/L.

Conclusions

Discrepancies between measurements may mask hypoglycaemia, and the potential benefits of controlling hyperglycaemia may not be achieved. Variation introduced by different devices, sample or source may have led to misclassification of treatment decisions contributing to the conflicting results of TGC studies.

Keywords

Blood glucose Point of care Tight glycaemic control Insulin Child Paediatric Intensive Critical Intensive insulin therapy 

Notes

Acknowledgments

The team would like to acknowledge the invaluable clinical support of PICU nurses, Biochemistry Laboratory and ECG technicians at Alder Hey Children’s NHS FT and L. Woodgate from University of Liverpool. We are grateful to Prof. M. Bland from York University for statistics advice. We appreciate the technical support from each device manufacturer.

Supplementary material

134_2011_2302_MOESM1_ESM.doc (354 kb)
Supplementary material 1 (DOC 353 kb)

References

  1. 1.
    Vlasselaers D, Milants I, Desmet L, Wouters PJ, Vanhorebeek I, van den Heuvel I, Mesotten D, Casaer MP, Meyfroidt G, Ingels C, Muller J, Van Cromphaut S, Schetz M, Van den Berghe G (2009) Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study. Lancet 373:547–556PubMedCrossRefGoogle Scholar
  2. 2.
    Vriesendorp TM, DeVries JH, van Santen S, Moeniralam HS, de Jonge E, Roos YB, Schultz MJ, Rosendaal FR, Hoekstra JB (2006) Evaluation of short-term consequences of hypoglycemia in an intensive care unit. Crit Care Med 34:2714–2718PubMedCrossRefGoogle Scholar
  3. 3.
    Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R (2001) Intensive insulin therapy in the critically ill patients. N Engl J Med 345:1359–1367PubMedCrossRefGoogle Scholar
  4. 4.
    Batki A, Nayyar P, Thomason H, Thorpe G (2008) Buyers guide: blood glucose systems centre for evidence based purchasing NHS 08008:www.pasa.nhs.uk
  5. 5.
    Sidebottom RA, Williams PR, Kanarek KS (1982) Glucose determinations in plasma and serum: potential error related to increased hematocrit. Clin Chem 28:190–192PubMedGoogle Scholar
  6. 6.
    Brunkhorst FM, Wahl HG (2006) Blood glucose measurements in the critically ill: more than just a blood draw. Crit Care 10:178PubMedCrossRefGoogle Scholar
  7. 7.
    Fogh-Andersen N, D’Orazio P (1998) Proposal for standardizing direct-reading biosensors for blood glucose. Clin Chem 44:655–659PubMedGoogle Scholar
  8. 8.
    D’Orazio P, Burnett RW, Fogh-Andersen N, Jacobs E, Kuwa K, Kulpmann WR, Larsson L, Lewenstam A, Maas AH, Mager G, Naskalski JW, Okorodudu AO (2005) Approved IFCC recommendation on reporting results for blood glucose (abbreviated). Clin Chem 51:1573–1576PubMedCrossRefGoogle Scholar
  9. 9.
    Scott MG, Bruns DE, Boyd JC, Sacks DB (2009) Tight glucose control in the intensive care unit: are glucose meters up to the task? Clin Chem 55:18–20PubMedCrossRefGoogle Scholar
  10. 10.
    Griesdale DE, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, Dhaliwal R, Henderson WR, Chittock DR, Finfer S, Talmor D (2009) Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ 180:821–827PubMedCrossRefGoogle Scholar
  11. 11.
    Van den Berghe G, Mesotten D, Vanhorebeek I (2009) Intensive insulin therapy in the intensive care unit. CMAJ 180:799–800PubMedCrossRefGoogle Scholar
  12. 12.
    Finfer S, Delaney A (2008) Tight glycemic control in critically ill adults. JAMA 300:963–965PubMedCrossRefGoogle Scholar
  13. 13.
    Sacks DB (2009) Therapy: intensive glucose control in the ICU: is sugar nice? Nat Rev Endocrinol 5:473–474PubMedCrossRefGoogle Scholar
  14. 14.
    Wiener RS, Wiener DC, Larson RJ (2008) Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 300:933–944PubMedCrossRefGoogle Scholar
  15. 15.
    National-Research-Ethics-Service (2009) Defining research. National patient safety agency:www.nres.npsa.uk
  16. 16.
    Clarke WL, Cox D, Gonder-Frederick LA, Carter W, Pohl SL (1987) Evaluating clinical accuracy of systems for self-monitoring of blood glucose. Diabetes Care 10:622–628PubMedCrossRefGoogle Scholar
  17. 17.
    Bland JM, Altman DG (1999) Measuring agreement in method comparison studies. Stat Methods Med Res 8:135–160PubMedCrossRefGoogle Scholar
  18. 18.
    Kanji S, Buffie J, Hutton B, Bunting PS, Singh A, McDonald K, Fergusson D, McIntyre LA, Hebert PC (2005) Reliability of point-of-care testing for glucose measurement in critically ill adults. Crit Care Med 33:2778–2785PubMedCrossRefGoogle Scholar
  19. 19.
    ISO (2003) In vitro diagnostic test systems-requirements for blood-glucose monitoring systems for self-testing in managing diabetes mellitus. EN ISO 15197 International Standards Organisation, Geneva, SwitzerlandGoogle Scholar
  20. 20.
    Boyd JC, Bruns DE (2001) Quality specifications for glucose meters: assessment by simulation modeling of errors in insulin dose. Clin Chem 47:209–214PubMedGoogle Scholar
  21. 21.
    Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hebert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ (2009) Intensive versus conventional glucose control in critically ill patients. N Engl J Med 360:1283–1297PubMedCrossRefGoogle Scholar
  22. 22.
    Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, Moerer O, Gruendling M, Oppert M, Grond S, Olthoff D, Jaschinski U, John S, Rossaint R, Welte T, Schaefer M, Kern P, Kuhnt E, Kiehntopf M, Hartog C, Natanson C, Loeffler M, Reinhart K (2008) Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 358:125–139PubMedCrossRefGoogle Scholar
  23. 23.
    Beardsall K, Vanhaesebrouck S, Ogilvy-Stuart AL, Vanhole C, Palmer CR, van Weissenbruch M, Midgley P, Thompson M, Thio M, Cornette L, Ossuetta I, Iglesias I, Theyskens C, de Jong M, Ahluwalia JS, de Zegher F, Dunger DB (2008) Early insulin therapy in very-low-birth-weight infants. N Engl J Med 359:1873–1884PubMedCrossRefGoogle Scholar
  24. 24.
    Preiser JC, Devos P, Ruiz-Santana S, Melot C, Annane D, Groeneveld J, Iapichino G, Leverve X, Nitenberg G, Singer P, Wernerman J, Joannidis M, Stecher A, Chiolero R (2009) A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med 35:1738–1748PubMedCrossRefGoogle Scholar
  25. 25.
    Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, Van Wijngaerden E, Bobbaers H, Bouillon R (2006) Intensive insulin therapy in the medical ICU. N Engl J Med 354:449–461PubMedCrossRefGoogle Scholar
  26. 26.
    Hirshberg E, Larsen G, Van Duker H (2008) Alterations in glucose homeostasis in the pediatric intensive care unit: hyperglycemia and glucose variability are associated with increased mortality and morbidity. Pediatr Crit Care Med 9:361–366PubMedCrossRefGoogle Scholar
  27. 27.
    Tang Z, Du X, Louie RF, Kost GJ (2000) Effects of pH on glucose measurements with handheld glucose meters and a portable glucose analyzer for point-of-care testing. Arch Pathol Lab Med 124:577–582PubMedGoogle Scholar
  28. 28.
    Posthouwer D, de Graaf MJ, Frederiks M, Remijn JA, Rommes JH, Schultz MJ, Spronk PE (2009) Time dependent decrease in blood glucose levels after sampling potentially affects intensive insulin therapy in the intensive care unit. Intensive Care Med 35:386–387PubMedCrossRefGoogle Scholar
  29. 29.
    Chan AY, Swaminathan R, Cockram CS (1989) Effectiveness of sodium fluoride as a preservative of glucose in blood. Clin Chem 35:315–317PubMedGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2011

Authors and Affiliations

  • Helen Hill
    • 1
    Email author
  • Paul Baines
    • 2
  • Paul Barton
    • 3
  • Paul Newland
    • 3
  • Dianne Terlouw
    • 4
  • Mark Turner
    • 5
  1. 1.Alder Hey Children’s NHS FTLiverpoolUK
  2. 2.PICU Alder Hey Children’s NHS FTLiverpoolUK
  3. 3.Biochemistry Alder Hey Children’s NHS FTLiverpoolUK
  4. 4.Liverpool School of Tropical MedicineLiverpoolUK
  5. 5.University of LiverpoolLiverpoolUK

Personalised recommendations