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Acute hyperglycemia is a reliable outcome predictor in children with severe traumatic brain injury

  • Clinical Article
  • Published:
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Abstract

Purpose

Hyperglycemia in the acute phase after trauma could adversely affect outcome in children with severe traumatic brain injury (TBI). The goal of this study was to identify the relationship between acute spontaneous hyperglycemia and outcome in children with severe TBI at hospital discharge and 6 months later.

Methods

A retrospective analysis of blood glucose levels in children with severe TBI at a Pediatric level I Trauma Center, between January 2000 and December 2005. Hyperglycemia was considered for a cut-off value of 11.1 mmol/l (200 mg/dl). Outcome was measured with Glasgow Outcome Scale (GOS) at hospital discharge and at 6 months. A multiple logistic regression analysis, the Student's t test and the χ 2 test were done.

Results

Hyperglycemia was noted within the first 48 h in 34% of the patients. Mortality (70% vs 14%, p < 10-5) was more frequent in hyperglycemic children and bad outcome upon hospital discharge in those who remained hyperglycemic during the first 48 h of hospitalization. GOS after 6 months demonstrated that those normoglycemic children had a better outcome (95%) than those who developed hyperglycemia during the first 48 h (83%, p = 0.01) after trauma.

Conclusion

Hyperglycemia could be considered as a marker of brain injury and when present upon admission, could reflect extensive brain damage with frequently associated mortality and bad outcome. The inability to maintain normal blood glucose levels during the first 48 h could be a predictive factor of bad outcome. Avoiding hyperglycemia in the initial phase could be a major issue in children with severe TBI.

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References

  1. Alexandrou G, Skiold B, Karlen J, Tessma MK, Norman M, Aden U, Vanpee M (2010) Early hyperglycemia is a risk factor for death and white matter reduction in preterm infants. Pediatrics 125:e584–e591

    Article  PubMed  Google Scholar 

  2. Anderson VA, Catroppa C, Haritou F, Morse S, Pentland L, Rosenfeld J, Stargatt R (2001) Predictors of acute child and family outcome following traumatic brain injury in children. Pediatr Neurosurg 34:138–148

    Article  PubMed  CAS  Google Scholar 

  3. Bardella IJ (1999) Pediatric advanced life support: a review of the AHA recommendations. American Heart Association. Am Fam Physician 60(6):1743–1750

    PubMed  CAS  Google Scholar 

  4. Bilotta F, Caramia R, Paoloni FP, Delfini R, Rosa G (2009) Safety and efficacy of intensive insulin therapy in critical neurosurgical patients. Anesthesiology 110:611–619

    Article  PubMed  CAS  Google Scholar 

  5. Bochicchio GV, Joshi M, Bochicchio KM, Pyle A, Johnson SB, Meyer W, Lumpkins K, Scalea TM (2007) Early hyperglycemic control is important in critically injured trauma patients. J Trauma 63:1353–1358

    Article  PubMed  CAS  Google Scholar 

  6. Bochicchio GV, Sung J, Joshi M, Bochicchio K, Johnson SB, Meyer W, Scalea TM (2005) Persistent hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma 58:921–924

    Article  PubMed  Google Scholar 

  7. Chiaretti A, De Benedictis R, Langer A, Di Rocco C, Bizzarri C, Iannelli A, Polidori G (1998) Prognostic implications of hyperglycaemia in paediatric head injury. Childs Nerv Syst 14:455–459

    Article  PubMed  CAS  Google Scholar 

  8. Chiaretti A, Piastra M, Pulitano S, Pietrini D, De Rosa G, Barbaro R, Di Rocco C (2002) Prognostic factors and outcome of children with severe head injury: an 8-year experience. Childs Nerv Syst 18:129–136

    Article  PubMed  Google Scholar 

  9. Cochran A, Scaife ER, Hansen KW, Downey EC (2003) Hyperglycemia and outcomes from pediatric traumatic brain injury. J Trauma 55:1035–1038

    Article  PubMed  Google Scholar 

  10. Danzl D (2002) Hypothermia. Semin Respir Crit Care Med 23:57–68

    Article  PubMed  Google Scholar 

  11. Diaz-Parejo P, Stahl N, Xu W, Reinstrup P, Ungerstedt U, Nordstrom CH (2003) Cerebral energy metabolism during transient hyperglycemia in patients with severe brain trauma. Intensive Care Med 29:544–550

    PubMed  Google Scholar 

  12. Ducrocq SC, Meyer PG, Orliaguet GA, Blanot S, Laurent-Vannier A, Renier D, Carli PA (2006) Epidemiology and early predictive factors of mortality and outcome in children with traumatic severe brain injury: experience of a French pediatric trauma center. Pediatr Crit Care Med 7:461–467

    Article  PubMed  Google Scholar 

  13. Durr JA, Hoffman WH, Sklar AH, el Gammal T, Steinhart CM (1992) Correlates of brain edema in uncontrolled IDDM. Diabetes 41:627–632

    Article  PubMed  CAS  Google Scholar 

  14. 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 360:1283–1297

    Article  PubMed  Google Scholar 

  15. Gaillard M, Herve C, Reynaud P, Petit JL (1989) Epidemiology of severe cranial injuries in children and the prognosis of injured patients hospitalized in neurosurgery units. Ann Pediatr (Paris) 36:194–198

    CAS  Google Scholar 

  16. Grinkeviciute DE, Kevalas R, Saferis V, Matukevicius A, Ragaisis V, Tamasauskas A (2007) Predictive value of scoring system in severe pediatric head injury. Medicina (Kaunas) 43:861–869

    Google Scholar 

  17. Hirsch IB (2002) In-patient hyperglycemia—are we ready to treat it yet? J Clin Endocrinol Metab 87:975–977

    Article  PubMed  CAS  Google Scholar 

  18. Jennett B (1975) Outcome of severe damage to the central nervous system. Scale, scope and philosophy of the clinical problem. Ciba Found Symp 34:3–21

    PubMed  Google Scholar 

  19. Jeremitsky E, Omert LA, Dunham CM, Wilberger J, Rodriguez A (2005) The impact of hyperglycemia on patients with severe brain injury. J Trauma 58:47–50

    Article  PubMed  CAS  Google Scholar 

  20. Kushner M, Nencini P, Reivich M, Rango M, Jamieson D, Fazekas F, Zimmerman R, Chawluk J, Alavi A, Alves W (1990) Relation of hyperglycemia early in ischemic brain infarction to cerebral anatomy, metabolism, and clinical outcome. Ann Neurol 28:129–135

    Article  PubMed  CAS  Google Scholar 

  21. Laird AM, Miller PR, Kilgo PD, Meredith JW, Chang MC (2004) Relationship of early hyperglycemia to mortality in trauma patients. J Trauma 56:1058–1062

    Article  PubMed  Google Scholar 

  22. Lam AM, Winn HR, Cullen BF, Sundling N (1991) Hyperglycemia and neurological outcome in patients with head injury. J Neurosurg 75:545–551

    Article  PubMed  CAS  Google Scholar 

  23. Marton E, Mazzucco M, Nascimben E, Martinuzzi A, Longatti P (2007) Severe head injury in early infancy: analysis of causes and possible predictive factors for outcome. Childs Nerv Syst 23:873–880

    Article  PubMed  Google Scholar 

  24. Michaud LJ, Rivara FP, Longstreth WT Jr, Grady MS (1991) Elevated initial blood glucose levels and poor outcome following severe brain injuries in children. J Trauma 31:1356–1362

    Article  PubMed  CAS  Google Scholar 

  25. Orliaguet GA, Meyer PG, Baugnon T (2008) Management of critically ill children with traumatic brain injury. Paediatr Anaesth 18:455–461

    Article  PubMed  Google Scholar 

  26. Piazza O, Storti MP, Cotena S, Stoppa F, Perrotta D, Esposito G, Pirozzi N, Tufano R (2007) S100B is not a reliable prognostic index in paediatric TBI. Pediatr Neurosurg 43:258–264

    Article  PubMed  CAS  Google Scholar 

  27. Pierrot M, Francois V, Minassian AT, Clavier N, Boulard G, Beydon L (2003) The impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999. Ann Fr Anesth Rèanim 22:12–17

    Article  PubMed  CAS  Google Scholar 

  28. Pillai S, Praharaj SS, Mohanty A, Kolluri VR (2001) Prognostic factors in children with severe diffuse brain injuries: a study of 74 patients. Pediatr Neurosurg 34:98–103

    Article  PubMed  CAS  Google Scholar 

  29. Rosner MJ, Newsome HH, Becker DP (1984) Mechanical brain injury: the sympathoadrenal response. J Neurosurg 61:76–86

    Article  PubMed  CAS  Google Scholar 

  30. Sung J, Bochicchio GV, Joshi M, Bochicchio K, Tracy K, Scalea TM (2005) Admission hyperglycemia is predictive of outcome in critically ill trauma patients. J Trauma 59:80–83

    Article  PubMed  CAS  Google Scholar 

  31. Tentillier E, Dupont M, Thicoipe M, Petitjean ME, Sztark F, Lassie P, Masson F, Debadie P (2004) Protocol for advanced prehospital emergency care of severe head injury. Ann Fr Anesth Rèanim 23:109–115

    PubMed  CAS  Google Scholar 

  32. Van den Berghe G, Wouters P, Weekers F (2001) Intensive insulin therapy in critically Ill patients. N Engl J Med 345:1359–1367

    Article  PubMed  Google Scholar 

  33. Vinchon M, Foort-Dhellemmes S, Nzeyimana C, Vallee L, Dhellemmes P (2003) Infantile traumatic subdural hematomas: outcome after five years. Pediatr Neurosurg 39:122–128

    Article  PubMed  Google Scholar 

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Acknowledgment

The authors acknowledge Mrs. Adeline Noiriat, secretary of the Department of Pediatric Neurosurgery-Hôpital Necker-Enfants Malades.

CAPES Brazil (Coordenação de Aperfeiçoamento de Pessoal de Nível Superior), Exchange Program for PhD studies, is a source of support.

This study is supported in part by a grant from Direction Régionale de la Recherche Clinique Assistance Publique Hôpitaux de Paris PHRC 2003 No. AOM 03018.

Conflicts of interest

The authors declare that they have no conflicts of interest.

Comments

The deleterious effect of hyperglycemia in the acute stage of critically ill patients, especially on their brain, whatever the age and cause be is not new information. However, few articles dedicated on this topic in children suffering from severe TBI (admitted with GCS < 8)have been previously published. The article from Tude Melo et al. brings a well-constructed retrospective analysis of 286 children admitted in their unit after a TBI with a GCS < 8. The cases have been stratified in four groups according to initial and the follow-up glycemia in the first 48 h, and the outcome was analyzed considering mortality and GOS at 6 months. A sound statistical analysis confirms the deleterious effect of the initial hyperglycemia persisting in the first 2 days after admission as an independent factor of increased mortality and bad functional outcome. Normoglycemic patients had a statistically significant better outcome than those who developed hyperglycemia during the first 48 h. Prevention of iatrogenic increase of glycemia (avoidance of fluid maintenance with solution containing glucose and steroid administration) is recommended by the authors, and although one could be tempted to try to treat hyperglycemia with insulin, there is, up to now, no proof of any benefit of such treatment. On the contrary, randomized multicenter studies in adults admitted in a ICU in a critical state that were assigned intensive versus conventional glucose control showed an increased mortality.

Benedict Rilliet

Geneva, Switzerland

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Authors and Affiliations

  1. Department of Pediatric Neurosurgery Hôpital Necker-Enfants Malades (Assistance Publique Hôpitaux de Paris-France), Université Descartes Paris 5, Paris, France

    José Roberto Tude Melo, Federico Di Rocco, Christian Sainte-Rose & Michel Zerah

  2. Post-Graduate Program in Medicine and Health, School of Medicine, Federal University of Bahia, Alameda dos Jasmins 200 702 B Cidade Jardim, Salvador, 40 296 200, Brazil

    José Roberto Tude Melo, Rodolfo Casimiro Reis & Jamary Olveira-Filho

  3. Pediatric Surgical Critical Care Unit, and Anesthesiology, Hôpital Necker-Enfants Malades (Assistance Publique Hôpitaux de Paris-France), Université Descartes Paris 5, Paris, France

    Stéphane Blanot, Thomas Baugnon & Philippe Meyer

  4. Hôpital National de Rehabilitation de Saint Maurice, Saint-Maurice, France

    Anne Laurent-Vannier

Authors
  1. José Roberto Tude Melo
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  2. Federico Di Rocco
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  3. Stéphane Blanot
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  4. Anne Laurent-Vannier
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  5. Rodolfo Casimiro Reis
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  9. Michel Zerah
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  10. Philippe Meyer
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Correspondence to José Roberto Tude Melo.

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Melo, J.R.T., Di Rocco, F., Blanot, S. et al. Acute hyperglycemia is a reliable outcome predictor in children with severe traumatic brain injury. Acta Neurochir 152, 1559–1565 (2010). https://doi.org/10.1007/s00701-010-0680-z

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  • DOI: https://doi.org/10.1007/s00701-010-0680-z

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