Design of the study: 

Prospective, randomized controlled study

​

Methods:

700 critically ill (PICU) patients enrolled: 317 infants (aged <1 year) and 383 children (aged >or=1 year)

• Patients were randomly assigned:

o infants intensive insulin therapy (glycemic targets: 50.4-79.2 mg/dL)

o children intensive insulin therapy (glycemic targets: 70.2-99 mg/dL)

o Conventional group with insulin therapy (glycemic target: 180-215 mg/dl)

•Patients and laboratory staff were blinded to treatment allocation.

• Primary endpoints were duration of PICU stay and inflammation. • Analysis was by intention to treat.

​

Results: ​

Mean blood glucose concentrations were lower in the intensive group than in the conventional group and children, p<0.0001 • Hypoglycemia (blood glucose <or=2.2 mmol/L) occurred in 87 (25%) patients in the intensive group (p<0.0001) vs five (1%) patients in the conventional group • Hypoglycemia defined as blood glucose less than 1.7 mmol/L arose in 17 (5%) patients vs 3 (1%) p=0.001 • Duration of PICU stay was shortest in the intensively treated group (5.51 days [95% CI 4.65-6.37] vs 6.15 days [5.25-7.05], p=0.017). • The inflammatory response was attenuated at day 5 (lower C-reactive protein in the intensive group compared with baseline) p=0.007 • The number of patients with extended stay in PICU was 132 (38%) in the intensive group vs 165 (47%) in the conventional group p=0.013 • 9 (3%) patients died in the intensively treated group vs 20 (6%) in the conventional group p=0.038

​

Conclusions: ​

Intensive insulin therapy reduced pediatric intensive care unit length of stay (primary outcome measure) and attenuated C-reactive protein concentrations >5 days. Other interesting points: • Groups were similar at enrollment and had comparable forms of nutrition and glucose infusion rates. • Steroid use and vasoactive-inotrope scores were not compared. • Long-term effects on outcomes were not evaluated, and the authors recognize the need for such follow-up studies

​

Take home message: ​

Targeting of blood glucose concentrations to age-adjusted normal fasting concentrations improved short-term outcome of patients in PICU but targeting age-adjusted fasting glucose ranges cannot be routinely recommended in critically ill children. • The effect on long-term survival, morbidity, and neurocognitive development needs to be investigated.