Hyperglycemia Pediatric

Sample Medical Guidelines

State of Wisconsin Emergency Medical Services Sample Medical Guidelines Note: Â· Most pediatric patients with hyperglycemia have diabetic ketoacidosis (DKA), which is a life-threatening complication of diabetes that includes severe dehydration and metabolic acidosis. Â· Sodium bicarbonate is contraindicated. Â· In children, the parents may not know the child has diabetes before the first episode of DKA. Â· The first clues of new onset diabetes may be excessive thirst or urination, including inappropriate wetting (e.g. wetting the bed or wetting pants). Priorities Assessment Findings Chief Complaint â€œHigh blood sugar,â€ Breathing Fast, Vomiting, Abdominal Pain, â€œDiabetic Comaâ€ OPQRST Check onset/duration of symptoms. Identify possible contributing factors. Associated Symptoms/ Pertinent Negatives Fever/Chills. Signs/Symptoms of infection. Polyuria, Polydipsia, Polyphagia, Adequate food and water intake? Increasing thirst? Increasing urine output? SAMPLE Known history of Diabetes. Medications for diabetes. Initial Exam ABCs and correct any immediately life-threatening problems. Detailed Focused Exam General Appearance: Appears sick? Dehydrated? Kussmaulâ€™s Respirations? Smell of Acetone on breath. Heart: Tachycardia? Hypotension? Resp: Rapid Respiration GI: Diffuse Abdominal Tenderness Skin: Cool, pale, diaphoretic? Warm, dry, flushed? Tenting? Neuro: ALOC? Focal deficits (CVA)? Goals of Therapy Use IV fluids to reduce glucose level, improve hydration, improve acid-base balance. Transport to hospital for insulin therapy to treat acidosis. Monitor for cerebral edema. Monitoring BP, HR, RR, EKG, SpO2, repeat glucose, neuro checks EMERGENCY MEDICAL RESPONDER (EMR) Â· Routine Medical Care. Â· Oxygen as needed. Â· Monitor vitals. EMERGENC Continue reading >>

Stress Hyperglycemia In Pediatric Critical Illness: The Intensive Care Unit Adds To The Stress!

Stress hyperglycemia (SH) commonly occurs during critical illness in children. The historical view that SH is beneficial has been questioned in light of evidence that demonstrates the association of SH with worse outcomes. In addition to intrinsic changes in glucose metabolism and development of insulin resistance, specific intensive care unit (ICU) practices may influence the development of SH during critical illness. Mechanical ventilation, vasoactive infusions, renal replacement therapies, cardiopulmonary bypass and extracorporeal life support, therapeutic hypothermia, prolonged immobility, nutrition support practices, and the use of medications are all known to mediate development of SH in critical illness. Tight glucose control (TGC) to manage SH has emerged as a promising therapy to improve outcomes in critically ill adults, but results have been inconclusive. Large variations in ICU practices across studies likely resulted in inconsistent results. Future studies of TGC need to take into account the impact of commonly used ICU practices and, ideally, standardize protocols in an attempt to improve the accuracy of conclusions from such studies. 1. Srinivasan, V, Spinella, PC, Drott, HR, Roth, CL, Helfaer, MA, Nadkarni, V. Association of timing, duration, and intensity of hyperglycemia with intensive care unit mortality in critically ill children. Pediatr Crit Care Med. 2004;5 (4): 329–36. Google Scholar, Crossref, Medline 2. Faustino, E V, Apkon, M. Persistent hyperglycemia in critically ill children. J Pediatr 2005;146 (1): 30–4. Google Scholar, Crossref, Medline 3. Wintergerst, KA, Buckingham, B, Gandrud, L, Wong, BJ, Kache, S, Wilson, DM. Association of hypoglycemia, hyperglycemia, and glucose variability with morbidity and death in the pediatric intensive ca Continue reading >>

A Randomized Trial Of Hyperglycemic Control In Pediatric Intensive Care

Whether an insulin infusion should be used for tight control of hyperglycemia in critically ill children remains unclear. We randomly assigned children (≤16 years of age) who were admitted to the pediatric intensive care unit (ICU) and were expected to require mechanical ventilation and vasoactive drugs for at least 12 hours to either tight glycemic control, with a target blood glucose range of 72 to 126 mg per deciliter (4.0 to 7.0 mmol per liter), or conventional glycemic control, with a target level below 216 mg per deciliter (12.0 mmol per liter). The primary outcome was the number of days alive and free from mechanical ventilation at 30 days after randomization. The main prespecified subgroup analysis compared children who had undergone cardiac surgery with those who had not. We also assessed costs of hospital and community health services. A total of 1369 patients at 13 centers in England underwent randomization: 694 to tight glycemic control and 675 to conventional glycemic control; 60% had undergone cardiac surgery. The mean between-group difference in the number of days alive and free from mechanical ventilation at 30 days was 0.36 days (95% confidence interval [CI], −0.42 to 1.14); the effects did not differ according to subgroup. Severe hypoglycemia (blood glucose, <36 mg per deciliter [2.0 mmol per liter]) occurred in a higher proportion of children in the tight-glycemic-control group than in the conventional-glycemic-control group (7.3% vs. 1.5%, P<0.001). Overall, the mean 12-month costs were lower in the tight-glycemic-control group than in the conventional-glycemic-control group. The mean 12-month costs were similar in the two groups in the cardiac-surgery subgroup, but in the subgroup that had not undergone cardiac surgery, the mean cost was signifi Continue reading >>

Stress Hyperglycemia: A Sign Of Familial Diabetes In Children

Abstract Stress hyperglycemia in children is considered a benign condition that usually does not mandate further investigation. In some clinical settings it might be the first sign of diabetes mellitus (DM). Two unrelated boys, one aged 2 years 7 months and the other aged 5 days, were evaluated in the emergency department for a febrile infection and found to have elevated blood glucose levels (238 and 150 mg/dL [preprandial], respectively). In both cases the elevated hemoglobin A1c levels (6.5% and 6.6%, respectively) combined with a history of gestational DM in the mother and positive family history for DM suggested maturity-onset diabetes of the young. Genetic analysis revealed 2 known heterozygote mutations in the glucokinase gene: c.697T→C p.C233R in the first case and c.616A→C p.T206P in the second case. Our findings suggest that stress hyperglycemia during early childhood in association with a positive family history of DM might be a sign of monogenic diabetes. Abstract Standard pharmacologic closure of the patent ductus arteriosus currently involves the administration of 1 of 2 cyclooxygenase inhibitors: either indomethacin or ibuprofen. However, both of these drugs can be associated with potentially significant adverse effects. We present here the cases of 5 preterm infants (gestational age: 26–32 weeks; postnatal age: 3–35 days) with large, hemodynamically significant patent ductus arteriosus who had either failed or had contraindications to ibuprofen therapy. Each of these infants was treated with off-label oral paracetamol (15 mg/kg per dose every 6 hours). Ductal closure was achieved within 48 hours in all the treated infants. No toxicity was observed. Continue reading >>

> Hyperglycemia And Diabetic Ketoacidosis

When blood glucose levels (also called blood sugar levels) are too high, it's called hyperglycemia. Glucose is a sugar that comes from foods, and is formed and stored inside the body. It's the main source of energy for the body's cells and is carried to each through the bloodstream. But even though we need glucose for energy, too much glucose in the blood can be unhealthy. Hyperglycemia is the hallmark of diabetes — it happens when the body either can't make insulin (type 1 diabetes) or can't respond to insulin properly (type 2 diabetes). The body needs insulin so glucose in the blood can enter the cells to be used for energy. In people who have developed diabetes, glucose builds up in the blood, resulting in hyperglycemia. If it's not treated, hyperglycemia can cause serious health problems. Too much sugar in the bloodstream for long periods of time can damage the vessels that supply blood to vital organs. And, too much sugar in the bloodstream can cause other types of damage to body tissues, which can increase the risk of heart disease and stroke, kidney disease, vision problems, and nerve problems in people with diabetes. These problems don't usually show up in kids or teens with diabetes who have had the disease for only a few years. However, they can happen in adulthood in some people, particularly if they haven't managed or controlled their diabetes properly. Blood sugar levels are considered high when they're above someone's target range. The diabetes health care team will let you know what your child's target blood sugar levels are, which will vary based on factors like your child's age. A major goal in controlling diabetes is to keep blood sugar levels as close to the desired range as possible. It's a three-way balancing act of: diabetes medicines (such as in Continue reading >>

Pediatric Type 1 Diabetes Mellitus Clinical Presentation

History The most easily recognized symptoms of type 1 diabetes mellitus (T1DM) are secondary to hyperglycemia, glycosuria, and DKA. Hyperglycemia Hyperglycemia alone may not cause obvious symptoms, although some children report general malaise, headache, and weakness. Children may also appear irritable and become ill-tempered. The main symptoms of hyperglycemia are secondary to osmotic diuresis and glycosuria. Glycosuria This condition leads to increased urinary frequency and volume (eg, polyuria), which is particularly troublesome at night (eg, nocturia) and often leads to enuresis in a previously continent child. These symptoms are easy to overlook in infants because of their naturally high fluid intake and diaper/napkin use. Polydipsia Increased thirst, which may be insatiable, is secondary to the osmotic diuresis causing dehydration. Weight loss Insulin deficiency leads to uninhibited gluconeogenesis, causing breakdown of protein and fat. Weight loss may be dramatic, although the child's appetite usually remains good. Failure to thrive and wasting may be the first symptoms noted in an infant or toddler and may precede frank hyperglycemia. Nonspecific malaise Although this condition may be present before symptoms of hyperglycemia or as a separate symptom of hyperglycemia, it is often only retrospectively recognized. Symptoms of ketoacidosis These symptoms include the following: Additional symptoms Hyperglycemia impairs immunity and renders a child more susceptible to recurrent infection, particularly of the urinary tract, skin, and respiratory tract. Candidiasis may develop, especially in the groin and in flexural areas. Continue reading >>

Not All Severe Hyperglycemia Is Diabetes

Abstract Severe hyperglycemia without ketosis at the clinical onset of insulin-dependent diabetes mellitus (IDDM) has been reported in children and adolescents.1 Non-diabetic children can develop modest hyperglycemia (usually in the range of 11 to 14 mmol/L (200 to 250 mg/dL)) without ketosis in response to physiologic stress such as trauma, burns, or sepsis,2,3 but severe hyperglycemia is seen rarely in this setting. We recently encountered the case of a 22-month-old infant with severe nonketotic hyperglycemic hyperosmolar syndrome due to gastroenteritis and dehydration who rapidly recovered and has had no subsequent evidence of diabetes mellitus. A 22-month-old Hispanic male infant was brought to the Yale-New Haven Hospital Pediatric Emergency Room with a 48-hour history of fever, diarrhea (8 to 10 stools/day), and vomiting (approximately hourly for the previous 24 hours). Abstract Retinal hemorrhages occur frequently in association with abusive head trauma.1 The injuries are venous [See table in the PDF] in origin and, as such, are similar to the retinal hemorrhages which frequently occur in full-term neonates after vaginal delivery. Because retinal hemorrhages in child abuse frequently are associated with intracranial bleeding, we questioned the possibility of a relationship between parturitional retinal hemorrhages and concurrent intracranial injuries. To answer this question we designed a prospective study in which we performed magnetic resonance imaging on 10 randomly selected full-term neonates in whom the presence of retinal hemorrhages was confirmed on fundascopic examination by a pediatric ophthalmologist. Continue reading >>

Hyperglycemia

Definition Hyperglycemia is a complex metabolic condition characterized by abnormally high levels of blood sugar (blood glucose) in circulating blood, usually as a result of diabetes mellitus (types 1 and 2), although it can sometimes occur in cystic fibrosis and near-drowning (submersion injury). Description Hyperglycemia, also known as diabetic ketoacidosis, is a condition that develops over a period of a few days as the blood glucose levels of a type 1 or type 2 diabetic gradually rise. Ketoacidosis occurs when increasing glucose levels are met by a lack of sufficient or effective insulin production, starting a sequence of physiologic events as follows: The combination of excess glucose production and low glucose utilization in the body raises levels of blood glucose, which leads to increased urinary output (diuresis) followed quickly by a loss of fluid and essential mineral salts (electrolytes) and, ultimately, dehydration . The loss of fluid may finally result in dehydration. If the entire process is severe enough over several hours (serum glucose levels over 800mg/dL), swelling can occur in the brain (cerebral edema), and coma can eventually result. In a metabolic shift to a catabolic (breaking down) process, cells throughout the body empty their electrolytes (sodium, potassium, and phosphate) into the bloodstream. Electrolytes control the fluid balance of the body and are important in muscle contraction, energy generation, and almost all major biochemical reactions in the body. As a result of electrolyte imbalance, many functions can become impaired. Free fatty acids from lipid stores are increased, encouraging the production of ketoacids in the liver, leading to an over-acidic condition (metabolic acidosis) that causes even more disruption in body processes. Wit Continue reading >>

Causes Of High Blood Glucose And Low Blood Glucose

Low or high blood sugar in a child with diabetes can cause loss of responsiveness. All of the cells in our body depend upon sugar in our blood as the main source of energy. This sugar comes from the foods that we eat. Certain organs in our body also make and store sugar. When the body is working properly, it automatically regulates the amount of sugar in the blood. When there is too much sugar in the blood, the body makes insulin, which lowers blood sugar. When blood sugar levels are too low, the body cuts back on the amount of insulin that it is making and lets the blood sugar levels rise. When blood sugar levels in the body are lower than normal, a child has hypoglycemia. Signs of hypo-glycemia in a healthy child are usually mild, such as irritability. In a child with diabetes, hypoglycemia can lead to loss of responsiveness if not treated quickly. A diabetic child can get hypoglycemia if he doesn’t eat enough or doesn’t eat at the right time. He can get hypoglycemia if he takes too much insulin. Blood sugar levels may drop because of exercise, being overheated, or illness. A diabetic child may have too much sugar in the body. This is called hyperglycemia. It is the opposite of hypoglycemia. This condition may be caused by too little insulin, illness, or stress. It may be caused by overeating, inactivity, or a combination of all of these factors. If you are not sure if the child has hypoglycemia or hyperglycemia, give sugar. See if the symptoms improve. Always call EMS if symptoms are severe or if the child becomes unresponsive. Signs of Hypoglycemia and Hyperglycemia Signs of Hypoglycemia Signs of Hyperglycemia Irritability Paleness Drowsiness Confusion Trembling Excessive Sweating Poor coordination Slurred speech Staggering Eventual loss of responsivene Continue reading >>

Glycemic Control In The Pediatric Intensive Care Unit Of Leuven: Two Years Of Experience

Go to: Critically ill patients have a severe dysregulation of their glucose homeostasis. Observational studies have shown that both hyperglycemia and hypoglycemia are associated, by a J-curved relation, with increased mortality rate in patients with severe illness.1 This association between stress hyperglycemia and poor outcome is known not only for critically ill adults but also for critically ill infants and children.2–7 Normalization of blood glucose levels within age-adjusted tight limits (tight glycemic control, TGC) leads to a reduction in the mortality and morbidity rate as was shown in three randomized controlled trials in the surgical, medical, and pediatric intensive care unit (PICU) of the Leuven University in Belgium.8–10 The trial in the Leuven PICU was performed with 700 infants and children who were randomly allocated to the intensive insulin therapy (IIT) group or the conventional insulin therapy (CIT) group.10 The target blood glucose ranges in the IIT group were the age-adjusted normal fasting levels of glycemia: 50–80 mg/dl for infants and 70–100 mg/dl for children. In the CIT group, insulin was administered only to prevent blood glucose levels from exceeding 215 mg/dl (which is the renal threshold). An important reduction in the duration of PICU stay, inflammatory response, and mortality was noted. Inevitably, IIT also led to an increased incidence of (short-lasting) hypoglycemia: approximately 25% patients had at least one hypoglycemic event (blood glucose < 40 mg/dl) during their entire stay in the PICU. The fear of causing iatrogenic hypoglycemic episodes,11 in addition to some follow-up clinical trials that either could not confirm this survival benefit or have even resulted in an increased mortality in patients who were treated with IIT, Continue reading >>