To study the association of timing, duration, and intensity of hyperglycemia with pediatric intensive care unit (PICU) mortality in critically ill children. Retrospective cohort study. PICU of a university-affiliated, tertiary care, children's hospital. A total of 152 critically ill children receiving vasoactive infusions or mechanical ventilation. None. With institutional review board approval, we reviewed a cohort of 179 consecutive children, 1 mo to 21 yrs of age, treated with mechanical ventilation or vasoactive infusions. We excluded 18 with <3 μg·kg−1·min−1 dopamine only, diabetes, or solid organ transplant and nine who died within 24 hrs of PICU admission. Peak blood glucose (BG) and time to peak BG during PICU admission, duration of hyperglycemia (percentage of PICU days with any BG of >126 mg/dL), and intensity of hyperglycemia (median BG during first 48 PICU hours) were analyzed for association with PICU mortality using chi-square, Student's t-test, and logistic regression. Peak BG of >126 mg/dL occurred in 86% of patients. Compared with survivors, nonsurvivors had higher peak BG (311 ± 115 vs. 205 ± 80 mg/dL, p < .001). Median time to peak BG was similar in nonsurvivors (23.5 hrs; interquartile ratio, 5–236 hrs) and survivors (19 hrs; inter-quartile ratio, 6–113 hrs). Duration of hyperglycemia was longer in nonsurvivors (71% ± 14% of PICU days) vs. survivors (37% ± 5% of PICU days, p < .001). Nonsurvivors had more intense hyperglycemia during the first 48 hrs in the PICU (126 ± 38 mg/dL) vs. survivors (116 ± 34 mg/dL, p < .05). Univariate logistic regression analysis showed that peak BG and the duration and intensity of hyperglycemia were each associated with PICU mortality (p < .05). Multivariate modeling controlling for age and Pediatric Risk of Mortality scores showed independent association of peak BG and duration of hyperglycemia with PICU mortality (p < .05). Hyperglycemia is common in critically ill children. Peak BG and duration of hyperglycemia are independently associated with mortality in our PICU. A prospective, randomized trial of strict glycemic control in this subset of critically ill children who are at high risk of mortality is both warranted and feasible.

In multicenter studies, tight glycemic control targeting a normal blood glucose level has not been shown to improve outcomes in critically ill adults or children after cardiac surgery. Studies involving critically ill children who have not undergone cardiac surgery are lacking. In a 35-center trial, we randomly assigned critically ill children with confirmed hyperglycemia (excluding patients who had undergone cardiac surgery) to one of two ranges of glycemic control: 80 to 110 mg per deciliter (4.4 to 6.1 mmol per liter; lower-target group) or 150 to 180 mg per deciliter (8.3 to 10.0 mmol per liter; higher-target group). Clinicians were guided by continuous glucose monitoring and explicit methods for insulin adjustment. The primary outcome was the number of intensive care unit (ICU)–free days to day 28. The trial was stopped early, on the recommendation of the data and safety monitoring board, owing to a low likelihood of benefit and evidence of the possibility of harm. Of 713 patients, 360 were randomly assigned to the lower-target group and 353 to the higher-target group. In the intention-to-treat analysis, the median number of ICU-free days did not differ significantly between the lower-target group and the higher-target group (19.4 days [interquartile range {IQR}, 0 to 24.2] and 19.4 days [IQR, 6.7 to 23.9], respectively; P=0.58). In per-protocol analyses, the median time-weighted average glucose level was significantly lower in the lower-target group (109 mg per deciliter [IQR, 102 to 118]; 6.1 mmol per liter [IQR, 5.7 to 6.6]) than in the higher-target group (123 mg per deciliter [IQR, 108 to 142]; 6.8 mmol per liter [IQR, 6.0 to 7.9]; P<0.001). Patients in the lower-target group also had higher rates of health care–associated infections than those in the higher-target group (12 of 349 patients [3.4%] vs. 4 of 349 [1.1%], P=0.04), as well as higher rates of severe hypoglycemia, defined as a blood glucose level below 40 mg per deciliter (2.2 mmol per liter) (18 patients [5.2%] vs. 7 [2.0%], P=0.03). No significant differences were observed in mortality, severity of organ dysfunction, or the number of ventilator-free days. Critically ill children with hyperglycemia did not benefit from tight glycemic control targeted to a blood glucose level of 80 to 110 mg per deciliter, as compared with a level of 150 to 180 mg per deciliter. (Funded by the National Heart, Lung, and Blood Institute and others; HALF-PINT ClinicalTrials.gov number, NCT01565941.)

OBJECTIVES. Specific patterns of calcium use during in-hospital pediatric cardiopulmonary resuscitation have not been reported since publication of pediatric advanced life support guidelines by the American Heart Association in 2000 recommended that calcium use during cardiopulmonary resuscitation be limited to select circumstances. We hypothesized that calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation and that its use is associated with worse survival to hospital discharge. METHODS. We reviewed 1477 consecutive pediatric cardiopulmonary resuscitation index events (for patients younger than 18 years) submitted to the National Registry of Cardiopulmonary Resuscitation from January 2000 through July 2004. The primary outcome was survival to hospital discharge. Secondary outcomes included survival of event and neurologic outcome. Multivariable logistic regression was performed to analyze the association between calcium use and outcomes. RESULTS. Calcium was used in 659 (45%) of 1477 events. Calcium was more likely to be used during cardiopulmonary resuscitation in the settings of pediatric facilities, ICUs, cardiac surgery, cardiopulmonary resuscitation duration of ≥15 minutes, asystole, and concurrently with other advanced life support medications: epinephrine, vasopressin, sodium bicarbonate, and magnesium sulfate. The use of calcium during cardiopulmonary resuscitation adjusted for confounding factors was associated with decreased survival to discharge and was not associated with favorable neurologic outcome. CONCLUSIONS. Calcium is used frequently during in-hospital pediatric cardiopulmonary resuscitation. Although epidemiologic associations do not necessarily indicate causality, calcium use during cardiopulmonary resuscitation is associated with decreased survival to hospital discharge and unfavorable neurologic outcome.

OBJECTIVE: We hypothesized that childhood obesity would be associated with decreased likelihood of survival to hospital discharge after in-hospital, pediatric cardiopulmonary resuscitation (CPR). METHODS: We reviewed 1477 consecutive, pediatric, CPR index events (defined as the first CPR event during a hospitalization in that facility for a patient <18 years of age) reported to the American Heart Association National Registry of Cardiopulmonary Resuscitation between January 2000 and July 2004. The primary outcome was survival to hospital discharge. A total of 1268 index subjects (86%) with complete registry data were included for analysis. Children were classified as obese (≥95th weight-for-length percentile if <2 years of age or ≥95th BMI-for-age percentile if ≥2 years of age) or underweight (<5th weight-for-length percentile if <2 years of age or <5th BMI-for-age percentile if ≥2 years of age), with adjustment for gender. RESULTS: Obesity was noted for 213 (17%) of 1268 subjects and underweight for 571 (45%) of 1268 subjects. Obesity was more likely to be associated with male gender, noncardiac medical illness, and cancer and inversely associated with heart failure. Underweight was more likely to be associated with male gender, cardiac surgery, and prematurity and inversely associated with age and cancer. Self-reported, process-of-care, CPR quality was generally worse for obese children. With adjustment for important potential confounding factors, obesity was independently associated with worse odds of event survival (adjusted odds ratio: 0.58 [95% confidence interval: 0.35–0.76]) and survival to hospital discharge (adjusted odds ratio: 0.62 [95% confidence interval: 0.38–0.93]) after in-hospital, pediatric CPR. Underweight was not associated with worse outcomes. CONCLUSIONS: Childhood obesity is associated with a lower rate of survival to hospital discharge after in-hospital, pediatric CPR.

Objectives: The impact of early enteral nutrition on clinical outcomes in critically ill children has not been adequately described. We hypothesized that early enteral nutrition is associated with improved clinical outcomes in critically ill children.Design: Secondary analysis of the Heart and Lung Failure-Pediatric Insulin Titration randomized controlled trial.Setting: Thirty-five PICUs.Patients: Critically ill children with hyperglycemia requiring inotropic support and/or invasive mechanical ventilation who were enrolled for at least 48 hours with complete nutrition data.Interventions: Subjects received nutrition via guidelines that emphasized enteral nutrition and were classified into early enteral nutrition (enteral nutrition within 48 hr of study randomization) and no early enteral nutrition (enteral nutrition after 48 hr of study randomization, or no enteral nutrition at any time).Measurements and Main Results: Of 608 eligible subjects, 331 (54%) received early enteral nutrition. Both early enteral nutrition and no early enteral nutrition groups had similar daily caloric intake over the first 8 study days (median, 36 vs 36 kcal/kg/d;p= 0.93). After controlling for age, body mass indexzscores, primary reason for ICU admission, severity of illness, and mean Vasopressor-Inotrope Score at the time of randomization, and adjusting for site, early enteral nutrition was associated with lower 90-day hospital mortality (8% vs 17%;p= 0.007), more ICU-free days (median, 20 vs 17 d;p= 0.02), more hospital-free days (median, 8 vs 0 d;p= 0.003), more ventilator-free days (median, 21 vs 19 d;p= 0.003), and less organ dysfunction (median maximum Pediatric Logistic Organ Dysfunction, 11 vs 12;p< 0.001).Conclusions: In critically ill children with hyperglycemia requiring inotropic support and/or mechanical ventilation, early enteral nutrition was independently associated with better clinical outcomes.