Insulinoterapia intravenosa contínua para controle de hiperglicemia em crianças criticamente enfermas: estudo clínico, prospectivo, randomizado e controlado
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Data
2019-05-28
Autores
Augusto, Fernanda Maíra
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Universidade Estadual Paulista (Unesp)
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AUGUSTO, F. M. Insulinoterapia intravenosa contínua para controle de hiperglicemia em crianças criticamente enfermas: estudo clínico, prospectivo, randomizado e controlado [tese]. Botucatu: Faculdade de Medicina de Botucatu, Universidade Estadual Paulista (Unesp); 2019. Objetivos: Avaliar prospectivamente o comportamento glicêmico de crianças graves, hiperglicêmicas e não diabéticas, os efeitos da insulinoterapia sobre morbimortalidade e segurança de protocolo de controle glicêmico com insulina intravenosa. Métodos: Estudo clínico, prospectivo, randomizado e controlado em UTIP, com crianças entre 28 dias e 16 anos de idade e duas glicemias >180mg/dL, entre 07/2010 e 11/2016. Os pacientes foram alocados por sorteio, em dois grupos: tratado com insulina (GT) e controle (GC). Foram excluídas crianças com duas glicemias >180mg/dL isoladas, diagnosticadas com diabetes mellitus durante a internação e que receberam insulina subcutânea ou em diálise peritoneal. Dados clínicos e glicemias foram coletados da admissão ao encerramento do protocolo. Os grupos foram comparados quanto à idade, peso, gênero, diagnósticos, PRISM, PELOD, uso de catecolaminas, sedação/analgesia e ventilação mecânica (VM), disfunções orgânicas, glicemia, hipoglicemia, Índice de Variação Glicêmica (IVG), Coeficiente de Variabilidade glicêmica (CV), tempo até meta glicêmica (80-180mg/dL), velocidade de oscilação glicêmica e mortalidade. Significância 5%. Resultados: Analisadas 116 crianças clínico-cirúrgicas e prevalência de hiperglicemia de 20%. GT (n=63) e GC (n=53) não diferiram estatisticamente quanto à idade, peso, gênero, diagnósticos, escores de gravidade, uso de drogas e VM, disfunções orgânicas, pico e média glicêmicos, tempo até atingir a meta glicêmica, hipoglicemia e mortalidade (p>0,05). O GT permaneceu mais tempo internado (p<0,001), obteve maior glicemia à admissão [GT: 292,4mg/dL ± 81,8; GC: 260 ± 77,5; p=0,031], com maiores CV [GC: 40,7% ± 31,3 vs GT: 56,8% ± 29,9; p=0,009] e IVG [GC: 67mg/dL ± 57,8 vs GT: 104,5 ± 69,2; p=0,002], no entanto com predominância de classes intermediárias de velocidade de variação da glicose no GT. Não houve diferença estatística quanto a velocidade de variação glicêmica (mediana), mas no GC houve maior amplitude de variação das velocidades individuais. Pacientes não sobreviventes do GC apresentaram maior frequência de hipoglicemia e variabilidade glicêmica. Conclusões: Insulinoterapia não aumentou a morbimortalidade de crianças hiperglicêmicas graves ou a frequência de hipoglicemia. O protocolo de tratamento com alvo moderado controlou a glicemia com velocidades intermediárias e o aumento de variabilidade glicêmica não impediu que a glicemia diminuísse em velocidade segura.
AUGUSTO, F. M. Continous intravenous insulin therapy for hyperglycemia control in critically ill children: a clinical, prospective, randomized and controlled study. [thesis]. Botucatu: Medical School of Botucatu, São Paulo State University (Unesp); 2019. Objectives: To prospectively assess the glycemic behavior of critically, hyperglycemic and non-diabetic children, the effects of insulin therapy on morbidity and mortality, and the safety of glycemic control protocol with intravenous insulin. Methods: A prospective, randomized, controlled and clinical pilot study in the PICU was designed and enrolled children between 28 days and 16 years of age and two blood glucose levels > 180mg/dL (10mmol/L), from July 2010 to November 2016. Patients were randomly assigned into two groups: treated with insulin (TG) and control (CG). Children with two isolated blood glucose levels >180mg/dL, diagnosed with diabetes mellitus during the study and who received subcutaneous insulin or in peritoneal dialysis were excluded. Clinical data and blood glucose levels were collected from admission to protocol closure. The groups were compared by age, weight, gender, diagnosis, PRISM, PELOD, use of drugs and mechanical ventilation (MV), organic dysfunctions, glycemia, hypoglycemia, Glycemic Variation Index (GVI), Glycemic Variability Coefficient (GVC), time to glycemic target (80-180mg/dL;4,4-10mmol/L), glycemic oscillation rate and mortality. Significance 5%. Results: 166 children with medical and surgical diagnoses were studied and the prevalence of hyperglycemia was 20%. TG (n=63) e CG (n=53) did not differ statistically regarding age, weight, gender, diagnoses, severity scores, use of drugs and MV, organ dysfunctions, glycemic peak and average, time to reach glycemic goal, hypoglycemia and mortality (p>0,05). TG stayed longer in PICU and in hospital (p<0,001), had higher admission glycemia [TG: 292,4mg/dL ± 81,8; CG: 260 ± 77,5; p=0,031], higher VC [CG:40,7% ± 31,3 vs TG: 56,8% ± 29,9; p=0,009] e GVI [CG: 67mg/dL ± 57,8 vs TG: 104,5mg/dL ± 69,2; p=0,002], however with predominance of intermediate classes of glucose variation velocity in TG. There was no significant statistical difference between glycemic variation velocity (median), but in CG there was greater range of variation of individual speeds. CG non survivors had higher frequency of hypoglycemia and glycemic variability. Conclusions: Insulin therapy did not increase morbidity and mortality of critically hyperglycemic children or the frequency of hypoglycemia. The treatment protocol with moderate goal controlled glycemia with intermediate velocities and increased glycemic variability didn’t prevent glycemia from decreasing at safe speed.
AUGUSTO, F. M. Continous intravenous insulin therapy for hyperglycemia control in critically ill children: a clinical, prospective, randomized and controlled study. [thesis]. Botucatu: Medical School of Botucatu, São Paulo State University (Unesp); 2019. Objectives: To prospectively assess the glycemic behavior of critically, hyperglycemic and non-diabetic children, the effects of insulin therapy on morbidity and mortality, and the safety of glycemic control protocol with intravenous insulin. Methods: A prospective, randomized, controlled and clinical pilot study in the PICU was designed and enrolled children between 28 days and 16 years of age and two blood glucose levels > 180mg/dL (10mmol/L), from July 2010 to November 2016. Patients were randomly assigned into two groups: treated with insulin (TG) and control (CG). Children with two isolated blood glucose levels >180mg/dL, diagnosed with diabetes mellitus during the study and who received subcutaneous insulin or in peritoneal dialysis were excluded. Clinical data and blood glucose levels were collected from admission to protocol closure. The groups were compared by age, weight, gender, diagnosis, PRISM, PELOD, use of drugs and mechanical ventilation (MV), organic dysfunctions, glycemia, hypoglycemia, Glycemic Variation Index (GVI), Glycemic Variability Coefficient (GVC), time to glycemic target (80-180mg/dL;4,4-10mmol/L), glycemic oscillation rate and mortality. Significance 5%. Results: 166 children with medical and surgical diagnoses were studied and the prevalence of hyperglycemia was 20%. TG (n=63) e CG (n=53) did not differ statistically regarding age, weight, gender, diagnoses, severity scores, use of drugs and MV, organ dysfunctions, glycemic peak and average, time to reach glycemic goal, hypoglycemia and mortality (p>0,05). TG stayed longer in PICU and in hospital (p<0,001), had higher admission glycemia [TG: 292,4mg/dL ± 81,8; CG: 260 ± 77,5; p=0,031], higher VC [CG:40,7% ± 31,3 vs TG: 56,8% ± 29,9; p=0,009] e GVI [CG: 67mg/dL ± 57,8 vs TG: 104,5mg/dL ± 69,2; p=0,002], however with predominance of intermediate classes of glucose variation velocity in TG. There was no significant statistical difference between glycemic variation velocity (median), but in CG there was greater range of variation of individual speeds. CG non survivors had higher frequency of hypoglycemia and glycemic variability. Conclusions: Insulin therapy did not increase morbidity and mortality of critically hyperglycemic children or the frequency of hypoglycemia. The treatment protocol with moderate goal controlled glycemia with intermediate velocities and increased glycemic variability didn’t prevent glycemia from decreasing at safe speed.
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Palavras-chave
Criança, Hipoglicemia, Insulina, Unidade de terapia intensiva, Glicose, Glicemia, Children, Hypoglycemya, Insulin, Intensive care unit, Glucose, Glycemia, Hiperglicemia, Hyperglycemia