title: Extreme stress hyperglycemia during acute illness in a pediatric emergency department.
abstract: OBJECTIVE
  Although mild stress hyperglycemia in pediatric illness is common, severe hyperglycemic responses (≥300 mg/dL [16.7 mmol/L]) to stress are unusual. We sought to determine the incidence and course of extreme stress hyperglycemia (ESH) in acute pediatric illness, including whether it is a marker of increased mortality or associated with subsequent development of diabetes mellitus (DM).
  
  
  METHODS
  We retrospectively reviewed a cohort of 55,120 consecutive visits over 6 years to a pediatric emergency department at which blood glucose concentrations were measured and report on visits with laboratory glucose 300 mg/dL (16.7 mmol/L) or greater without DM.
  
  
  RESULTS
  There were 72 cases of ESH (incidence of 0.13%). Median age was 8.8 years; 63% were male. The most common diagnoses were respiratory illness (49%), trauma (15%), and seizure (8%), and 65% of patients had received glucose-influencing interventions before evaluation. Eighty-five percent were ill appearing, 60% were admitted to the intensive care unit, and half had acidemic pH values. The overall mortality rate was 22%. Despite treatment of hyperglycemia in only 8 patients, glucose concentrations decreased to 150 mg/dL (8.3 mmol/L) or less within 48 hours in 67% and before discharge or death in 85% of patients. Preceding symptoms and concurrent laboratory results were helpful to exclude diabetes, and none of the surviving patients with follow-up available went on to develop type 1 or 2 DM.
  
  
  CONCLUSIONS
  Although rare, ESH (≥300 mg/dL [16.7 mmol/L]) does occur in acute pediatric illness, in most cases is at least partially iatrogenic, and is a marker of severe illness and high mortality. Normoglycemia is typically restored quickly with treatment of the primary illness. No association was found with a subsequent diagnosis of DM.
authors.affiliation: Medicine Critical Care Program, Department of Medicine, Children's Hospital Boston, Harvard Medical School, Boston, MA. jdfisher1@cox.net
authors.forename: Scott L
authors.initials: SL
authors.lastname: Weiss
authors.forename: Jamin
authors.initials: J
authors.lastname: Alexander
authors.forename: Michael S D
authors.initials: MS
authors.lastname: Agus
mesh_terms: D000208:Acute Disease; D001786:Blood Glucose / Q000378:metabolism*; D002648:Child; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D006943:Hyperglycemia / Q000453:epidemiology / Q000209:etiology / Q000628:therapy*; D015994:Incidence; D015278:Intensive Care Units, Pediatric; D008297:Male; D012140:Respiratory Tract Diseases / Q000097:blood / Q000150:complications*; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D014481:United States / Q000453:epidemiology
chemical_list: D001786:Blood Glucose
references.citation: Pediatrics. 2006 Jul;118(1):173-9
references.pmid: 16818563
references.citation: N Engl J Med. 1973 Apr 5;288(14):700-3
references.pmid: 4569497
references.citation: N Engl J Med. 2008 Jan 10;358(2):125-39
references.pmid: 18184958
references.citation: N Engl J Med. 2001 Nov 8;345(19):1359-67
references.pmid: 11794168
references.citation: J Pediatr. 1990 Jul;117(1 Pt 1):75-7
references.pmid: 2196361
references.citation: Crit Care Med. 1982 Oct;10(10):696-7
references.pmid: 7116895
references.citation: Ann Surg. 1982 Oct;196(4):420-35
references.pmid: 6751244
references.citation: J Pediatr. 2005 Jan;146(1):30-4
references.pmid: 15644818
references.citation: Intensive Care Med. 2004 May;30(5):748-56
references.pmid: 14991101
references.citation: J Pediatr. 1970 Nov;77(5):818-23
references.pmid: 5504073
references.citation: Lancet. 2009 Feb 14;373(9663):547-56
references.pmid: 19176240
references.citation: Pediatr Pulmonol. 1995 Mar;19(3):153-5
references.pmid: 7792116
references.citation: Pediatr Crit Care Med. 2004 Jul;5(4):329-36
references.pmid: 15215001
references.citation: J Pediatr Endocrinol Metab. 1997 May-Jun;10(3):283-6
references.pmid: 9388819
references.citation: Pediatr Crit Care Med. 2007 Nov;8(6):519-23
references.pmid: 17906597
references.citation: J Pediatr. 1993 Sep;123(3):347-54
references.pmid: 8355109
references.citation: J Pediatr. 1989 Nov;115(5 Pt 1):676-80
references.pmid: 2681635
references.citation: Diabetes Res. 1988 Dec;9(4):161-7
references.pmid: 3073902
references.citation: Pediatrics. 2008 Nov;122(5):988-93
references.pmid: 18977977
references.citation: J Trauma. 2003 Jul;55(1):33-8
references.pmid: 12855878
references.citation: J Pediatr. 2008 Sep;153(3):379-84
references.pmid: 18534209
references.citation: JAMA. 2008 Aug 27;300(8):933-44
references.pmid: 18728267
references.citation: Acta Paediatr. 1995 Mar;84(3):305-7
references.pmid: 7780253
references.citation: Chest. 2007 Jul;132(1):268-78
references.pmid: 17625087
references.citation: Q J Med. 1992 Jan;82(297):71-80
references.pmid: 1438670
references.citation: Pediatrics. 1992 Feb;89(2):330-2
references.pmid: 1734406
references.citation: J Pediatr. 1991 May;118(5):827-8
references.pmid: 2019946
references.citation: N Engl J Med. 2006 Feb 2;354(5):449-61
references.pmid: 16452557
references.citation: N Engl J Med. 2009 Mar 26;360(13):1283-97
references.pmid: 19318384
references.citation: Diabetes Care. 2003 Jan;26 Suppl 1:S5-20
references.pmid: 12502614
references.citation: J Pediatr. 1994 Apr;124(4):547-51
references.pmid: 8151468
references.citation: N Engl J Med. 1973 Sep 20;289(12):618-21
references.pmid: 4198822
references.citation: Indian J Pediatr. 1997 Mar-Apr;64(2):205-10
references.pmid: 10771837