title: Impact of stress-induced diabetes on outcomes in severely burned children.
abstract: BACKGROUND
  Post-burn hyperglycemia leads to graft failure, multiple organ failure, and death. A hyperinsulinemic-euglycemic clamp is used to keep serum glucose between 60 and 110 mg/dL. Because of frequent hypoglycemic episodes, a less-stringent sliding scale insulin protocol is used to maintain serum glucose levels between 80 and 160 mg/dL after elevations >180 mg/dL.
  
  
  METHODS
  We randomized pediatric patients with massive burns into 2 groups, patients receiving sliding scale insulin to lower blood glucose levels (n = 145) and those receiving no insulin (n = 98), to determine the differences in morbidity and mortality. Patients 0 to 18 years old with burns covering ≥ 30% of the total body surface area and not randomized to receive anabolic agents were included in this study. End points included glucose levels, infections, resting energy expenditure, lean body mass, bone mineral content, fat mass, muscle strength, and serum inflammatory cytokines, hormones, and liver enzymes.
  
  
  RESULTS
  Maximal glucose levels occurred within 6 days of burn injury. Blood glucose levels were age dependent, with older children requiring more insulin (p < 0.05). Daily maximum and daily minimum, but not 6 am, glucose levels were significantly different based on treatment group (p < 0.05). Insulin significantly increased resting energy expenditure and improved bone mineral content (p < 0.05). Each additional wound infection increased incidence of hyperglycemia (p = 0.004). There was no mortality in patients not receiving insulin, only in patients who received insulin (p < 0.004). Muscle strength was increased in patients receiving insulin (p < 0.05).
  
  
  CONCLUSIONS
  Burn-induced hyperglycemia develops in a subset of severely burned children. Length of stay was reduced in the no insulin group, and there were no deaths in this group. Administration of insulin positively impacted bone mineral content and muscle strength, but increased resting energy expenditure, hypoglycemic episodes, and mortality. New glucose-lowering strategies might be needed.
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX; Institute for Translational Sciences, University of Texas Medical Branch, Galveston, TX; Sealy Center for Molecular Medicine, University of Texas Medical Branch, Galveston, TX. Electronic address: ccfinner@utmb.edu.
authors.forename: Celeste C
authors.initials: CC
authors.lastname: Finnerty
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Arham
authors.initials: A
authors.lastname: Ali
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Josef
authors.initials: J
authors.lastname: McLean
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Nicole
authors.initials: N
authors.lastname: Benjamin
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Robert P
authors.initials: RP
authors.lastname: Clayton
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Clark R
authors.initials: CR
authors.lastname: Andersen
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX.
authors.forename: Ronald P
authors.initials: RP
authors.lastname: Mlcak
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: Oscar E
authors.initials: OE
authors.lastname: Suman
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX.
authors.forename: Walter
authors.initials: W
authors.lastname: Meyer
authors.affiliation: Shriners Hospitals for Children-Galveston, University of Texas Medical Branch, Galveston, TX; Department of Surgery, University of Texas Medical Branch, Galveston, TX.
authors.forename: David N
authors.initials: DN
authors.lastname: Herndon
mesh_terms: D000293:Adolescent; D000367:Age Factors; D015415:Biomarkers / Q000097:blood; D001786:Blood Glucose / Q000378:metabolism; D001823:Body Composition / Q000187:drug effects; D002056:Burns / Q000097:blood / Q000150:complications* / Q000401:mortality / Q000628:therapy; D002153:Calorimetry, Indirect; D002648:Child; D002675:Child, Preschool; D016207:Cytokines / Q000097:blood; D004734:Energy Metabolism / Q000187:drug effects; D005260:Female; D006801:Humans; D006943:Hyperglycemia / Q000097:blood / Q000175:diagnosis / Q000188:drug therapy* / Q000209:etiology; D007004:Hypoglycemic Agents / Q000494:pharmacology / Q000627:therapeutic use*; D007223:Infant; D007231:Infant, Newborn; D007328:Insulin / Q000494:pharmacology / Q000627:therapeutic use*; D008099:Liver / Q000187:drug effects / Q000502:physiology; D008297:Male; D015233:Models, Statistical; D053580:Muscle Strength / Q000187:drug effects; D016896:Treatment Outcome
chemical_list: D015415:Biomarkers; D001786:Blood Glucose; D016207:Cytokines; D007004:Hypoglycemic Agents; D007328:Insulin