Supplementary Material
Incidence and impact outcome of hyperglycemia in severe scorpion
envenomed children requiring intensive care admission.
Kamilia Chtara1, Mabrouk Bahloul1, Olfa Turki1, Najeh Baccouche1, Kais Regaieg1, Chokri Ben
Hamida1, Hedi Chelly1, Imen Chabchoub2, Anis Chaari1, Mounir Bouaziz1.
1. Service de réanimation médicale, CHU Habib Bourguiba Sfax-Tunisie.
2. Service de pédiatrie générale, CHU Hedi Chaker Sfax-Tunisie.
Correspondence to:
Professor Mabrouk Bahloul
Service de Réanimation médicale.
Hôpital Habib Bourguiba
Route el Ain Km 1 3029 Sfax
Tunisie.
Tel: 0021698698267
Fax: 00 216 74 242 621
E-mail: bahloulmab@yahoo.fr
Key Words: scorpion envenomation, children, pulmonary edema, hyperglycemia, outcome
Statistics
Data were entered centrally by medical personnel using the SPSS version 18.0 for Windows.
Categorical data were expressed in proportion and subgroups and continuous variables were
expressed as means (± SD). We analyzed the comparability of two groups (with and without
hyperglycaemia) by the χ2 test (or Fisher's exact test), the two-group t-test, or the Mann–
Whitney-U test, as appropriate. The level of significance was set at p < 0.05.
Table E1. Laboratory data at admission of all study population and in each
group.
Parameters
Global
Population
(n=626)
Hyperglycemia Hyperglycemia
group
free group
(n=316)
(n=310)
p
Sodium (mmol/l)
140 ± 6
140 ± 6.1
140 ± 5.6
0.18
Potassium (mmol/l)
4.1 ± 0.7
4.12 ± 0.73
4.24 ± 0.61
0.041
Glycemia on ICU
admission
Glycemia 24 hours after
on ICU admission
Plasma proteins (g/l)
11.6 ± 6
16.07 ± 5.3
7.1 ± 1.6
<0.0001
7.9 ± 3.8
8.7 ± 4.3
6.6 ± 2
<0.0001
69.9 ± 8.8
70.4 ± 9.2
69.4 ± 8.3
0.16
Leucocytes (cells / mm3)
17787 ± 8034
19414 ± 8656
16038 ± 6906
<0.0001
Hb (g/dl)
12.4 ± 1.8
12.4 ± 1.7
12.4 ± 1.9
0.95
Blood urea (mmol/l)
7.12 ± 3.2
7.12 ± 3.6
7.12 ± 2.9
0.98
Blood creatinine (µmol/l)
pH
84
± 67
81
± 25
85
± 76
0.88
7.33 ± 0.10
7.33 ± 0.11
7.33 ± 0.09
0.65
PaO2 (mmHg)
137 ± 75
143 ± 78
132 ± 72
0.47
PaO2/FiO2 ratio
279 ± 145
287 ± 150
271 ± 142
0.69
PCO2 (mmHg)
34 ± 10
35.1 ± 10
34.4 ± 9.6
0.56
Hb: haemoglobin concentration, PaCo2: arterial carbon dioxide tension, Pa O2 : arterial oxygen
tension , MV: mechanical ventilation
Biological glycemia (mmol/l) on ICU admission
Figure E 1. Correlations between PRISM score on ICU admission and
Biological glycemia on ICU admission (P < .05, r = 0.39)
PRISM Score on ICU admission
Figure E 2. Correlations between leukocytes levels on ICU admission and Biological
glycemia on ICU admission (P < .05, r = 0.25)
Figure E 3. Comparison of glycemia between hyperglycemia and normoglycemia
groups on ICU admission and 24 hours later. (Medians are represented as black lines; 25th
to 75th percentiles, as boxes; and ranges, as error bars.)
P<0.001
P<0.001
Figure E 4. Comparison of glycemia between deaths and survivors groups on ICU
admission and 24 hours later. (Medians are represented as black lines; 25th to 75th
percentiles, as boxes; and ranges, as error bars.)
Supplementary Discussion
Our study showed that hyperglycemia is frequently observed in severe scorpion envenomation
in children requiring ICU admission. Moreover, it showed that compared to normoglycemic
patients, hyperglycemic patients had a significantly increased mortality rate, respiratory
failure, use of mechanical ventilation, pulmonary edema and the use of inotropes. Moreover,
it showed that ICU stay was significantly higher in the hyperglycemic group in comparison
with the hyperglycemia free group.
The correlation between the young age and the severity of clinical manifestations after
scorpion envenomation is well-established. In fact, the signs and symptoms of envenomation
are usually more severe in children, especially younger ones. Multiple organ failure (MOF)
among scorpion envenomated children has reported by many investigators.
Scorpion envenoming syndrome results in a severe autonomic storm with a massive release of
catecholamines, increased levels of angiotensin II, an increase in glucagon, cortisol, thyroid
hormones; either suppressed insulin levels or hyperinsulinaemia (insulin resistance), increased
circulating free fatty acid levels. The rise in the counter-regulatory hormones (glucagon,
cortisol, and catecholamines) opposes the anabolic actions of insulin resulting in a variety of
clinical manifestations leading to hyperglycemia. These changes may lead to a syndrome of
fuel-energy deficits and to an inability of the vital organs to utilise the existing metabolic
substrates, ultimately resulting in multisystem organ failure (MSOF) and death.
In our study, more than 50% of the analysed population developed hyperglycemia on ICU
admission. Moreover, we founded that the presence of hyperglycemia was associated with the
severity of clinical manifestations on ICU admission. In fact the presence of hyperglycemia
was associated with the presence of respiratory failure, pulmonary edema, hemodynamic
instability, multisystem organ failure, an increased mortality and an increased of ICU length
stay. Moreover, the presence of hyperglycemia was associated with an increase of nosocomial
infection.
The pediatric risk of mortality (PRISM) score has been widely used as a severity score in
critically ill children, in various clinical situations. Moreover, it was established that this score
predict outcome in severe scorpion envenomation in children. In our study, we founded a
significantly association between PRISM score and the presence of hyperglycemia. In fact
hyperglycemia was more observed in severe cases of scorpion envenomation.
Although hyperleukocytosis is often described after scorpion envenomation, its correlation
with a poor outcome after scorpion envenomation was rarely reported in the literature. In our
study, we founded a good association a high value of leucocytes levels and the presence of
hyperglycemia. This association may be explained by two mechanisms. The first is the stress
due to the envenomation and the release of corticosteroids and catecholamines. The second is
the liberation of cytokines (TNF-alpha, IL-1b, IL-6, IL-8) secondary to the envenomation.
These two mechanisms lead to hyperglycemia and hyperleukocytosis.
Study limitations.
All retrospective studies suffer from incomplete or inconsistent information. The species of
scorpion was not identified in our records. Moreover the proportion of patients receiving
steroids is significantly higher in the hyperglycemia group. However, the proportion of
patients receiving steroids before and/or on ICU admission was increased in two groups (82
% vs 91%). For this reason we think that hyperglycemia is essentially due to the severity of
scorpion envenomation.