Preconditioning with glucose-insulin-potassium solution and restoration of myocardial function during coronary surgery (original) (raw)
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Role of Glucose-Insulin-Potassium solution for myocardial protection during open-heart surgery
Southern Medical Journal, 2021
The purpose of this review was to verify the function and potential mechanisms of glucose-insulin-potassium (GIK) solution infusion in cardiac surgery with regard to cardiac protection. Myocardial damage is associated with cardiac surgical procedures involving hypothermic cardiac arrest and cardiopulmonary bypass (CPB). One of the most critical targets for cardiac surgery during anesthesia is to reduce myocardial damage.In terms of cardiac morbidity and mortality, effective intraoperative cardiac protection primarily defines postoperative outcomes. Well studied techniques and recognized cardiac safety methods do have some drawbacks in their functions. One solution to this issue is increased metabolic assistance, intended to minimize perceived ischemic injury.In practical use, many modern techniques such as glucose insulin potassium infusion are still restricted in terms of their added efficacy in cardiac protection. Providing glucose and insulin to the critically ischaemic cell has ...
European Journal of Cardio-Thoracic Surgery, 2006
Glucose-insulin-potassium (GIK) solutions have been used in cardiac surgery for more than 40 years. At that time, membrane-polarizing and stabilizing effects on cardiomyocyte's action potential were regarded the main benefit. Two meta-analyses described methodological flaws in the early studies (e.g., case numbers, randomization principles, and levels of significance), and came to clearly different recommendations with regard to the usage of GIK in the therapy of acute myocardial function. During the 70s, as promising therapies for the treatment of AMI had become available (e.g., b-blockers and thrombolytic agents), the GIK technique was more widely introduced in cardiac surgery, e.g., during valve replacement. At present, 74 of 91 studies provide convincing evidence for the beneficial effects of insulin and/or GIK in cardiac surgery that go far beyond simple metabolic benefits and also include better recovery of myocardial tissue after ischemia. Yet, the exact underlying mechanisms remain still unknown. In this review article, two questions will be answered: why did GIK not become daily routine in cardiac surgery in spite of positive results from clinical studies, and does this technique merit more acceptance among the potential users? In view of the increasing number of older patients at higher risk, the demand for improving surgical procedures has renewed the interest in the GIK concept. The more recent literature suggests that the entire potential of GIK solutions has not been fully disclosed. A large single or multicenter trial with sound endpoints is mandatory.
Myocardial protection with Glucose-Insulin-Potassium infusion during adult cardiac surgery
Pakistan Journal of Medical Sciences, 2017
Background & Objective: Recent meta-analysis reports have called for more randomized trials to evaluate the effectiveness of GIK solution in patients of cardiac surgery. So this study was conducted to evaluate the effectiveness of Glucose-insulin-potassium (GIK) solutions in non-diabetic patients undergoing coronary artery bypass grafting. Methods: A total number of one hundred and sixty (160) patients were randomized into two equal groups; GIK Group and non-GIK group. In GIK group, 5% dextrose containing 70 IU/L regular insulin and 70 meq/L of potassium was administered. The infusion was started at a rate of 30 ml/hour after induction of anesthesia and before the start of cardiopulmonary bypass. The infusion was started again after removal of aortic cross clamp and was continued for six hours after the operation. Results: In early post-operative period, peak CKMB levels were high in non-GIK group 48.50±19.79 IU/L versus 33.40±14.69 IU/L in GIK group (p-value <0.001). There was no statistically significant difference in requirements of inotropic support between the groups. The mean duration of inotropic support in GIK group was only 5.50±6.88 hours in GIK group and 8.64±7.74 hours in non-GIK group (p-value 0.008). Mean ventilation time in GIK group was 5.06±2.39 hours versus 6.55±3.58 hours in non-GIK group (p-value 0.002). Similarly, ICU stay period was also shorter in GIK group (p-value 0.01). We did not found any detrimental effect of GIK infusion on non-cardiac complications e.g. renal, pulmonary and neurologic complications. Conclusion: Glucose-insulin-potassium (GIK) infusion has a beneficial role in myocardial protection and is associated with better post-operative outcomes without increasing the risk of non-cardiac complications.
Journal of Bashir Institute of Health Sciences
Background: Glucose-insulin-potassium (GIK) infusion is most commonly used in diabetic patients during cardiopulmonary bypass. Many studies suggest that the use of GIK infusion has beneficial outcomes mainly in myocardial protection, as myocardial protection is the main goal of Perfusionist during bypass surgery. In Pakistan, GIK is used normally in the diabetic patient as it has a good effect on insulin maintenance. Most surgeons use GIK in diabetic patients but many of the studies suggest that it has good post-op outcomes especially in myocardial protection. Method: This was an observational cross-sectional study conducted for 6 months, from November 2019 to April 2020 at the Pakistan Institute of medical sciences department of Cardiac surgery. Ethical approval was taken from the hospital ethical committee. It was consisting of 80 patients, 40 from group A (GIK infused) and 40 from group B (GIK non-infused) by using the Non-probability convenient sampling technique. Data was colle...
Journal of Clinical Monitoring and Computing, 2019
Heart failure is the main cause of poor outcome following open heart surgery and experimental studies have demonstrated that glucose-insulin-potassium (GIK) infusion exerts cardioprotective effects by reducing myocardial ischemia-reperfusion injuries. This randomized controlled trial was designed to assess the effects of GIK on left ventricular function in moderateto-high risk patients undergoing on-pump isolated coronary artery bypass surgery (CABGS), or combined with aortic valve replacement. The primary outcomes were the effects of GIK on two-and three-dimensional left ventricular ejection fraction (2D and 3D-LVEF), and on transmitral flow propagation velocity (Vp), that occurred between the pre-and post-CPB periods. GIK administration was associated with favorable interaction effects (p < 0.001) on 2D-LVEF, 3D-LVEF and Vp changes over the study periods. In GIK pretreated patients (N = 54), 2-D and 3D-LVEF and Vp increased slightly during surgery (mean difference [MD] + 3.5%, 95% confidence interval [95% CI] − 0.2 to 7.1%, MD + 4.0%, 95% CI 0.6-7.4%, and MD + 22.2%, 95% CI 16.0-28.4%, respectively). In contrast, in the Placebo group (N = 46), 2D-and 3D-LVEF, as well as Vp all decreased after CPB (MD − 7.5% [− 11.6 to − 3.4%], MD − 12.0% [− 15.2 to − 8.8%] and MD − 21.3% [− 25.7 to − 16.9%], respectively). In conclusion, the administration of GIK resulted in better preservation of systolic and diastolic ventricular function in the early period following weaning from CPB.
Seminars in Thoracic and Cardiovascular Surgery
The infusion of glucose-insulin-potassium (GIK) has yielded conflicting results in terms of cardioprotective effects. We conducted a meta-analysis to examine the impact of perioperative GIK infusion in early outcome after cardiac surgery. Randomized controlled trials (RCTs) were eligible if they examined the efficacy of GIK infusion in adults undergoing cardiac surgery. The main study endpoint was postoperative myocardial infarction (MI) and secondary outcomes were hemodynamics, any complications and hospital resources utilization. Subgroup analyses explored the impact of the type of surgery, GIK composition and timing of administration. Odds ratio (OR) or mean difference (MD) with 95% confidence interval (CI) were calculated with a random-effects model. Fifty-three studies (n=6129) met the inclusion criteria. Perioperative GIK infusion was effective in reducing MI (k=32 OR 0.66[0.48, 0.89] P=0.0069), acute kidney injury (k=7 OR 0.57[0.4, 0.82] P=0.0023) and hospital length of stay (k=19 MD-0.89[-1.63,-0.16] days P=0.0175). Postoperatively, the GIK-treated group presented higher cardiac index (k=14 MD 0.43[0.29, 0.57] L/min P<0.0001) and lesser hyperglycemia (k=20 MD-30[-47,-13] mg/dL P=0.0005) than in the usual care group. The GIK-associated protection for MI was effective when insulin infusion rate exceeded 2 mUI/kg/min and after coronary artery bypass surgery. Certainty of evidence was low given imprecision of the effect estimate, heterogeneity in outcome definition and risk of bias. Perioperative GIK infusion is associated with improved early outcome and reduced hospital resource utilization after cardiac surgery. Supporting evidence is heterogenous and further research is needed to standardize the optimal timing and composition of GIK solutions.
British Journal of Anaesthesia, 2013
† Effects of glucoseinsulin-potassium (GIK) infusion on myocardial damage during coronary artery surgery were studied. † Biomarkers of myocardial damage were measured after reperfusion of the heart in patients with or without the ongoing infusion. † GIK attenuated the levels of creatinine kinase-MB and troponin-T. † This study provides biochemical evidence of myocardial protective role of GIK infusion. Background. The aim of this randomized and controlled trial was to investigate the effect of a glucose-insulin-potassium (GIK) solution on myocardial protection in acute coronary syndrome (ACS) patients undergoing urgent multivessel off-pump coronary artery bypass (OPCAB) surgery. Methods. Sixty-six patients were randomly allocated either to receive 0.3 ml kg 21 h 22 GIK solution (potassium 80 mEq and regular insulin 325 IU in 500 ml of 50% glucose) or equivalent volume of normal saline (control) upon anaesthetic induction until 6 h after reperfusion. The primary endpoints were to compare the concentrations of creatine kinase-MB (CK-MB) and troponin-T between the groups after reperfusion. The secondary endpoints were to compare the incidences of postoperative troponin-T .0.8 ng ml 21 and myocardial infarction (MI) between the groups. Results. Highest CK-MB [8.7 (4.4) vs 13.1 (7.9) ng ml 21 , P¼0.006] and troponin-T [0.20 (0.13-0.49) vs 0.48 (0.18-0.91) ng ml 21 , P,0.0001] values after reperfusion were significantly lower in the GIK group compared with the control group. The area under the curve of serially measured troponin-T was also significantly smaller in the GIK group compared with the control group [0.83 (0.43-1.81) vs 0.46 (0.31-1.00), P¼0.036]. Significantly fewer patients in the GIK group showed troponin-T .0.8 ng ml 21 after reperfusion compared with the control group (3 vs 11, P¼0.033). The incidence of postoperative MI was similar between the groups. Conclusions. GIK administration in ACS patients undergoing urgent multivessel OPCAB significantly attenuated the degree of ensuing myocardial injury without complications related to glycaemic control. Clinical Trial Registry. URL: http://clinicaltrials.gov/ct2/show/NCT01384656?term=GIK+ AND+OPCAB&rank=1. Unique identification number NCT01384656.
Journal of the American Heart Association, 2020
Background-Laboratory studies demonstrate glucose-insulin-potassium (GIK) as a potent cardioprotective intervention, but clinical trials have yielded mixed results, likely because of varying formulas and timing of GIK treatment and different clinical settings. This study sought to evaluate the effects of modified GIK regimen given perioperatively with an insulin-glucose ratio of 1:3 in patients undergoing cardiopulmonary bypass surgery. Methods and Results-In this prospective, randomized, double-blinded trial with 930 patients referred for cardiac surgery with cardiopulmonary bypass, GIK (200 g/L glucose, 66.7 U/L insulin, and 80 mmol/L KCl) or placebo treatment was administered intravenously at 1 mL/kg per hour 10 minutes before anesthesia and continuously for 12.5 hours. The primary outcome was the incidence of in-hospital major adverse cardiac events including all-cause death, low cardiac output syndrome, acute myocardial infarction, cardiac arrest with successful resuscitation, congestive heart failure, and arrhythmia. GIK therapy reduced the incidence of major adverse cardiac events and enhanced cardiac function recovery without increasing perioperative blood glucose compared with the control group. Mechanistically, this treatment resulted in increased glucose uptake and less lactate excretion calculated by the differences between arterial and coronary sinus, and increased phosphorylation of insulin receptor substrate-1 and protein kinase B in the hearts of GIK-treated patients. Systemic blood lactate was also reduced in GIK-treated patients during cardiopulmonary bypass surgery. Conclusions-A modified GIK regimen administered perioperatively reduces the incidence of in-hospital major adverse cardiac events in patients undergoing cardiopulmonary bypass surgery. These benefits are likely a result of enhanced systemic tissue perfusion and improved myocardial metabolism via activation of insulin signaling by GIK.
Therapy with insulin in cardiac surgery: controversies and possible solutions
The Annals of Thoracic Surgery, 2003
Insulin has been used in the treatment of patients undergoing cardiac surgery or suffering from acute myocardial infarction. Most of these investigations have demonstrated that the metabolic cocktail consisting of glucoseinsulin-potassium (GIK) improves recovery of function and outcome after cardiac surgery and substantially reduces mortality of patients with acute myocardial infarction. There is also evidence suggesting that insulin is not effective under these conditions, as demonstrated in a recent large randomized trial in cardiac surgery. It is therefore not surprising that insulin or GIK is not used routinely in clinical practice. Many hypotheses have been advanced to explain the effects of insulin and GIK but none of them has enjoyed convincing support. In cardiac surgery the many different application protocols described make it difficult to compare the results. The application of GIK after cardiac surgery may be complicated by severe disturbances in glucose or potassium homeostasis. In this article we review the literature in this field, addressing the areas of controversy. We discuss the different mechanisms suggested and we propose potential solutions. We conclude that a multifactorial mechanism is likely to explain the effects of insulin or GIK after ischemia and we propose that in a practical sense the application of high-dose insulin during reperfusion, utilizing a newly described, direct nonmetabolic effect, is a convincing concept. We will further demonstrate our clinical experience in establishing a protocol for putting this concept into clinical practice.