Postoperative hyperglycaemia of diabetic patients undergoing cardiac surgery - a clinical audit (original) (raw)
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Diabetes Care, 2016
The management of postoperative hyperglycemia is controversial and generally does not take into account pre-existing diabetes. We analyzed clinical and economic outcomes associated with postoperative hyperglycemia in cardiac surgery patients, stratifying by diabetes status. RESEARCH DESIGN AND METHODS Multicenter cohort study in 4,316 cardiac surgery patients operated on in 2010. Glucose was measured at 6-h intervals for 48 h postoperatively. Outcomes included cost, hospital length of stay (LOS), cardiac and respiratory complications, major infections, and death. Associations between maximum glucose levels and outcomes were assessed with multivariable regression and recycled prediction analyses. RESULTS In patients without diabetes, increasing glucose levels were associated with a gradual worsening of outcomes. In these patients, hyperglycemia (‡180 mg/dL) was associated with an additional cost of 3,192(953,192 (95% CI 1,972 to 4,456), an additional hospital LOS of 0.8 days (0.4 to 1.3), an increase in infections of 1.6% (0.5 to 2.8), and an increase in respiratory complications of 2.6% (0.0 to 5.3). However, among patients with insulin-treated diabetes, optimal outcomes were associated with glucose levels considered to be hyperglycemic (180 to 240 mg/dL). This level of hyperglycemia was associated with cost reductions of 3,192(956,225 (212,886 to 2222), hospital LOS reductions of 1.6 days (23.7 to 0.4), infection reductions of 4.1% (29.1 to 0.0), and reductions in respiratory complication of 12.5% (222.4 to 23.0). In patients with non-insulin-treated diabetes, outcomes did not differ significantly when hyperglycemia was present. CONCLUSIONS Glucose levels <180 mg/dL are associated with better outcomes in most patients, but worse outcomes in patients with diabetes with a history of prior insulin use. These findings support further investigation of a stratified approach to the management of patients with stress-induced postoperative hyperglycemia based on prior diabetes status.
Clinical Effects of Hyperglycemia in the Cardiac Surgery Population: The Portland Diabetic Project
Endocrine Practice, 2006
Objective: To determine the outcome effects of hyperglycemia, and its pharmacologic reduction with continuous intravenous insulin infusions (CII) in the cardiac surgery patient population. Methods: The Portland Diabetic Project is a prospective, non-randomized, observational study of 5,510 consecutive diabetic cardiac surgery patients treated between January 1987 and November 2005 Results: This study was the first to reveal that hyperglycemia in the first 3 postoperative days is independently predictive of mortality (P<0.0001), deep sternal wound infection (P= 0.0001), and increased length of stay (P<0.002) in diabetic cardiac surgery patients. Conversely, CII, designed to achieve predetermined target glucose levels, was shown to independently reduce the risks of death and deep sternal wound infection by 60% and 77%, respectively (P<0.001 for both). Target glucose levels <150mg/dL and a 3-day postoperative duration of CII therapy are both important variables that determine the impact of the CII therapy on improved outcomes. Conclusions: Perioperative hyperglycemia in cardiac surgery patients adversely alters mortality, length of stay, and infection rates. Three days of CII eliminates the incrementally increased risks of these complications previously seen in diabetic patients.
Rationale for glycemic control in cardiac surgical patients: The portland diabetic project
Insulin, 2006
This is a critical abstract of an economic evaluation that meets the criteria for inclusion on NHS EED. Each abstract contains a brief summary of the methods, the results and conclusions followed by a detailed critical assessment on the reliability of the study and the conclusions drawn. Health technology The author investigated the administration of continuous intravenous insulin (CII) in surgical patients with diabetes mellitus. This intervention was compared with subcutaneous (SC) insulin administration. Type of intervention Treatment. Economic study type Cost-effectiveness analysis. Study population The study population comprised patients with diabetes mellitus (including non-insulin and insulin-dependent diabetes mellitus) who were undergoing open-heart surgical procedures such as coronary artery bypass grafting (CABG) and isolated valve procedures. Setting The study setting was tertiary care. The economic study was undertaken in Portland, USA. Dates to which data relate The effectiveness and resource data were derived from patients enrolled in the study between 1987 and 2004. The price year was not stated. Source of effectiveness data The effectiveness data were derived from a single study. Link between effectiveness and cost data The costing study was undertaken prospectively on the same patient sample as that used in the effectiveness study.
Endocrine Practice, 2004
Objective: To describe the main findings of the Portland Diabetic Project, which elucidates the adverse relationship between hyperglycemia and outcomes of cardiac surgical procedures in patients with diabetes and delineates the protective effects of intravenous insulin therapy in reducing those adverse outcomes. Results: In this ongoing 17-year prospective, nonrandomized, interventional study of 4,864 patients with diabetes who underwent an openheart surgical procedure, we investigated the effects of hyperglycemia, and its subsequent reduction by continuous intravenous insulin (CII) therapy, on in hospital outcomes. Increasing blood glucose levels were found to be directly associated with increasing rates of death, deep sternal wound infections (DSWI), length of hospital stay (LOS), and hospital cost. In separate multivariate analyses, increasing hyperglycemia was found to be independently predictive of increasing mortality (P<0.0001), DSWI (P = 0.017), and LOS (P<0.002). Conversely, CII therapy, designed to achieve predetermined target blood glucose levels, independently reduced the risks of death and DSWI by 57% and 66%, respectively (P<0.0001 for both). Target blood glucose levels of less than 150 mg/dL and a 3day postoperative duration of CII therapy are both important variables that determine the effect of the CII therapy on improved outcomes. Coronary artery bypass graftingrelated mortality (2.5%) and DSWI rates (0.8%) in patients with diabetes were normalized to those of the nondiabetic population by the use of the Portland CII Protocol. Conclusion: Perioperative hyperglycemia in patients undergoing a cardiac surgical procedure affects biochemical and physiologic functions, which, in turn, adversely alter mortality, LOS, and infection rates. The Portland CII Protocol is a costefficient method that effectively eliminates hyperglycemia and reduces postoperative morbidity and mortality in patients with diabetes undergoing an openheart operation. CII protocols should be the standard care for glycometabolic control in all patients undergoing cardiac surgical procedures. 2 Abbreviations: AHA = American Heart Association; 3BG = 3day average postoperative blood glucose; CABG = coronary artery bypass grafting; CII = continuous intravenous insulin; DSWI deep sternal wound infection; ICU = intensivecare unit; LOS = length of hospital stay; OR = odds ratio; RR = relative risk; SQI = subcutaneous insulin.
The Journal of Clinical Endocrinology & Metabolism, 2010
The impairment of insulin sensitivity, a marker of surgical stress, is important for outcomes. Objective: The aim was to assess the association between the quality of preoperative glycemic control, intraoperative insulin sensitivity, and adverse events after cardiac surgery. Design and Setting: We conducted a prospective cohort study at a tertiary care hospital. Subjects: Nondiabetic and diabetic patients scheduled for elective cardiac surgery were included in the study. Based on their glycosylated hemoglobin A (HbA 1c), diabetic patients were allocated to a group with good (HbA 1c Ͻ6.5%) or poor (HbA 1c Ͼ6.5%) glycemic control. Intervention: We used the hyperinsulinemic-normoglycemic clamp technique. Main Outcome Measures: The primary outcome was insulin sensitivity measurement. Secondary outcomes were major complications within 30 d after surgery including mortality, myocardial failure, stroke, dialysis, and severe infection (severe sepsis, pneumonia, deep sternal wound infection). Other outcomes included minor infections, blood product transfusions, and the length of intensive care unit and hospital stay. Results: A total of 143 nondiabetic and 130 diabetic patients were studied. In diabetic patients, a negative correlation (r ϭ Ϫ0.527; P Ͻ 0.001) was observed between HbA 1c and intraoperative insulin sensitivity. Diabetic patients with poor glycemic control had a greater incidence of major complications (P ϭ 0.010) and minor infections (P ϭ 0.006). They received more blood products and spent more time in the intensive care unit (P ϭ 0.030) and the hospital (P Ͻ 0.001) than nondiabetic patients. For each 1 mg ⅐ kg Ϫ1 ⅐ min Ϫ1 decrease in insulin sensitivity, the incidence of major complications increased (P ϭ 0.004). Conclusions: In diabetic patients, HbA 1c levels predict insulin sensitivity during surgery and possibly outcome. Intraoperative insulin resistance is associated with an increased risk of complications, independent of the patient's diabetic state.
High Incidence of Insulin Resistance and Dysglycemia Amongst Nondiabetic Cardiac Surgical Patients
The Annals of Thoracic Surgery, 2012
Background. Undiagnosed glycometabolic dysfunction is prominent amongst nondiabetic cardiac surgical patients, whereas perioperative dysglycemia is associated with adverse outcomes. This study assessed whether the preoperative level of insulin resistance predicts the degree of perioperative dysglycemia in nondiabetic, normoglycemic cardiac surgical patients.