Glycemic Control in Cardiac Surgery (original) (raw)
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Predictors of hyperglycemia after cardiac surgery in nondiabetic patients
The Journal of Thoracic and Cardiovascular Surgery, 2013
Objective: Postoperative hyperglycemia is associated with poor clinical outcomes in patients undergoing cardiac surgery. However, some experts consider hyperglycemia to be an epiphenomenon related to acute stress. We investigated whether preoperative patient characteristics can predict hyperglycemia after cardiac surgery in nondiabetic patients. Methods: This is a retrospective study of nondiabetic patients undergoing cardiac surgery at a single center during the years 2004 to 2009. Hyperglycemia was defined as 2 consecutive blood glucose readings of 150 mg/dL or greater during the 72 hours after cardiac surgery. Results: This study included 1453 patients with hyperglycemia and 2205 patients without hyperglycemia. Hyperglycemic patients were older, were more likely to be men, had higher body mass index, were more likely to be hypertensive and hypercholesterolemic, and had lower left ventricular ejection fractions; in addition, a greater proportion had a history of cardiovascular disease and renal failure. Multivariate logistic regression analysis showed age, gender, body mass index, preoperative serum creatinine, left ventricular ejection fraction, previous cardiac surgery, and preoperative cardiogenic shock to be independently associated with hyperglycemia (P<.05 for all). Hyperglycemic patients had more intraoperative and postoperative complications. Conclusions: Preoperative patient characteristics are associated with hyperglycemia after cardiac surgery.
Glucose Homeostasis during the Perioperative Period of Cardiac Surgery: A Narrative Review Citation
Carbognani. Glucose Homeostasis during the Perioperative Period of Cardiac Surgery: A Narrative Review. Cardiology and Cardiovascular Medicine 5 (2021): 36-46. Abstract Hyperglycemia and insulin resistance are frequent in intensive care patients and have been associated with worse outcomes. The control of blood glucose levels has an impact on the morbidity and mortality of intensive care patients. The authors focused on the perioperative period of cardiac surgery and reviewed the various mechanisms that contribute to hyperglycemia, such as surgical trauma, heparinization, cooling, rewarming and cardioplegia. The consequences of perioperative hyperglycemia in terms of morbidity and mortality, and the possible management strategies (including GIK, GIN and normoglycemic hyperinsulinism) were also reviewed.
Perioperative glycemic control and its outcome in patients following open heart surgery
Annals of Cardiac Anaesthesia
Background: Diabetes is not uncommon in patients requiring cardiac surgery. These patients have a higher incidence of morbidity and mortality. Subsequently, diabetes represents a major medico-economic problem in both developed and developing countries. This study was designed to observe the association between glycemic control and outcome of patients after open heart surgery in adult population. Materials and Methods: Data was collected retrospectively in all patients who underwent open cardiac surgery (coronary artery bypass grafting, valve, or bypass grafting with valve surgery) and survived 72 hours postoperatively and had diabetes. The study was conducted from January 2015 to December 2016. Results: Of the 129 patients included in the study, male dominated 101 (78.3%). Most frequent surgery was coronary artery bypass grafting (CABG) 123 (95.3%), CABG plus aortic valve replacement 4 (3.1%), and CABG plus mitral valve replacement 2 (1.6%). Considering diabetes, only 3 (2.3%) were on diet control, 112 (86.8%) on oral hypoglycemic agents (OHA), whereas 9 (7%) had control on both insulin and OHA. Only 5 (3.9%) had type I diabetes. The mean fasting blood sugar (FBS) was 154.58 g/dl, and the mean duration of diabetic mellitus was observed 12.32 years. Microvascular and macrovascular complications were 26/129 (20.16%) and 17/129 (13.17%), respectively. Total 75 (58.1%) patients did not require insulin and 54 (41.9%) were treated with insulin intraoperatively to keep the blood glucose level less than 200 g/dl. Cardiac arrhythmias were frequent in the insulin group (P < 0.05), which was also associated with increased stay in the cardiac intensive care unit. Conclusion: Inadequate glycemic control during open cardiac surgery can possibly lead to increased perioperative morbidity and mortality and with decreased long-term survival and recurrent ischemic events. Therefore, aiming for blood glucose levels around 140 mg/dl appears reasonable. Further studies are required to define specific glucose ranges for a clearer definition of recommended blood glucose goals in postoperative cardiac patients for the best outcomes in patients with diabetes mellitus.
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.
2012
The purpose of this study was to investigate the effects of three different glycemic control conditions (tight, conventional, and standard) in the intraoperative period on: 1) postoperative surgical site infections, and 2) postoperative procalcitonin, and C-reactive protein levels in patients undergoing open-heart surgery. Secondary aims of the study were to investigate the effects of the three glycemic treatment conditions on: 1) intraoperative blood glucose; 2) intraoperative glycemic stability; and 3) intensive care unit length of stay, in patients undergoing open-heart surgery. An experimental design with a multilevel, single factor, within-subjects design was utilized. Patients were nested within anesthesia provider teams. The design was counterbalanced by means of a Latin square, where each of three anesthesia provider teams dispensed each of three glycemic control conditions once. Thirty-seven participants were randomized to either tight glycemic control (n =15), which maintained blood glucose 110-149 mg/dl via continuous intravenous insulin infusion, conventional glycemic control (n = 11), which maintained blood glucose 150-180 mg/dl via continuous intravenous insulin infusion, or standard glycemic control (n =11) which maintain blood glucose 150-180 mg/dl via intravenous bolus injections of insulin. The main findings of this study were that there were no significant differences between the three glycemic interventional treatment groups in 1) thirty-day surgical site infections, 2) postoperative C-reactive protein or procalcitonin concentrations 3) intensive care unit length of stay, 4) intraoperative blood glucose levels, or 5) glycemic vii stability. An association between intraoperative peak blood glucose and surgical site infection was established. Participants that experienced higher peak blood glucose levels intraoperatively exhibited increased surgical site infections. Procalcitonin levels were significantly elevated in participants that experienced a surgical site infection, but Creactive protein showed no significant difference between participants with or without a surgical site infection. Coronary artery bypass graft surgery concomitant with valve replacement surgery was associated with a higher rate of surgical site infections compared coronary artery bypass graft surgery or valve surgery independently. In conclusion, an association was found between higher peak intraoperative blood glucose levels and increased surgical site infections, therefore maintaining intraoperative blood glucose levels below 180 mg/dl via a continuous intravenous infusion of insulin, may reduce postoperative surgical site infections in the open-heart patient. The use of tight glycemic control during the intraoperative period can be achieved safely, with the use of judicious protocols, but its benefits remain unproven. Inflammatory biomarker procalcitonin was predictive of infection, where C-reactive protein was not. The addition of procalcitonin to routine postoperative blood work, in open-heart patients, may benefit providers in the diagnosis and early treatment of surgical site infections. This study was underpowered. Further studies with appropriate sample size, may be able to determine if tight glycemic control, compared to moderate glycemic control, in the intraoperative period is of benefit to patients undergoing open-heart surgery.
Prevalence and Clinical Outcome of Hyperglycemia in the Perioperative Period in Noncardiac Surgery
Diabetes Care, 2010
OBJECTIVE Hospital hyperglycemia, in individuals with and without diabetes, has been identified as a marker of poor clinical outcome in cardiac surgery patients. However, the impact of perioperative hyperglycemia on clinical outcome in general and noncardiac surgery patients is not known. RESEARCH DESIGN AND METHODS This was an observational study with the aim of determining the relationship between pre- and postsurgery blood glucose levels and hospital length of stay (LOS), complications, and mortality in 3,184 noncardiac surgery patients consecutively admitted to Emory University Hospital (Atlanta, GA) between 1 January 2007 and 30 June 2007. RESULTS The overall 30-day mortality was 2.3%, with nonsurvivors having significantly higher blood glucose levels before and after surgery (both P < 0.01) than survivors. Perioperative hyperglycemia was associated with increased hospital and intensive care unit LOS (P < 0.001) as well as higher numbers of postoperative cases of pneumoni...
Diabetes Is Associated With Reduced Stress Hyperlactatemia in Cardiac Surgery
Diabetes care, 2017
Hyperglycemia and hyperlactatemia are associated with increased morbidity and mortality in critical illness. We evaluated the relationship among hyperlactatemia, glycemic control, and diabetes mellitus (DM) after cardiac surgery. This was a retrospective cohort study of 4,098 cardiac surgery patients treated between 2011 and 2015. Patients were stratified by DM and glucose-lowering medication history. Hyperglycemia (glucose >180 mg/dL), hypoglycemia (<70 mg/dL), and the hyperglycemic index (HGI) were assessed postoperatively (48 h). The relationship between lactate and glucose levels was modeled using generalized linear regression. Mortality was analyzed using an extended Cox regression model. Hyperglycemia occurred in 26.0% of patients without DM (NODM), 46.5% with DM without prior drug treatment (DMNT), 62.8% on oral medication (DMOM), and 73.8% on insulin therapy (DMIT) (P < 0.0001). Hypoglycemia occurred in 6.3%, 9.1%, 8.8%, and 10.8% of NODM, DMNT, DMOM, and DMIT, resp...
Journal of Cardiothoracic Surgery, 2011
Background: Hyperglycaemia is a common occurrence during cardiac surgery, however, there remains some uncertainty surrounding the role of tight glycaemic control (blood glucose <180 mg/dL) during and/or after surgery. The aim of this study was to systematically review the literature to determine the effects of tight versus normal glycaemic control, during and after cardiac surgery, on measures of morbidity and mortality. Method: The literature was systematically reviewed, based on pre-determined search criteria, for clinical trials evaluating the effect of tight versus normal glycaemic control during and/or after cardiac surgery. Each paper was reviewed by two, independent reviewers and data extracted for statistical analysis. Data from identified studies was combined using meta-analysis (RevMan5 ® ). The results are presented either as odds ratios (OR) or mean differences (MD) with 95% confidence intervals (CIs). Results: A total of seven randomised controlled trials (RCTs) were identified in the literature, although not all trials could be used in each analysis. Tight glycaemic control reduced the incidence of early mortality (death in ICU) (OR 0.52 [95% CI 0.30, 0.91]); of post-surgical atrial fibrillation (odds ratio (OR 0.76 [95%CI 0.58, 0.99]); the use of epicardial pacing (OR 0.28 [95%CI 0.15, 0.54]); the duration of mechanical ventilation (mean difference (MD) -3.69 [95% CI -3.85, -3.54]) and length of stay in the intensive care unit (ICU) (MD -0.57 [95%CI -0.60, -0.55]) days.
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.
Importance of Perioperative Glycemic Control in General Surgery
Annals of Surgery, 2013
Objective-To determine the relationship of perioperative hyperglycemia and insulin administration on outcomes in elective colon/rectal and bariatric operations. Background-There is limited evidence to characterize the impact of perioperative hyperglycemia and insulin on adverse outcomes in patients, with and without diabetes, undergoing general surgical procedures. Methods-The Surgical Care and Outcomes Assessment Program is a Washington State quality improvement benchmarking-based initiative. We evaluated the relationship of perioperative hyperglycemia (>180 mg/dL) and insulin administration on mortality, reoperative interventions, and infections for patients undergoing elective colorectal and bariatric surgery at 47 participating hospitals between fourth quarter of 2005 and fourth quarter of 2010. Results-Of the 11,633 patients (55.4 ± 15.3 years; 65.7% women) with a serum glucose determination on the day of surgery, postoperative day 1, or postoperative day 2, 29.1% of patients were hyperglycemic. After controlling for clinical factors, those with hyperglycemia had a significantly increased risk of infection [odds ratio (OR) 2.0; 95% confidence interval (CI), 1.63-2.44], reoperative interventions (OR, 1.8; 95% CI, 1.41-2.3), and death (OR, 2.71; 95% CI, 1.72-4.28). Increased risk of poor outcomes was observed both for patients with and without diabetes. Those with hyperglycemia on the day of surgery who received insulin had no significant increase in infections (OR, 1.01; 95% CI, 0.72-1.42), reoperative interventions (OR, 1.29; 95% CI, 0.89-1.89), or deaths (OR, 1.21; 95% CI, 0.61-2.42). A dose-effect relationship was found between the