Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting

Impact of the insulin and glucose content of the postoperative fluid on the outcome after pediatric cardiac surgery

INTRODUCTION

The aim of this study was to investigate the role of the insulin and glucose content of the maintenance fluid in influencing the outcomes of pediatric patients undergoing heart surgery.

METHODS

A total of 2063 consecutive pediatric patients undergoing cardiac surgery were screened between 2003 and 2008. A dextrose and an insulin propensity-matched group were constructed. In the dextrose model, 5% and 10% dextrose maintenance infusions were compared below 20 kg of weight.

RESULTS

A total of 171 and 298 pairs of patients were matched in the insulin and glucose model, respectively. Mortality was lower in the insulin group (12.9% vs. 7%, p = 0.049). The insulin group had longer intensive care unit (ICU) stay [days, 10.9 (5.8-18.4) vs. 13.7 (8.2-21), p = 0.003], hospital stay [days, 19.8 (13.6-26.6) vs. 22.7 (17.6-29.7), p < 0.01], duration of mechanical ventilation [hours, 67 (19-140) vs. 107 (45-176), p = 0.006], and the incidence of severe infections (18.1% vs. 28.7%, p = 0.01) and dialysis (11.7% vs. 24%, p = 0.001) was higher. In the dextrose model, the incidence of pulmonary complications (13.09% vs. 22.5%, p < 0.01), low cardiac output (17.11% vs. 30.9%, p < 0.01), and severe infections (10.07% vs. 20.5%, p < 0.01) was higher, and the duration of the hospital stay [days, 16.4 (13.1-21.6) vs. 18.1 (13.8-24.6), p < 0.01] was longer in the 10% dextrose group.

CONCLUSIONS

Insulin treatment appeared to decrease mortality, and lower glucose content was associated with lower occurrence of adverse events.

Postoperative hyperglycemia and atrial fibrillation after coronary artery bypass graft surgery

BACKGROUND

Postoperative atrial fibrillation (AF) is a common complication following coronary artery bypass grafting (CABG). We investigated the risk factors for postoperative AF and analyzed the relationship between blood sugar concentration (BS) and AF after CABG.

METHODS AND RESULTS

A total of 199 consecutive patients who underwent isolated CABG were retrospectively examined and classified according to the presence (n=95) or absence (n=104) of postoperative AF. On univariate analysis mean postoperative BS (P<0.001), postoperative drainage volume (P<0.001), age (P=0.034), presence of diabetes mellitus (DM; P=0.004), and postoperative estimated glomerular filtration rate (P=0.032) were significant risk factors for postoperative AF. On multivariate analysis mean postoperative BS (OR, 1.041; 95% CI: 1.008-1.079; P<0.001), postoperative drainage volume (OR, 1.003; 95% CI: 1.001-1.006; P=0.001), and age (OR, 1.040; 95% CI: 1.002-1.083; P=0.041) were significant risk factors for postoperative AF. Postoperative AF often occurred in patients with high postoperative BS, irrespective of DM. The BS cut-off that predicted postoperative AF occurrence was 180 mg/dl. A strong positive correlation existed between the time of the maximum postoperative BS and AF onset time (ρ=0.746).

CONCLUSIONS

Mean postoperative BS and postoperative drainage volume are risk factors for AF after CABG. AF was strongly associated with maximum postoperative BS. Intensive glycemic control could reduce AF occurrence after CABG.

Near-euglycemia can be achieved safely in pediatric total pancreatectomy islet autotransplant recipients using an adapted intravenous insulin infusion protocol

BACKGROUND

Children with severe chronic pancreatitis may undergo total pancreatectomy with islet autotransplantation (TPIAT) to relieve pain while minimizing the risk of postsurgical diabetes. Because overstimulation of transplanted islets by hyperglycemia can result in β-cell loss, we developed a specialized intravenous insulin infusion protocol (IIP) for pediatric TPIAT recipients to maintain euglycemia or near-euglycemia posttransplant.

SUBJECTS AND METHODS

Our objective was to review glucose control using an IIP specific for TPIAT recipients at a single institution. We reviewed postoperative blood glucose (BG) levels for 32 children 4-18 years old with chronic pancreatitis who underwent TPIAT between July 2011 and June 2013. We analyzed the proportion of BG values in the range of 70-140 mg/dL, mean glucose, glucose variability, and occurrence of hypoglycemia during the IIP; we also evaluated the transition to subcutaneous therapy (first 72 h with multiple daily injections [MDI]).

RESULTS

During IIP, the mean patient BG level was 116±27 mg/dL, with 83.1% of all values in the range of 70-140 mg/dL. Hypoglycemia was rare, with only 2.5% of values <70 mg/dL. The more recent era (n=16) had a lower mean BG and less variability than the early era (first 16 patients) (P≤0.004). Mean glucose level (116 vs. 128 mg/dL) and glucose variability were significantly lower during the IIP compared with MDI therapy (P<0.0001).

CONCLUSIONS

Tight glycemic control without excessive severe hypoglycemia was achieved in children undergoing TPIAT using an IIP specifically designed for this population; the ability to maintain BG in target range improved with experience with the protocol.

Predictors of infections following cranioplasty: a retrospective review of a large single center study

Introduction. The variables that predispose to postcranioplasty infections are poorly described in the literature. We formulated a multivariate model that predicts the risk of infection in patients undergoing cranioplasty. Method. Retrospective review of all patients who underwent cranioplasty following craniectomy from January, 2000, to December, 2011. Tested predictors were age, sex, diabetic status, hypertensive status, reason for craniectomy, urgency status of craniectomy, location of cranioplasty, reoperation for hematoma, hydrocephalus postcranioplasty, and material type. A multivariate logistic regression analysis was performed. Results. Three hundred forty-eight patients met the study criteria. Infection rate was 26.43% (92/348). Of these cases with infection, 56.52% (52/92) were superficial (supragaleal), 43.48% (40/92) were deep (subgaleal), and 31.52% (29/92) were present in both the supragaleal and subgaleal spaces. The predominant pathogen was coagulase-negative staphylococcus (30.43%) followed by methicillin-resistant Staphylococcus aureus (22.83%) and methicillin-sensitive Staphylococcus aureus (15.22%). Approximately 15.22% of all cultures were polymicrobial. Multivariate analysis revealed convex craniectomy, hemorrhagic stroke, and hydrocephalus to be associated with an increased risk of infection (OR = 14.41; P < 0.05, OR = 4.33; P < 0.05, OR = 1.90; P = 0.054, resp.). Conclusion. Many of the risk factors for infection after cranioplasty are modifiable. Recognition and prevention of the risk factors would help decrease the infection's rate.

The 100 most cited publications in cardiac surgery: a bibliometric analysis

INTRODUCTION

This study is a citation analysis of the top 100 most cited papers in adult cardiac surgery. Bibliometric analyses are viewed as a proxy marker of a paper's influence and, therefore, an analysis of the most influential papers published in recent decades.

METHODS

Impact factor ranking as of 2012 was used to decide which journals to include in our searches. The Thompson Reuters Web of Knowledge was used to search for citations of all papers relevant to cardiac surgery within selected journals. Journals in the areas of surgery, cardiothoracic surgery, general medicine, anaesthesia, perfusion and pathology were included.

RESULTS

The most frequently cited paper was found to be that of Nashef et al. (Eur J Cardiothorac Surg 16(1):9-13, 1999) introducing the EuroSCORE operative risk evaluation system. A number of authors including Alderman, Carpentier and Cox had more than one paper in the top 100.

CONCLUSION

Despite the potential flaws with bibliometric analysis, and its application to cardiac surgery, there is inherent merit in an analysis of this type.

Impact of perioperative glycemic control strategy on patient survival after coronary bypass surgery

BACKGROUND

Glycemic control in the perioperative period decreases mortality and morbidity, but data are scarce with regard to the effects of glucose control approaches on survival. We assessed long-term survival in patients treated with 2 strategies of glucose control after first-time isolated coronary artery bypass graft.

METHODS

In a previously published trial, patients were prospectively randomized to strict (90-120 mg/dL) or liberal (121-180 mg/dL) glucose control protocols. The aim of this study was to assess long-term data on survival and health-related quality of life based on the original prospective randomized study population.

RESULTS

No differences were found in cumulative survival between the strict (95.5%) and liberal (93.5%) target range groups (log-rank = 0.32, p = 0.57) over a mean follow-up of 40.0 ± 4.4 months. Physical health-related quality of life significantly improved in all patients from baseline to 6 months after surgery (F = 17.73, p < 0.001), and there were no differences in improvement of health-related quality of life between the 2 target range groups (F = 0.15, p = 0.70).

CONCLUSIONS

These results support our previous findings and indicate that a liberal glycemic control strategy after coronary artery bypass leads to survival rates and improvements in health-related quality of life that are similar to those achieved with a strict target range. In addition, the liberal strategy is superior in glucose control and target range management.

Glycemic instability of non-diabetic patients after spine surgery: a prospective cohort study

PURPOSE

Blood glucose (BG) dysregulation is a well-known condition for patients sustaining medical adverse events, such as sepsis or myocardial infarction. However, it has never been described following spine surgery. Our purpose was to assess postoperative glycemic dysregulation of non-diabetic patients undergoing spine surgery and determine if this is related to any complications within a 3-month postoperative period.

METHODS

All the non-diabetic patients undergoing spine surgery in our center were prospectively included over a 6-month period. BG capillary measures were collected from the preoperative fasting period to the end of postoperative Day 3, six times a day. Patients were followed for 3 months after surgery.

RESULTS

Data collected from 75 patients were eventually analyzed. A significant increase of BG level was observed from the preoperative to the second postoperative hour (P < 0.0001), remaining significantly elevated until Day 3 (P < 0.0001). Significant correlations were found between perioperative factors (age, smoking, revision status, instrumentation, operation time, blood loss and transfusion) and glycemic parameters. Day 2 mean BG level was found significantly higher for patients surgically revised than those not revised (P = 0.04).

CONCLUSIONS

Non-diabetic patients experience a statistically significant increase in BG levels in the first 3 days following a spine surgery. This increase in BG might be correlated with postsurgical complications.

Pharmacotherapy for Hyperglycemia in Noncritically Ill Hospitalized Patients

In Brief Hyperglycemia in the hospital setting affects 38-46% of noncritically ill hospitalized patients. Evidence from observational studies indicates that inpatient hyperglycemia, in patients with and without diabetes, is associated with increased risks of complications and mortality. Substantial evidence indicates that correction of hyperglycemia through insulin administration reduces hospital complications and mortality in critically ill patients, as well as in general medicine and surgery patients. This article provides a review of the evidence on the different therapies available for hyperglycemia management in noncritically ill hospitalized patients.

Hyperglycemia After Cardiac Surgery

Background

The Surgical Care Improvement Project #4 (SCIP#4) performance measure is used to evaluate achievement of target blood glucose control after cardiac surgery.

Objectives

The purpose of this study was to identify patient characteristics and outcomes in patients undergoing cardiac surgery who met the SCIP#4 performance measure versus those who did not.

Methods

A retrospective case-control design was used.

Results

Preoperative hemoglobin A1C (HbA1C) level and history of diabetes were 2 major risk factors for failing to meet the SCIP#4 measure. A trend toward a longer length of stay was observed, mortality was 3 times more prevalent, and renal failure was 4 times more frequent in patients who did not meet the SCIP#4 quality measure.

Conclusions

Not meeting the SCIP#4 measure is associated with adverse outcomes. History of diabetes and preoperative HbAIC level should be considered when evaluating strategies for managing postsurgical hyperglycemia.

Protective effects of tight glucose control during cardiopulmonary bypass on myocardium in adult nondiabetic patients undergoing valve replacement

BACKGROUND

In this study, we aimed to evaluate the protective effect of tight glucose control during cardiopulmonary bypass on myocardium in adult nondiabetic patients undergoing isolated aortic valve replacement in a prospective and randomized trial.

METHODS

Sixty-five adult nondiabetic patients undergoing selective isolated aortic valve replacement were enrolled and randomly assigned to an insulin group (patients received a continuous insulin infusion during surgery; n = 33) or a control group (patients were not administered insulin unless their blood glucose level exceeded 200 mg/dL; n = 32). Cardiac troponin I was assayed preoperatively, and then at 2, 6, 12, 24, and 48 hours after aortic cross-declamping. The pre-, intra-, and postoperative relevant data of all selected patients were analyzed.

RESULTS

Tight glucose control reduced postoperative peak release by 48% for cardiac troponin I compared with the control group (0.48 ± 0.12 vs 0.71 ± 0.17 ng/mL; P < 0.0001). Patients with continuous insulin infusion had lower peak inotropic score during the first postoperative 24 hours and peak level of blood glucose (5.8 ± 2.2 vs 8.2 ± 3.1 μg/kg/min; P < 0.0001; 131.9 ± 23.8 vs 191.1 ± 38.5 mg/dL; P < 0.001, respectively), shorter duration of mechanical ventilation and intensive care unit stay and hospital stay compared with the control group (11.6 ± 2.9 hours vs 14.8 ± 3.5 hours; P = 0.0002; 28.4 ± 7.2 hours vs 36.5 ± 7.8 hours; P < 0.0001; 9.4 ± 3.3 days vs 11.5 ± 4.2 days; P = 0.0283, respectively).

CONCLUSIONS

Tight glucose control during cardiopulmonary bypass might provide myocardial protection in adult nondiabetic patients undergoing isolated aortic valve replacement.

New insights into insulin: The anti-inflammatory effect and its clinical relevance

Hyperglycemia, a commonly exhibited metabolic disorder in critically ill patients, activates the body’s inflammatory defense mechanism, causing the waterfall release of numerous inflammatory mediators and cytokines, and eventually leads to organ damage. As the only glucose-lowering hormone in the body, insulin not only alleviates the detrimental effects of hyperglycemia through its metabolic regulation, but also directly modulates inflammatory mediators and acts upon immune cells to enhance immunocompetence. In this sense, hyperglycemia is pro-inflammatory whereas insulin is anti-inflammatory. Therefore, during the past 50 years, insulin has not only been used in the treatment of diabetes, but has also been put into practical use in dealing with cardiovascular diseases and critical illnesses. This review summarizes the recent advances regarding the anti-inflammatory effects of insulin in both basic research and clinical trials, with the hope of aiding in the design of further experimental research and promoting effective insulin administration in clinical practice.

Anaesthesia and pancreatic surgery: Techniques, clinical practice and pain management

Pancreatic cancer continues to pose a major public health concern. The incidence of the disease is nearly equivalent to the death rate associated with the diagnosis of pancreatic cancer. Thus, there exists a need for continued improvement in the diagnostic, therapeutic and palliative care of these patients. There have been significant advances made over the years in the areas of critical care, anesthesia, and surgical technique, which have led to improved mortality rates and survival after resection for pancreatic cancer. Resections are performed with the goals of negative margins and minimal blood loss and referral to high-volume centers and surgeons is encouraged. However, 5-year survival rate after curative resection still remains at less than 20%. Perioperative management of pancreatic and periampullary cancer poses a considerable challenge to the pancreatic surgeon, anesthesiologist and the intensive care team. Major morbidity is often secondary to pancreatic anastomotic leakage and fistula or infection. The anesthesiologist plays a crucial role in the perioperative management of such patients and in the pain control. Pancreatic ductal adenocarcinoma has a high rate of neural invasion (80%-100%) and can be associated with moderate to severe pain. In the recent past, new information has emerged on many issues including preoperative biliary drainage, nutritional support, cardiovascular assessment, perioperative fluid therapy and hemodynamic optimization. Careful patient selection and appropriate preoperative evaluation can greatly contribute to a favorable outcome after major pancreatic resections.

Interventions for coronary artery disease (surgery vs angioplasty) in diabetic patients

Patients with diabetes develop more widespread and more severe atherosclerotic coronary artery disease than patients without diabetes. Medical management of this coronary disease is inferior to revascularization for more complex or more widespread disease. Revascularization by percutaneous intervention (PCI) for patients with diabetes is associated with high mortality and complication rates. Surgical revascularization by coronary artery bypass grafting, yields superior results to PCI for patients with diabetes and coronary artery disease. Patients with diabetes benefit from the same medical management of their coronary artery disease and secondary risk modification as patients without diabetes.

Role of surgical revascularization in diabetic patients with coronary artery disease

Diabetes is a well-known risk factor for morbidity and mortality associated with coronary artery disease. Currently, diabetics represent approximately a quarter of patients requiring coronary revascularization in the USA. The purpose of this article is to review and analyze the available data in surgical revascularization of diabetic patients with coronary artery disease. The review will also examine new developments in myocardial revascularization and assess their probable impact on the long-term outcome of diabetic patients.

Diabetes and cardiovascular disease: from evidence to clinical practice - position statement 2014 of Brazilian Diabetes Society

There is a very well known correlation between diabetes and cardiovascular disease but many health care professionals are just concerned with glycemic control, ignoring the paramount importance of controlling other risk factors involved in the pathogenesis of serious cardiovascular diseases. This Position Statement from the Brazilian Diabetes Society was developed to promote increased awareness in relation to six crucial topics dealing with diabetes and cardiovascular disease: Glicemic Control, Cardiovascular Risk Stratification and Screening Coronary Artery Disease, Treatment of Dyslipidemia, Hypertension, Antiplatelet Therapy and Myocardial Revascularization. The issue of what would be the best algorithm for the use of statins in diabetic patients received a special attention and a new Brazilian algorithm was developed by our editorial committee. This document contains 38 recommendations which were classified by their levels of evidence (A, B, C and D). The Editorial Committee included 22 specialists with recognized expertise in diabetes and cardiology.

Performance of the Medtronic Sentrino continuous glucose management (CGM) system in the cardiac intensive care unit

BACKGROUND

Maintaining glucose in the target range, while avoiding hypoglycemia, is challenging in critically ill patients. We investigated the performance and safety of Medtronic Sentrino, a newly developed continuous glucose management (CGM) system for critically ill adults.

METHODS

This was a prospective, single-center, single-arm, open-label study in adult patients with cardiac ICU admission. Sentrino subcutaneous glucose sensors were inserted into patients' thigh with planned study participation of 72 h. Sensor glucose results were displayed, and the system's alerts and alarms fully enabled. Reference blood glucose was collected from central venous catheter and analyzed with a blood gas analyzer. Treatment decisions were made independently of sensor glucose values, according to the existing standard of care.

RESULTS

A total of 21 patients were enrolled; all successfully completed the study. Sensor glucose values were displayed 96% of the time, and 870 paired blood glucose-sensor glucose points were analyzed. Overall mean absolute relative difference (MARD) was 12.8% (95% CI 11.9% to 13.6%). No clinically significant differences in accuracy were seen within subgroups of hemodynamic status (MARD 12.3% and 13.1% for compromised vs stable hemodynamics). Consensus grid analysis showed >99% of sensor glucose values within A/B zones. No device or study-related adverse events were reported. 100% of clinicians found Sentrino easy to use after two patients.

CONCLUSIONS

In our single-center experience, Sentrino CGM system demonstrated good accuracy and reliability, with no device-related adverse events in critically ill cardiac patients, and was easy to use and integrate in the cardiac ICU.

TRIAL REGISTRATION NUMBER

NCT01763567.

A novel glucose-insulin infusion maintains perioperative glycaemic control through multiple transitions of care

To measure the efficacy of the Glucose-Insulin Infusion--Parkland Protocol (GIPPr) compared to subcutaneous (SC) insulin, blood glucose readings were reviewed in diabetic adults admitted for surgical intervention of a soft tissue or bone infection in Dallas, Texas. Hypoglycaemia occurred in 0.69% of readings in GIPPr-treated patients compared to 4.52% in SC-treated patients. The GIPPr maintained a higher proportion of blood glucose readings between 3.89-10 mmol/L compared to SC insulin (85.40% versus 50.68%).

Management of the hospitalized patient with type 1 diabetes mellitus

Patients with type 1 diabetes mellitus (T1DM) have minimal to absent pancreatic β-cell function and rely on the exogenous delivery of insulin to obtain adequate and life-sustaining glucose homeostasis. Maintaining glycemic control is challenging in hospitalized patients with T1DM, as insulin requirements are influenced by the presence of acute medical or surgical conditions, as well as altered nutritional intake. The risks of hyperglycemia, ketoacidosis, hypoglycemia, and glycemic variability are increased in hospitalized patients with T1DM. Diabetic ketoacidosis and severe hypoglycemia are the 2 most common emergency conditions that account for the majority of hospital admissions in patients with T1DM. The association between hyperglycemia and increased risk of complications and mortality in patients with type 2 diabetes (T2DM) is well established; however, the impact of glycemic control on clinical outcomes has not been determined in patients with T1DM who present without ketoacidosis. To decrease complications associated with insulin therapy, health care professionals must be well versed in the use of insulin because it is a common source of medication error. For non-critically ill, hospitalized patients, subcutaneous insulin given to cover basal and prandial needs instead of sliding scale is the preferred method of insulin dosing. Protocols are available for initiating and titrating insulin doses, as well as for transitioning from an insulin infusion to a subcutaneous regimen. In our review, we identify and discuss special considerations related to inpatient glycemic control of non-ketotic patients with T1DM. Additionally, point differences and similarities associated with the management of patients with T2DM are discussed.

Accuracy of a first-generation intravenous blood glucose monitoring system in subjects with diabetes mellitus: a multicenter study

BACKGROUND

Hyperglycemia and hypoglycemia in hospitalized patients have been associated with increased morbidity and mortality. Improvements in glucose monitoring technology may be helpful in the clinical management of critically ill patients with abnormal glucose levels. A first-generation intravenous blood glucose monitoring (IVBG) system was developed to facilitate glycemic control therapy in hospitalized patients. A nonrandomized, single-arm, multicenter study was performed to evaluate the safety and accuracy of the IVBG system in insulin-treated subjects with diabetes mellitus.

METHODS

The IVBG system is a bedside monitor that automatically measures venous blood glucose (BG) concentration. In this study, BG was measured every 7.5 min by the IVBG system. Reference samples [venous blood samples measured on the Yellow Springs Instruments (YSI) glucose analyzer] were drawn every 15 min during inpatient studies on days 1, 2, and 3. Fifty insulin-treated healthy volunteers with diabetes were studied, and a maximum of 72 reference samples were collected. Effectiveness was primarily evaluated by assessing the proportion of IVBG BG measurements within the 15 mg/dl or 20% criterion [15 mg/dl (for YSI <75 mg/dl) or 20% (for YSI ≥75 mg/dl)] compared with YSI. Adverse events and adverse device effects were evaluated.

RESULTS

A total of 95% of all IVBG values were within the 15 mg/dl or 20% criterion. The IVBG system BG measurement showed significant linear relationship with the laboratory YSI standard. Catheter insertion site irritation was mild and infrequent. No serious adverse events were reported. A total of 33% of the sensors were replaced during the 3-day use due to problematic IV lines or sensor/system errors.

CONCLUSIONS

This clinical performance evaluation demonstrates that the IVBG system provides accurate and safe continuous BG measurements in healthy insulin-treated patients with diabetes.

Alcohol consumption improves insulin signaling in the myocardium

BACKGROUND

In a previous study, we demonstrated that swine with metabolic syndrome treated with alcohol had improved insulin signaling. We developed a follow-up study to evaluate the effects of alcohol on ischemic myocardium in animals without metabolic syndrome.

METHODS

Fourteen Yorkshire swine underwent placement of an ameroid constrictor to induce chronic myocardial ischemia. Postoperatively, one group was supplemented with ethanol (ETOH), and one group was supplemented with sucrose (SUC) daily to normalize caloric intake. After 7 weeks, all animals underwent dextrose challenge and harvest of nonischemic and ischemic myocardium. Tissues were analyzed for protein expression and histologic analysis.

RESULTS

There was no difference in body mass index, serum glucose or insulin levels. However, ethanol supplementation up-regulated phosphoinostitide 3-kinase, phosphorylated protein kinase B, protein kinase B, and phosphorylated Forkhead Box 01 expression, which may promote insulin signaling, and down-regulated inhibitors of insulin signaling pIRS1 and pIRS2. There was no difference in intramyocardial glycogen but there was increased GLUT4 expression in the ETOH group, which may promote glucose use.

CONCLUSION

Despite similar serum glucose and insulin levels, alcohol consumption up-regulates the insulin signaling pathway in the absence of metabolic syndrome in both nonischemic and chronically ischemic myocardium. These results suggest that alcohol selectively up-regulates the insulin signaling pathway despite normoglycemia.

Intensity of peri-operative glycemic control and postoperative outcomes in patients with diabetes: a meta-analysis

AIMS

Peri-operative hyperglycemia is a risk factor for postoperative morbidity and mortality. However, the role of specific glycemic targets in reducing this risk has not been defined, particularly among patients with diabetes. Thus, our objective was to conduct a meta-analysis relating distinct peri-operative glycemic targets and postoperative outcomes in patients with diabetes.

METHODS

A systematic review was performed by two authors utilizing pre-specified terms: "diabetes mellitus" and "perioperative" and "mortality" and "blood glucose" or "strict glucose control" or "intensive insulin therapy" in PUBMED, CENTRAL and EMBASE. Glycemic control was considered strict when perioperative targets ranged between 100 and 150mg/dL (5.6-8.3mmol/l), moderate when the targets ranged between 150 and 200mg/dL 8.3-11.1mmol/l), and liberal when the target was >200mg/dL (11.1mmol/l). The data were combined utilizing the Dersimoan-Laird random-effects method. The primary endpoint was postoperative mortality with secondary endpoints of postoperative atrial fibrillation, wound infection, and stroke.

RESULTS

The literature search yielded 760 studies, of which only 6 met inclusion criteria. When compared with a liberal target, pooled data showed that a moderate glycemic target was associated with reduced postoperative mortality (OR=0.48, 95% CI 0.24-0.76) and stroke (OR=0.61, 95% CI 0.38-0.98), but no differences in atrial fibrillation or wound infection were found. There were no significant differences in postoperative outcomes between moderate versus strict perioperative glycemic target.

CONCLUSIONS

Pooled results suggest that in patients with diabetes, a moderate peri-operative glycemic target (150-200mg/dl [5.6-8.3mmol/l]) is associated with reduction in postoperative mortality and stroke compared with a liberal target (>200mg/dl [11.1mmol/l]), whereas no significant additional benefit was found with more strict glycemic control (<150mg/dl [5.6mmol/l]).

Revisiting tight glycemic control in perioperative and critically ill patients: when one size may not fit all

Glycemic control has received intense scrutiny in the last decade as an important aspect of patient care. Earlier studies suggested that tight glycemic control (target level of 80 - 110 mg/dL) improved outcomes in intensive care unit (ICU) patients. Subsequent trials did not confirm the same benefit. Moreover, increased mortality was found in association with such tight control compared with a less strict target. As a result, tight glucose control has become less popular. The interaction between diabetic status and outcomes in relation to glucose control strategies and/or chronic glycemic state in perioperative and critically ill patients was examined. Tight glucose control appears to be more beneficial in patients without diabetes than in those with known diabetes. It also may be more beneficial in improving outcomes in surgical rather than nonsurgical ICU patients, and in decreasing sepsis rather than mortality. Tight glycemic control was associated with a high incidence of hypoglycemia, which may offset some of its potential benefits. Tight glycemic control in the perioperative and intensive care settings should not be totally abandoned either as a clinical practice or as a subject of future research. Beneficial effects of tight glycemic control may be demonstrated when the appropriate glycemic targets are matched to the appropriate population.

Analysis: New point-of-care blood glucose monitoring system for the hospital demonstrates satisfactory analytical accuracy using blood from critically ill patients--an important step toward improved blood glucose control in the hospital

Patients managed in the intensive care units (ICUs) and general wards of the hospital experience a high incidence of hyperglycemia, hypoglycemia, and glycemic variability, despite significant hospital resources devoted to glucose control. Optimized glucose meters and monitoring systems are required to improve the safety and efficacy of insulin delivery and glucose control in the hospital. Safe insulin dosing requires timely and accurate glucose measurements, especially during dynamic changes in nutrition, insulin sensitivity, and physiological stress. In the current issue of Journal of Diabetes Science and Technology, Mitsios and coauthors describe the analytical accuracy of the new Accu-Check® Inform II blood glucose (BG) monitoring system commercialized by F. Hoffmann-La Roche Ltd. The point-of-care glucose meter achieved the desired degree of accuracy and precision, as defined by Clinical and Laboratory Standards Institute POCT12-A3 guidelines when evaluated using venous blood from 600 critically ill patients from multiple ICUs at two medical centers. Venous whole blood samples were used to obtain glucose meter results in duplicate. The remaining blood sample was centrifuged to obtain plasma for central hospital laboratory testing using the hexokinase method within 5 min of meter testing. A total of 98.8% of the 1200 Accu-Check Inform II meter's glucose values were within ± 12.5% (± 12 mg/dl) of the mean laboratory glucose value, and 99.8% were within ± 20% (± 20 mg/dl), thus meeting the Clinical and Laboratory Standards Institute criteria. Future studies are required to evaluate the clinical performance of the new BG monitoring system in the intended-use patient populations and critical care environments, using arterial, peripheral venous, central venous, and capillary blood samples.

Effects of intensive glycemic control on outcomes of cardiac surgery

OBJECTIVES

To investigate the effects of postoperative intensive glycemic control on patient outcomes.

BACKGROUND

Ineffective perioperative glycemic control has been associated with high mortality and morbidity rates among cardiac surgery patients.

METHODS

212 cardiac surgery patients were allocated by a quasi-experimental design to: a) a control group (n = 107) with targeted blood glucose levels 161-200 mg/dl or b) a therapy group (n = 105) with blood glucose target 120-160 mg/dl. We compared the two groups on their mortality, length of stay, duration of intubation, incidence of severe hypoglycemia and frequency of postoperative infections.

RESULTS

The mean postoperative blood glucose levels were significantly lower for the therapy group compared with the control group (153.9 mg/dl vs. 173.9 md/dl, p < 0.001). The intensive glycemic control was strongly associated with decreased in-hospital mortality (7 deaths/105 patients for the control group vs. 1 death/105 patients for the therapy group; p = 0.033). We did not identify any statistically significant associations regarding the other patient outcomes.

CONCLUSIONS

This randomized quasi-experimental trial found lower in-hospital mortality with more intense blood glucose control. Effective postoperative glycemic control did not affect the other studied patient outcomes.

Change in the perioperative blood glucose and blood lactate levels of non-diabetic patients undergoing coronary bypass surgery

In the present study, a retrospective analysis of the trends and factors affecting blood glucose and blood lactate levels was carried out for non-diabetic adult patients who had undergone coronary artery bypass graft (CABG) surgery. Between October 2009 and October 2011, 200 non-diabetic adult patients undergoing CABG surgery were examined. Glucose and lactic acid levels were observed successively during surgery [following the induction of anesthesia, cardio-pulmonary bypass (CPB), aortic cross-clamping and aortic stop flow infusion], at the end of surgery and after surgery [1, 6, 12, 24 and 48 h after admission to the intensive care unit (ICU)]. The results of blood gas analyses and other related indicators for trend analysis were investigated. The peak blood glucose and blood lactate levels during CPB, as well as other CPB factors, were also analyzed. Following aortic cross-clamping, intraoperative blood glucose and blood lactate levels increased gradually with increasing operative time. Postoperatively, blood glucose and blood lactate levels continued to rise. Blood glucose and blood lactic acid levels during CPB were positively correlated. The blood glucose and blood lactate levels of non-diabetic adult patients undergoing CABG increased gradually with operative time following aortic cross-clamping. Moreover, blood glucose and blood lactate levels were positively correlated with the duration of CPB and duration of aortic cross-clamping.

Randomized study comparing a Basal-bolus with a basal plus correction insulin regimen for the hospital management of medical and surgical patients with type 2 diabetes: basal plus trial

OBJECTIVE

Effective and easily implemented insulin regimens are needed to facilitate hospital glycemic control in general medical and surgical patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

This multicenter trial randomized 375 patients with T2D treated with diet, oral antidiabetic agents, or low-dose insulin (≤ 0.4 units/kg/day) to receive a basal-bolus regimen with glargine once daily and glulisine before meals, a basal plus regimen with glargine once daily and supplemental doses of glulisine, and sliding scale regular insulin (SSI).

RESULTS

Improvement in mean daily blood glucose (BG) after the first day of therapy was similar between basal-bolus and basal plus groups (P = 0.16), and both regimens resulted in a lower mean daily BG than did SSI (P = 0.04). In addition, treatment with basal-bolus and basal plus regimens resulted in less treatment failure (defined as >2 consecutive BG >240 mg/dL or a mean daily BG >240 mg/dL) than did treatment with SSI (0 vs. 2 vs. 19%, respectively; P < 0.001). A BG <70 mg/dL occurred in 16% of patients in the basal-bolus group, 13% in the basal plus group, and 3% in the SSI group (P = 0.02). There was no difference among the groups in the frequency of severe hypoglycemia (<40 mg/dL; P = 0.76).

CONCLUSIONS

The use of a basal plus regimen with glargine once daily plus corrective doses with glulisine insulin before meals resulted in glycemic control similar to a standard basal-bolus regimen. The basal plus approach is an effective alternative to the use of a basal-bolus regimen in general medical and surgical patients with T2D.

Microcirculation and its relation to continuous subcutaneous glucose sensor accuracy in cardiac surgery patients in the intensive care unit

OBJECTIVE

Continuous glucose monitoring could be helpful for glucose regulation in critically ill patients; however, its accuracy is uncertain and might be influenced by microcirculation. We investigated the microcirculation and its relation to the accuracy of 2 continuous glucose monitoring devices in patients after cardiac surgery.

METHODS

The present prospective, observational study included 60 patients admitted for cardiac surgery. Two continuous glucose monitoring devices (Guardian Real-Time and FreeStyle Navigator) were placed before surgery. The relative absolute deviation between continuous glucose monitoring and the arterial reference glucose was calculated to assess the accuracy. Microcirculation was measured using the microvascular flow index, perfused vessel density, and proportion of perfused vessels using sublingual sidestream dark-field imaging, and tissue oxygenation using near-infrared spectroscopy. The associations were assessed using a linear mixed-effects model for repeated measures.

RESULTS

The median relative absolute deviation of the Navigator was 11% (interquartile range, 8%-16%) and of the Guardian was 14% (interquartile range, 11%-18%; P = .05). Tissue oxygenation significantly increased during the intensive care unit admission (maximum 91.2% [3.9] after 6 hours) and decreased thereafter, stabilizing after 20 hours. A decrease in perfused vessel density accompanied the increase in tissue oxygenation. Microcirculatory variables were not associated with sensor accuracy. A lower peripheral temperature (Navigator, b = -0.008, P = .003; Guardian, b = -0.006, P = .048), and for the Navigator, also a higher Acute Physiology and Chronic Health Evaluation IV predicted mortality (b = 0.017, P < .001) and age (b = 0.002, P = .037) were associated with decreased sensor accuracy.

CONCLUSIONS

The results of the present study have shown acceptable accuracy for both sensors in patients after cardiac surgery. The microcirculation was impaired to a limited extent compared with that in patients with sepsis and healthy controls. This impairment was not related to sensor accuracy but the peripheral temperature for both sensors and patient age and Acute Physiology and Chronic Health Evaluation IV predicted mortality for the Navigator were.

Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program

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 effectiveness of insulin-related glucose control (worst 180-250 mg/dL, best <130 mg/dL) and adverse outcomes.

CONCLUSIONS

Perioperative hyperglycemia was associated with adverse outcomes in general surgery patients with and without diabetes. However, patients with hyperglycemia who received insulin were at no greater risk than those with normal blood glucoses. Perioperative glucose evaluation and insulin administration in patients with hyperglycemia are important quality targets.

Inpatient glycemic control: best practice advice from the Clinical Guidelines Committee of the American College of Physicians

Hyperglycemia is associated with poor outcomes in hospitalized medical and surgical patients. Although some early evidence showed benefits of intensive insulin therapy (IIT), recent evidence does not show a consistent benefit and even shows harm associated with the use of IIT. The overuse of some therapeutic interventions and the resulting harms to a patient are an important component of unnecessary health care costs. The goal of this article is to address the management of hyperglycemia and evaluate the benefits and harms associated with the use of IIT to achieve tight glycemic control in hospitalized patients with or without diabetes mellitus. This article is based on the evidence review and the guideline developed by the American College of Physicians on this topic. Best Practice Advice 1: Clinicians should target a blood glucose level of 7.8 to 11.1 mmol/L (140 to 200 mg/dL) if insulin therapy is used in SICU/MICU patients. Best Practice Advice 2: Clinicians should avoid targets less than 7.8 mmol/L (<140mg/dL) because harms are likely to increase with lower blood glucose targets.

Intensive glucose control and hypoglycaemia: a new cardiovascular risk factor?

Intensive glucose control is widely practiced in patients with diabetes mellitus and patients acutely admitted to hospitals with concomitant stress-induced hyperglycaemia. Such a strategy increases the risk of hypoglycaemia by several-fold. Hypoglycaemia leads to a surge in catecholamine levels with a profound haemodynamic response. In patients with a decreased cardiac reserve, such significant changes can culminate in serious or even fatal cardiovascular outcomes. This review is aimed at discussing in depth the evidence to date that links hypoglycaemia with cardiovascular mortality, reviewing the likely mechanisms underlying this association, as well as summarising these from a cardiologist's perspective.

The impact of hypoglycaemia on patients admitted to hospital with medical emergencies

AIMS

To quantify the frequency of biochemical hypoglycaemia in acutely unwell patients in the medical assessment unit and relate this to their subsequent outcomes.

METHODS

A retrospective audit was conducted on all emergency medical patients attending the medical assessment unit between November 2010 and April 2011. Capillary blood glucose measurements were obtained and electronically stored for all patients. Admission details, presence of diabetes, type of diabetes and treatment, length of stay in hospital and death in hospital were obtained from the hospital clinical coding data and electronic discharge summary. The incidence of hypoglycaemia in patients with and without diabetes was quantified. The mean age, length of stay and percentage of death in hospital were compared between groups with and without hypoglycaemia.

RESULTS

One hundred and thirty-eight (9.5%) patients with diabetes and 70 (2.7%) patients without diabetes had an episode of hypoglycaemia in the medical assessment unit. Patients with diabetes and hypoglycaemia on admission had a significantly longer length of stay (mean ± sd) (10.3 ± 11.2 vs. 7.3 ± 9.5 days, P = 0.001) and higher rate of hospital mortality (14.5 vs. 5.2%, P < 0.001) compared with those without hypoglycaemia. Patients without diabetes with hypoglycaemia had a longer length of stay (mean ± sd) (9.1 ± 10.5 vs. 6.7 ± 9.9 days, P = 0.05) and a higher rate of hospital mortality (24.3 vs. 5.4%, P < 0.001) compared with those without hypoglycaemia.

CONCLUSION

Hypoglycaemia is associated with an increased length of stay in hospital and an increased in-hospital mortality rate. Hypoglycaemia may have contributed to the poorer outcome, but would also appear to be a marker of disease severity in unwell patients, especially patients with sepsis.

[Insulin therapy among inpatients]

To identify patients with known diabetes or hospital-related hyperglycemia. To establish blood glucose targets according to patient's clinical state. To draw up protocols by using basal, bolus (nutritional/prandial), and supplemental insulin and not "sliding scale insulin". To avoid hypoglycaemia particularly during intravenous insulin protocols in intensive care unit. To set up glucose monitoring with a regular training of medical staff. To perform HbA1c during hospital stay to plan the treatment after discharge. To organize follow-up of the patients with hospital-related hyperglycemia.