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Hagerman A, Schorer R, Putzu A, Keli-Barcelos G, Licker M. Cardioprotective Effects of Glucose-Insulin-Potassium Infusion in Patients Undergoing Cardiac Surgery: A Systematic Review and Meta-Analysis. Semin Thorac Cardiovasc Surg 2022; 36:167-181. [PMID: 36356908 DOI: 10.1053/j.semtcvs.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/01/2022] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Andres Hagerman
- Dept. of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Raoul Schorer
- Dept. of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Alessandro Putzu
- Dept. of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Marc Licker
- University of Geneva, Faculty of Medicine, Geneva, Switzerland.
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Pittas AG, Siegel RD, Lau J. Insulin Therapy and In-Hospital Mortality in Critically Ill Patients: Systematic Review and Meta-analysis of Randomized Controlled Trials. JPEN J Parenter Enteral Nutr 2017; 30:164-72. [PMID: 16517961 DOI: 10.1177/0148607106030002164] [Citation(s) in RCA: 68] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hyperglycemia is common in critically ill hospitalized patients and has been associated with adverse outcomes, including increased mortality. In this review, we examine the effect of insulin therapy on mortality in critically ill patients. METHODS We updated our previous systematic review and meta-analysis to include recently published trials that report data on the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. We also include a short primer on the methods of systematic reviews and meta-analyses, outlining the specific steps and challenges of this methodology. We performed an electronic search in the English language of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles for randomized controlled trials that reported mortality data on critically ill hospitalized adult patients treated with insulin (regardless of method of administration). RESULTS We identified 38 relevant studies that entered the analysis. We found that therapy with insulin in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients. The beneficial effect of insulin was evident in the surgical intensive care unit (relative risk [RR], 0.58; confidence interval [CI], 0.22-0.62) and in patients with diabetes (RR, 0.76; CI, 0.62-0.92). There was a trend toward benefit in patients with acute myocardial infarction (RR, 0.89; CI, 0.76-1.03). Targeting euglycemia appears to be the main determinant of the benefit of insulin therapy (RR, 0.73; CI, 0.57-0.94). CONCLUSIONS Insulin therapy in adult patients hospitalized for a critical illness, other than hyperglycemic crises, may decrease mortality in certain groups of patients.
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Affiliation(s)
- Anastassios G Pittas
- Division of Endocrinology, Diabetes and Metabolism and Institute for Clinical Research and Health Policy Studies, Tufts-New England Medical Center, 750 Washington Street #268, Boston, MA 02111, USA.
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Smit JWA, Romijn JA. Acute Insulin Resistance in Myocardial Ischemia: Causes and Consequences. Semin Cardiothorac Vasc Anesth 2016; 10:215-9. [PMID: 16959753 DOI: 10.1177/1089253206291153] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Diabetes mellitus is associated with increased risk for cardiovascular mortality because of multiple pathophysiologic mechanisms. Acute stress-induced hyper-glycemia during acute myocardial infarction has gained much attention, as blood glucose levels seem to be an independent risk factor for acute myocardial infarction–related death. Clinical studies that identify stress-induced hyperglycemia as a risk factor are reviewed and its causes are discussed. They can be summarized as the consequence of acute insulin resistance, which in its turn is caused by stress hormones and by proinflammatory cytokines. Hyperglycemia causes the release of proinflammatory cytokines, the induction of reactive radicals, alterations in cardiovascular substrate metabolism, and propagation of coagulation and apoptosis. These all have harmful effects during and after acute myocardial infarction. Recommendations are for strict glycemic control in hyperglycemic patients with acute myocar-dial infarction, although the target glucose level is still a subject of debate.
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Affiliation(s)
- Johannes W A Smit
- Department of Endocrinology and Metabolic Diseasis, Leiden University Medical Center, RC Leiden, The Netherlands.
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Ujueta F, Weiss EN, Sedlis SP, Shah B. Glycemic Control in Coronary Revascularization. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:12. [PMID: 26820983 DOI: 10.1007/s11936-015-0434-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OPINION STATEMENT Hyperglycemia in the setting of coronary revascularization is associated with increased adverse cardiovascular events in patients with or without diabetes mellitus. Data suggest that acute peri-procedural hyperglycemia causes an increase in inflammation, platelet activity, and endothelial dysfunction and is associated with plaque instability and infarct size. While peri-procedural blood glucose level is an independent predictor of adverse outcomes in patients undergoing coronary revascularization, treatment strategies remain uncertain. Randomized clinical trials of glucose-insulin-potassium infusions have consistently shown no benefit, while those comparing insulin therapy versus standard of care have demonstrated mixed results, likely due to the failure to reach euglycemia with these strategies. Although no glucose-lowering agent has been shown to be superior in peri-procedural glycemic control, the continuation of clinically prescribed long-acting glucose-lowering medications in patients with diabetes mellitus prior to coronary angiography and possible percutaneous coronary intervention may be the simplest and most effective approach to maintain euglycemia and decrease the associated increase in inflammation and platelet activity. However, alternative strategies such as therapies targeted at the underlying mechanism of harm (e.g., more potent anti-platelet therapy, anti-inflammatory therapy) should also be considered and warrant further investigation.
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Affiliation(s)
- Francisco Ujueta
- VA New York Harbor Healthcare System, Manhattan Campus, New York, NY, USA.,New York University School of Medicine, New York, NY, 10016, USA
| | - Ephraim N Weiss
- VA New York Harbor Healthcare System, Manhattan Campus, New York, NY, USA.,New York University School of Medicine, New York, NY, 10016, USA
| | - Steven P Sedlis
- VA New York Harbor Healthcare System, Manhattan Campus, New York, NY, USA.,New York University School of Medicine, New York, NY, 10016, USA
| | - Binita Shah
- VA New York Harbor Healthcare System, Manhattan Campus, New York, NY, USA. .,New York University School of Medicine, New York, NY, 10016, USA.
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Hyperinsulinemic Normoglycemia Does Not Meaningfully Improve Myocardial Performance during Cardiac Surgery: A Randomized Trial. Anesthesiology 2015. [PMID: 26200180 DOI: 10.1097/aln.0000000000000723] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Glucose-insulin-potassium (GIK) administration during cardiac surgery inconsistently improves myocardial function, perhaps because hyperglycemia negates the beneficial effects of GIK. The hyperinsulinemic normoglycemic clamp (HNC) technique may better enhance the myocardial benefits of GIK. The authors extended previous GIK investigations by (1) targeting normoglycemia while administering a GIK infusion (HNC); (2) using improved echocardiographic measures of myocardial deformation, specifically myocardial longitudinal strain and strain rate; and (3) assessing the activation of glucose metabolic pathways. METHODS A total of 100 patients having aortic valve replacement for aortic stenosis were randomly assigned to HNC (high-dose insulin with concomitant glucose infusion titrated to normoglycemia) versus standard therapy (insulin treatment if glucose >150 mg/dl). The primary outcomes were left ventricular longitudinal strain and strain rate, assessed using speckle-tracking echocardiography. Right atrial tissue was analyzed for activation of glycolysis/pyruvate oxidation and alternative metabolic pathways. RESULTS Time-weighted mean glucose concentrations were lower with HNC (127 ± 19 mg/dl) than standard care (177 ± 41 mg/dl; P < 0.001). Echocardiographic data were adequate in 72 patients for strain analysis and 67 patients for strain rate analysis. HNC did not improve myocardial strain, with an HNC minus standard therapy difference of -1.2% (97.5% CI, -2.9 to 0.5%; P = 0.11). Strain rate was significantly better, but by a clinically unimportant amount: -0.16 s (-0.30 to -0.03 s; P = 0.007). There was no evidence of increased glycolytic, pyruvate oxidation, or hexosamine biosynthetic pathway activation in right atrial samples (HNC, n = 20; standard therapy, 22). CONCLUSION Administration of glucose and insulin while targeting normoglycemia during aortic valve replacement did not meaningfully improve myocardial function.
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Ali-Hassan-Sayegh S, Mirhosseini SJ, Zeriouh M, Dehghan AM, Shahidzadeh A, Karimi-Bondarabadi AA, Sabashnikov A, Popov AF. Safety and efficacy of glucose–insulin–potassium treatment in coronary artery bypass graft surgery and percutaneous coronary intervention. Interact Cardiovasc Thorac Surg 2015; 21:667-76. [DOI: 10.1093/icvts/ivv222] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2014] [Accepted: 07/09/2015] [Indexed: 11/13/2022] Open
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Shim JK, Yang SY, Yoo YC, Yoo KJ, Kwak YL. Myocardial protection by glucose–insulin–potassium in acute coronary syndrome patients undergoing urgent multivessel off-pump coronary artery bypass surgery. Br J Anaesth 2013; 110:47-53. [DOI: 10.1093/bja/aes324] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Kalmovich B, Bar-Dayan Y, Boaz M, Wainstein J. Continuous glucose monitoring in patients undergoing cardiac surgery. Diabetes Technol Ther 2012; 14:232-8. [PMID: 22235800 DOI: 10.1089/dia.2011.0154] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES Hyperglycemia is a prominent feature among patients exposed to major stress such as in cardiac surgery. The implementation of a continuous glucose monitoring system (CGMS) for glucose monitoring during cardiac surgery was assessed. SUBJECTS AND METHODS Fifty-nine consecutive patients who underwent cardiac surgery were monitored by CGMS. Patients' fluid glucose content, drug requirements, and hemodynamic and physiologic parameters were evaluated. RESULTS Of the 59 patients, 32 completed the monitoring with CGMS. Patients were divided into three groups: diabetes patients, patients without diabetes history who developed significant hyperglycemia perioperatively, and patients who did not develop hyperglycemia. Hyperglycemia was most frequently observed postoperatively. Hyperglycemic patients required significantly more insulin (81±40 vs. 34±37 units, P=0.005) and experienced an increased early complication rate, although this difference was not significant. CGMS erroneously detected late-phase operative and immediate postoperative hypoglycemia in approximately one-third of patients as reflected from venous blood sample measurements. CONCLUSIONS CGMS enables close monitoring and optimal control of blood glucose among patients undergoing major cardiac surgery, although its reliability is limited during the cardiac surgery phase and in the early postoperative period, because of incorrect hypoglycemic readings.
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Affiliation(s)
- Boaz Kalmovich
- Surgery Department, Wolfson Medical Center, Holon, Israel
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Klein LJ, Visser FC. The effect of insulin on the heart : Part 1: Effects on metabolism and function. Neth Heart J 2011; 18:197-201. [PMID: 20428418 DOI: 10.1007/bf03091761] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Positive inotropic effects of insulin were described early after the isolation of insulin from the pancreas but data on the effect of insulin on the heart are conflicting. Systemic insulin administration results in a reduction in circulating free fatty acids and an improvement in myocardial glucose uptake, which causes an efficiency improvement in the myocardial cell. There is strong evidence that insulin administration results in functional improvement in dysfunctional myocardium. (Neth Heart J 2010;18:197-201.).
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Affiliation(s)
- L J Klein
- Department of Cardiology, VU Medical Centre, Amsterdam, the Netherlands
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Fan Y, Zhang AM, Xiao YB, Weng YG, Hetzer R. Glucose–insulin–potassium therapy in adult patients undergoing cardiac surgery: a meta-analysis. Eur J Cardiothorac Surg 2011; 40:192-9. [DOI: 10.1016/j.ejcts.2010.10.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2010] [Revised: 10/04/2010] [Accepted: 10/07/2010] [Indexed: 01/12/2023] Open
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Rabi D, Clement F, McAlister F, Majumdar S, Sauve R, Johnson J, Ghali W. Effect of perioperative glucose-insulin-potassium infusions on mortality and atrial fibrillation after coronary artery bypass grafting: a systematic review and meta-analysis. Can J Cardiol 2010; 26:178-84. [PMID: 20548978 DOI: 10.1016/s0828-282x(10)70394-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Glucose-insulin infusions (with potassium [GIK] or without [GI]) have been advocated in the setting of coronary artery bypass graft (CABG) surgery to optimize myocardial glucose use and to minimize ischemic injury. OBJECTIVE To conduct a meta-analysis assessing whether the use of GIKGI infusions perioperatively reduce in-hospital mortality or atrial fibrillation (AF) after CABG surgery. METHODS Electronic databases (Medline, EMBASE and Cochrane Central Register of Controlled Trials [CENTRAL]) and references of retrieved articles were searched for randomized controlled trials that evaluated the effects of GIK or GI infusions, before or during CABG surgery, on in-hospital mortality andor postoperative AF. Pooled ORs and 95% CIs were calculated for each outcome. RESULTS Twenty trials were identified and eligible for review. The summary OR for in-hospital mortality was 0.88 (95% CI 0.56 to 1.40), based on 44 deaths among 2326 patients. While postoperative AF was a more frequent outcome (occurring in 519 of 1540 patients in the 10 trials reporting this outcome), the overall pooled estimate of effect was nonsignificant (OR 0.79, 95% CI 0.54 to 1.15). This latter finding needs to be interpreted cautiously because it is accompanied by significant heterogeneity across trials. CONCLUSIONS Perioperative use of GIKGI does not significantly reduce mortality or atrial fibrillation in patients undergoing CABG surgery. Unless future trial data in support of GIKGI infusions become available, the routine use of these treatments in patients undergoing CABG surgery should be discouraged because the safety of these infusions has not been systematically examined.
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Affiliation(s)
- Doreen Rabi
- Department of Medicine, University of Calgary, Calgary, Canada.
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA focused update on perioperative beta blockade incorporated into the ACC/AHA 2007 guidelines on perioperative cardiovascular evaluation and care for noncardiac surgery. J Am Coll Cardiol 2009; 54:e13-e118. [PMID: 19926002 DOI: 10.1016/j.jacc.2009.07.010] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF. 2009 ACCF/AHA Focused Update on Perioperative Beta Blockade Incorporated Into the ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2009; 120:e169-276. [PMID: 19884473 DOI: 10.1161/circulationaha.109.192690] [Citation(s) in RCA: 209] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Puskarich MA, Runyon MS, Trzeciak S, Kline JA, Jones AE. Effect of glucose-insulin-potassium infusion on mortality in critical care settings: a systematic review and meta-analysis. J Clin Pharmacol 2009; 49:758-67. [PMID: 19417124 DOI: 10.1177/0091270009334375] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
This study seeks to measure the treatment effect of glucose-insulin-potassium (GIK) infusion on mortality in critically ill patients. A systematic review of randomized controlled trials is conducted, comparing GIK treatment with standard care or placebo in critically ill adult patients. The primary outcome variable is mortality. Two authors independently extract data and assess study quality. The primary analysis is based on the random effects model to produce pooled odds ratios (ORs) with 95% confidence intervals (CIs). The search yields 1720 potential publications; 23 studies are included in the final analysis, providing a sample of 22,525 patients. The combined results demonstrate no heterogeneity (P=.57, I2=0%) and no effect on mortality (OR=1.02; 95% CI, 0.93-1.11) with GIK treatment. No experimental studies of shock or sepsis populations are identified. This meta-analysis finds that there is no mortality benefit to GIK infusion in critically ill patients; however, study populations are limited to acute myocardial infarction and cardiovascular surgery patients. No studies are identified using GIK in patients with septic shock or other forms of circulatory shock, providing an absence of evidence regarding the effect of GIK as a therapy in patients with shock.
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Affiliation(s)
- Michael A Puskarich
- Department of Emergency Medicine, Carolinas Medical Center, PO Box 32861, Charlotte, NC 28232-2861, USA
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Glycemic control in critical care: current benefits and future needs. Int Anesthesiol Clin 2009; 47:139-51. [PMID: 19131757 DOI: 10.1097/aia.0b013e318194ffc6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Gandhi GY, Murad MH, Flynn DN, Erwin PJ, Cavalcante AB, Bay Nielsen H, Capes SE, Thorlund K, Montori VM, Devereaux PJ. Effect of perioperative insulin infusion on surgical morbidity and mortality: systematic review and meta-analysis of randomized trials.7. Mayo Clin Proc 2008; 83:418-30. [PMID: 18380987 DOI: 10.4065/83.4.418] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) to evaluate the effect of perioperative insulin infusion on outcomes important to patients. PATIENTS AND METHODS We used 6 search strategies including an electronic database search of MEDLINE, EMBASE, and Cochrane CENTRAL, from their inception up to May 1, 2006, and included RCTs of perioperative insulin infusion (with or without glucose targets) measuring outcomes in patients undergoing any surgery. Pairs of reviewers working independently assessed the methodological quality and characteristics of included trials and abstracted data on perioperative outcomes (ie, outcomes that occurred during hospitalization or within 30 days of surgery). RESULTS We identified 34 eligible trials. In the 14 trials that assessed mortality, there were 68 deaths among 2192 patients randomized to insulin infusion compared with 98 deaths among 2163 patients randomized to control therapy (random-effects pooled relative risk, 0.69; 95% confidence interval [CI], 0.51-0.94; 99% CI, 0.46-1.04; I2, 0%; 95% CI, 0.0%-47.4%). Hypoglycemia increased in the intensively treated group (20 trials, 119/1470 patients in insulin infusion vs 48/1476 patients in control group; relative risk, 2.07; 95% CI, 1.29-3.32; 99% CI, 1.09-3.88; I2, 31.5%; 95% CI, 0.0%-59.0%). No significant effect was seen in any other outcomes. The available mortality data represent only 40% of the optimal information size required to reliably detect a plausible treatment effect; potential methodological and reporting biases weaken inferences. CONCLUSION Perioperative insulin infusion may reduce mortality but increases hypoglycemia in patients who are undergoing surgery; however, mortality results require confirmation in large and rigorous RCTs.
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Affiliation(s)
- Gunjan Y Gandhi
- Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, 200 First St SW, Rochester, MN 55905, USA.
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Evans R, Niu Y. Hypolipidaemic effects of high-dose insulin therapy. Br J Anaesth 2008; 100:429-33. [DOI: 10.1093/bja/aen027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof EL, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Riegel B, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) Developed in Collaboration With the American Society of Echocardiography, American Society of Nuclear Cardiology, Heart Rhythm Society, Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, Society for Vascular Medicine and Biology, and Society for Vascular Surgery. J Am Coll Cardiol 2007; 50:e159-241. [PMID: 17950159 DOI: 10.1016/j.jacc.2007.09.003] [Citation(s) in RCA: 257] [Impact Index Per Article: 15.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Fleisher LA, Beckman JA, Brown KA, Calkins H, Chaikof E, Fleischmann KE, Freeman WK, Froehlich JB, Kasper EK, Kersten JR, Riegel B, Robb JF, Smith SC, Jacobs AK, Adams CD, Anderson JL, Antman EM, Buller CE, Creager MA, Ettinger SM, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Hunt SA, Lytle BW, Nishimura R, Ornato JP, Page RL, Tarkington LG, Yancy CW. ACC/AHA 2007 Guidelines on Perioperative Cardiovascular Evaluation and Care for Noncardiac Surgery. Circulation 2007; 116:e418-99. [PMID: 17901357 DOI: 10.1161/circulationaha.107.185699] [Citation(s) in RCA: 377] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Eiferman D, Perez-Tamayo RA, Abe K, Okum E, Higgins R. Real-time monitoring of cardiac metabolism using biosensors shows myocardial protection during ischemia-reperfusion injury with glucose-insulin-potassium administration. Surgery 2007; 142:150-5. [PMID: 17689679 DOI: 10.1016/j.surg.2007.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2006] [Revised: 03/14/2007] [Accepted: 03/16/2007] [Indexed: 11/22/2022]
Abstract
BACKGROUND Systemic infusion of glucose-insulin-potassium (GIK) is thought to confer myocardial protection during ischemia-reperfusion injury. Our laboratory has experience with real-time monitoring of glucose and pH levels using needle-mounted biosensors. We tested the hypothesis that GIK enhances myocardial metabolism as displayed by real-time myocardial metabolic monitoring. METHODS A total of 40 kg male swine were randomized to receive GIK (n = 7) or lactated Ringer's (n = 7) solution intravenously at 1.5 mL/kg/hour. Ischemia was induced in the left anterior distribution (LAD) by 20 minutes LAD occlusion, followed by 20 minutes reperfusion. Hearts were instrumented anteriorly and posteriorly with continuously recording myocardial pH and glucose biosensors. Biopsies from the LAD distribution were taken at baseline, maximum ischemia, and after reperfusion to assess cardiac adenosine triphosphate (ATP) levels. RESULTS GIK animals had less myocardial pH decrease than controls during both ischemia (pH decrease -0.03 vs -0.37, P = .04) and reperfusion (pH decrease -0.10 vs -0.44, P = .05). Neither ATP (74% vs 73% decrease from baseline) nor glucose (27% vs 33% decrease from baseline) varied significantly between groups during ischemia. GIK animals had faster normalization of ATP (100% vs 79% increase from ischemia) and glucose (69% vs 28% increase from ischemia) during reperfusion. CONCLUSIONS Real-time myocardial metabolic monitoring shows that cardiac pH is improved by GIK during ischemia-reperfusion injury; however, ATP and glucose levels were not significantly enhanced. GIK animals trended toward earlier recovery during reperfusion. Mediators of this metabolic enhancement need to be explored.
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Affiliation(s)
- Daniel Eiferman
- Department of Cardiovascular Surgery, Rush University Medical Center, Chicago, Ill, USA.
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Sokos GG, Bolukoglu H, German J, Hentosz T, Magovern GJ, Maher TD, Dean DA, Bailey SH, Marrone G, Benckart DH, Elahi D, Shannon RP. Effect of glucagon-like peptide-1 (GLP-1) on glycemic control and left ventricular function in patients undergoing coronary artery bypass grafting. Am J Cardiol 2007; 100:824-9. [PMID: 17719327 DOI: 10.1016/j.amjcard.2007.05.022] [Citation(s) in RCA: 184] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2007] [Revised: 05/17/2007] [Accepted: 05/17/2007] [Indexed: 01/04/2023]
Abstract
Increasing evidence suggests that tight glycemic control improves clinical outcomes after coronary artery bypass grafting (CABG). However, the risk for hypoglycemia with insulin often results in less aggressive glycemic control. Glucagon-like peptide-1 (GLP-1) is a naturally occurring peptide whose insulinotropic effects are predicated on the glucose concentration, minimizing the risk for hypoglycemia. This study was conducted to examine whether perioperative treatment with GLP-1 would affect glycemic control and improve hemodynamic recovery after CABG. Twenty patients with coronary heart disease and preserved left ventricular function who were scheduled to undergo CABG were randomized to receive standard therapy at the discretion of the surgeon or treatment with GLP-1 (1.5 pmol/kg/min) as a continuous infusion beginning 12 hours before CABG and continuing for 48 hours. Perioperative hemodynamics, the left ventricular ejection fraction, plasma glucose, and requirements for insulin drips and inotropic support were monitored. There were no differences between groups in the preoperative, postoperative, or 7-day left ventricular ejection fraction (GLP-1 61 +/- 4%, control 59 +/- 3%) or cardiac index at 18 hours (GLP-1 3.0 +/- 0.2 L/min/m(2), control 3.3 +/- 0.4 L/min/m(2)). However, the control group required greater use of inotropic and vasoactive infusions during the 48 hours after the operation to achieve the same hemodynamic result. There were also more frequent arrhythmias requiring antiarrhythmic agents in the control group. GLP-1 resulted in better glycemic control in the pre- and perioperative periods (GLP-1 95 +/- 3 mg/dl, control 140 +/- 10 mg/dl, p </=0.02), with 45% less insulin requirements to achieve the same glycemic control in the postoperative period (GLP-1 139 +/- 4 mg/dl, control 140 +/- 3 mg/dl). In conclusion, the perioperative use of GLP-1 achieves better glycemic control and comparable hemodynamic recovery without the requirements for high-dose insulin or inotropes.
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Affiliation(s)
- George G Sokos
- Department of Medicine, Allegheny General Hospital, Pittsburgh, Pennsylvania, USA
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Hafidh SA, Reuter MD, Chassels LJ, Aradhyula S, Bhutto SS, Alpert MA. Effect of intravenous insulin therapy on clinical outcomes in critically ill patients. Am J Med Sci 2007; 333:354-61. [PMID: 17570988 DOI: 10.1097/maj.0b013e318065a940] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Hyperglycemia commonly occurs in critically ill patients, even in the absence of diabetes mellitus, and is associated with increased morbidity and mortality rates in such patients. METHODS Medline search using the terms intravenous insulin, intensive care, myocardial infarction, cardiac surgery and stroke. RESULTS AND CONCLUSIONS Intravenous insulin therapy with or without adjunctive subcutaneous insulin therapy has been shown to improve morbidity and reduce mortality rates in surgical intensive care populations compared with subcutaneous insulin alone or oral hypoglycemic therapy. The evidence for such is less compelling in medical intensive care populations. Intravenous insulin therapy alone or in combination with glucose and potassium infusion appears to improve clinical outcomes in cardiac surgery patients, but there is conflicting evidence concerning its effect on morbidity and mortality rates after myocardial infarction. Insufficient evidence exists to determine the effect of intravenous insulin therapy on outcomes in other populations including stroke patients, those undergoing major noncardiac surgery, and burn patients. Intravenous insulin nomograms and nurse-driven protocols may improve blood glucose control, resulting in improved clinical outcomes.
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Affiliation(s)
- Saad A Hafidh
- Department of Medicine, St. John's Mercy Medical Center, St. Louis, Missouri 63141, USA
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Langley J, Adams G. Insulin-based regimens decrease mortality rates in critically ill patients: a systematic review. Diabetes Metab Res Rev 2007; 23:184-92. [PMID: 17089369 DOI: 10.1002/dmrr.696] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To determine whether treatment with glucose-insulin-potassium (GIK), insulin and glucose, or insulin by itself is beneficial in limiting organ damage after acute myocardial infarction (AMI) and reducing mortality and morbidity among critically ill hyperglycaemic patients. METHODS Systematic review of randomized controlled trials. MAIN OUTCOME MEASURE To assess whether tight glycaemic control reduces morbidity and mortality. STUDIES REVIEWED Randomized controlled trials of insulin-based regimens in the treatment of critically ill patients. RESULTS Nine hundred and twenty-four potentially relevant studies were identified and screened for retrieval. Of these, 16 randomized controlled trials met the inclusion criteria (Table 1). Ten studies examined the effects of GIK, and six of these studies reported a mortality reduction with GIK treatment in addition to enhanced myocardial performance. Five studies examined the administration of insulin. Among these studies, tight glycaemic control of blood glucose in one study was shown to reduce morbidity and mortality of patients in intensive care. Only one study examined insulin/glucose therapy, and it showed a post-myocardial infarction mortality reduction of one year. CONCLUSIONS There is increasing evidence that maintaining normoglycaemia and treatment with insulin-based regimens is beneficial in limiting organ damage and significantly reduces both morbidity and mortality in critically ill patients who require intensive care therapy.
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Affiliation(s)
- Jane Langley
- Intensive Care, Lincoln County Hospital, Greetwell Road, Lincoln, Lincolnshire, LN2 5QY, UK
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Shim YH, Kweon TD, Lee JH, Nam SB, Kwak YL. Intravenous glucose-insulin-potassium during off-pump coronary artery bypass surgery does not reduce myocardial injury. Acta Anaesthesiol Scand 2006; 50:954-61. [PMID: 16923090 DOI: 10.1111/j.1399-6576.2006.01115.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND This randomized, double-blind, placebo-controlled study was designed to determine whether an intra-operative, intravenous infusion of glucose-insulin-potassium (GIK) could be helpful in the prevention of myocardial ischemia and in the maintenance of intra-operative cardiac performance in patients undergoing off-pump coronary artery bypass (OP-CAB) surgery. METHODS Eighty two adults undergoing elective OP-CAB surgery were randomly divided into two groups that received intravenously either 5% dextrose in water or GIK (50% dextrose in 500 ml of water; regular insulin, 125 IU; potassium, 80 mmol) at 0.75 ml/kg/h immediately before the induction of anesthesia to the end of surgery. To evaluate myocardial damage, creatine kinase MB and troponin T were measured before surgery, immediately after arrival in the intensive care unit and on the first post-operative day. To assess cardiac performance, hemodynamic data were obtained before and after the induction of anesthesia, before and after the bypass graft and after sternal closure. Blood glucose was measured at the same time. RESULTS There was no significant difference in cardiac enzymes, hemodynamic parameters and blood glucose between the two groups. The use of vasoactive, inotropic and/or anti-arrhythmic agents, insulin and supplemental glucose was not significantly different between the groups. CONCLUSION The results suggest that the intravenous administration of GIK during OP-CAB surgery neither reduces myocardial damage nor improves intra-operative cardiac performance in patients without contractile dysfunction.
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Affiliation(s)
- Y H Shim
- Department of Anesthesiology & Pain Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kwak YL. Reduction of Ischemia During Off-Pump Coronary Artery Bypass Graft Surgery. J Cardiothorac Vasc Anesth 2005; 19:667-77. [PMID: 16202908 DOI: 10.1053/j.jvca.2005.04.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2005] [Indexed: 12/11/2022]
Affiliation(s)
- Young Lan Kwak
- Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, 134 Shinchon-Dong, Seodaemun-Ku, Seoul, Korea.
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Kosiborod M, Rathore SS, Inzucchi SE, Masoudi FA, Wang Y, Havranek EP, Krumholz HM. Admission glucose and mortality in elderly patients hospitalized with acute myocardial infarction: implications for patients with and without recognized diabetes. Circulation 2005; 111:3078-86. [PMID: 15939812 DOI: 10.1161/circulationaha.104.517839] [Citation(s) in RCA: 445] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The relationship between admission glucose levels and outcomes in older diabetic and nondiabetic patients with acute myocardial infarction is not well defined. METHODS AND RESULTS We evaluated a national sample of elderly patients (n=141,680) hospitalized with acute myocardial infarction from 1994 to 1996. Admission glucose was analyzed as a categorical (< or =110, >110 to 140, >140 to 170, >170 to 240, >240 mg/dL) and continuous variable for its association with mortality in patients with and without recognized diabetes. A substantial proportion of hyperglycemic patients (eg, 26% of those with glucose >240 mg/dL) did not have recognized diabetes. Fewer hyperglycemic patients without known diabetes received insulin during hospitalization than diabetics with similar glucose levels (eg, glucose >240 mg/dL, 22% versus 73%; P<0.001). Higher glucose levels were associated with greater risk of 30-day mortality in patients without known diabetes (for glucose range from < or =110 to >240 mg/dL, 10% to 39%) compared with diabetics (range, 16% to 24%; P for interaction <0.001). After multivariable adjustment, higher glucose levels continued to be associated with a graded increase in 30-day mortality in patients without known diabetes (referent, glucose < or =110 mg/dL; range from glucose >110 to 140 mg/dL: hazard ratio [HR], 1.17; 95% CI, 1.11 to 1.24; to glucose >240 mg/dL: HR, 1.87; 95% CI, 1.75 to 2.00). In contrast, among diabetic patients, greater mortality risk was observed only in those with glucose >240 mg/dL (HR, 1.32; 95% CI, 1.17 to 1.50 versus glucose < or =110 mg/dL; P for interaction <0.001). One-year mortality results were similar. CONCLUSIONS Elevated glucose is common, rarely treated, and associated with increased mortality risk in elderly acute myocardial infarction patients, particularly those without recognized diabetes.
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Affiliation(s)
- Mikhail Kosiborod
- Section of Cardiovascular Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208088, New Haven, CT 06520-8088, USA
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Cardiac Surgery. Clin Nutr 2005. [DOI: 10.1016/b978-0-7216-0379-7.50036-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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LaDisa JF, Krolikowski JG, Pagel PS, Warltier DC, Kersten JR. Cardioprotection by glucose-insulin-potassium: dependence on KATP channel opening and blood glucose concentration before ischemia. Am J Physiol Heart Circ Physiol 2004; 287:H601-7. [PMID: 15044191 DOI: 10.1152/ajpheart.00122.2004] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We tested the hypothesis that glucose-insulin-potassium (GIK)-induced protection against myocardial infarction depends on ATP-dependent K(+) (K(ATP)) channel activation and is abolished by hyperglycemia before the ischemia. Dogs were subjected to a 60-min coronary artery occlusion and 3-h reperfusion in the absence or presence of GIK (25% dextrose; 50 IU insulin/l; 80 mM/l KCl infused at 1.5 ml x kg(-1) x h(-1)) beginning 75 min before coronary artery occlusion or 5 min before reperfusion. The role of K(ATP) channels was evaluated by pretreatment with glyburide (0.1 mg/kg). The efficacy of GIK was investigated with increases in blood glucose (BG) concentrations to 300 or 600 mg/dl or experimental diabetes (alloxan/streptozotocin). Infarct size (IS) was 29 +/- 2% of the area at risk in control experiments. GIK decreased (P < 0.05) IS when administered beginning 5 min before reperfusion. This protective action was independent of BG (13 +/- 2 and 12 +/- 2% of area at risk; BG = 80 or 600 mg/dl, respectively) but was abolished in dogs receiving glyburide (30 +/- 4%), hyperglycemia before ischemia (27 +/- 4%), or diabetes (25 +/- 3%). IS was unchanged by GIK when administered before ischemia independent of BG (31 +/- 3, 27 +/- 2, and 35 +/- 3%; BG = 80, 300, and 600 mg/dl, respectively). The insulin component of GIK promotes cardioprotection by K(ATP) channel activation. However, glucose decreases K(ATP) channel activity, and this effect predominates when hyperglycemia is present before ischemia.
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Affiliation(s)
- John F LaDisa
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI 53226, USA
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Abstract
PURPOSE OF REVIEW The recent publication of the results of an aggressive approach to the treatment of hyperglycaemia in critically ill patients, and a rekindling of interest in the use of an infusion of glucose insulin and potassium as adjunctive therapy in a diverse group of patients with cardiovascular disease, warrants a review of the multiple effects of insulin and a review of laboratory and clinical studies. RECENT FINDINGS The use of an aggressive protocol to maintain normoglycaemia in critically ill patients has been demonstrated to be a beneficial technique in the critical care setting. Implementation of the protocol outside of a research setting appears to be feasible. Recent studies on the use of insulin in addition to glucose and potassium in patients with diverse cardiovascular diseases have also demonstrated positive results. SUMMARY This review will summarize some of the putative beneficial effects of insulin as a pharmacological agent, and review recent clinical data. Although the relative benefits of normoglycaemia in the critical care setting and the beneficial effects of insulin are difficult to differentiate, a substantial overlap exists. The extent to which these converging therapies (aggressive normoglycaemia and insulin pharmacotherapy) will be applicable to diverse clinical settings has yet to be determined.
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Affiliation(s)
- Thomas Solano
- General Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Australia.
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Abstract
This review discusses the myocardial protective property of the insulin/glucose-insulin-potassium regimen and the mechanisms involved in this beneficial action. Several recent studies suggest that insulin not only is useful to control hyperglycemia and maintain glucose homeostasis but also may have the unique property to protect the myocardium from reperfusion injury and ischemia and prevent apoptosis of myocardial cells. The insulin/glucose-insulin-potassium (GIK) regimen suppresses the production of tumor necrosis factor-alpha, interleukin-6, macrophage migration inhibitory factor and other pro-inflammatory cytokines, and free radicals; and enhances the synthesis of endothelial nitric oxide and anti-inflammatory cytokines interleukin-4 and interleukin-10. Thus, the insulin/GIK regimen brings about its cardioprotective action. This may also explain why the insulin/GIK regimen is useful in sepsis and septic shock, myocardial recovery in acute myocardial infarction, and critical illness. It is suggested that the infusion of adequate amounts of insulin to patients with acute myocardial infarction, congestive heart failure, cardiogenic shock, and critical illness preserves myocardial integrity and function and ensures rapid recovery. In view of the suppressive action of insulin on the synthesis of proinflammatory cytokines and free radicals, it is possible that the insulin/GIK regimen, when used in a timely and appropriate fashion, may also protect other tissues and organs and facilitate in the recovery of patients who are critically ill.
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Affiliation(s)
- Undurti N Das
- EFA Sciences LLC, Norwood, Massachusetts 02062, USA.
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van Wezel HB, Jong SWMD. Clinical Use of Glucose-Insulin-Potassium in Cardiac Surgery andAcute Myocardial Infarction: An Overview. Semin Cardiothorac Vasc Anesth 2003. [DOI: 10.1177/108925320300700114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Harry B. van Wezel
- Department of Anesthesiology, Academic Medical Center, Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Abstract
PURPOSE OF REVIEW Cardiovascular disease is one of the most important causes of morbidity and mortality in western countries, generating an increasing number of admissions to intensive care units. Cardiac failure has long been associated with nutritional disorders, malnutrition and cachexia being frequent during the late phases of congestive heart failure: undernutrition is also a determinant of outcome, even after cardiac transplantation. RECENT FINDINGS It has been shown that early metabolic support can improve the recovery of the ischaemic heart. This paper reviews recent findings on substrates that can support the failing myocardium, which are mainly glucose-insulin, glutamine, taurine, selenium, thiamine, folic acid, and omega-3 fatty acids. Ischaemia-reperfusion generates tissue lesions that can be partly prevented through substrate manipulation. SUMMARY Shifting the substrate metabolism from lipids to carbohydrates and reinforcing the antioxidant status reduces the deleterious biological and clinical consequences of acute ischaemic events. The use of the glucose-insulin-potassium infusion has become widespread with the re-discovery of its value in modulating cellular metabolism and accelerating recovery of the ischaemic myocardium. Antioxidants have gained acceptance in the perioperative phase, as well as in chronic heart failure. This constitutes another piece of evidence in favour of early metabolic and nutritional intervention. There also appears to be room for the prevention of acute deterioration of cardiac function after surgery with the preoperative administration of oral supplements containing omega-3 fatty acids.
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Affiliation(s)
- Mette M Berger
- Intensive Care Unit and Burns Centre, University Hospital, Lausanne, Switzerland.
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van Wezel HB, de Jong SWM. Glucose, Free Fatty Acids, and Insulin Following Acute Myocardial Ischemia. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Abstract
Stress hyperglycemia and diabetes mellitus with myocardial infarction are associated with increased risk for in-hospital mortality, congestive heart failure, or cardiogenic shock. Hyperglycemia triggers free radical generation and suppresses endothelial nitric oxide generation, and thus initiates and perpetuates inflammation. Conversely, insulin suppresses production of tumor necrosis factor-alpha and free radicals, enhances endothelial nitric oxide generation, and improves myocardial function. It is proposed that the balance between insulin and plasma glucose levels is critical to recovery and/or complications that occur following acute myocardial infarction and in the critically ill. Adequate attention should be given to maintaining euglycemia (plasma glucose <or= 110 mg/dl) in order to reduce infarct size and improve cardiac function while using a glucose-insulin-potassium cocktail.
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