A primer for achieving glycemic control in the cardiac surgical patient

Postoperative Insulin Dose for Cardiac Artery Bypass Graft and Other Cardiac Surgeries in Patients with Type 2 Diabetes: A Retrospective Study

Purpose

Recommendations on perioperative glycemic control in cardiac surgery are based on coronary artery bypass graft surgery (CABG), though coronary artery disease and valvular disease are pathologically distinct. We aimed to compare the postoperative insulin requirement between CABG and other cardiac surgeries in type 2 diabetic patients and identify predictive factors for the maximum postoperative insulin dose.

Patients and Methods

We retrospectively included 60 Japanese patients with diabetes/glucose intolerance (HbA1c > 37 mmol/mol [5.6%]) who were hospitalized for cardiovascular surgery between April 2017 and March 2019. We categorized the subjects into the CABG and non-CABG groups, and performed subgroup analysis on patients who received postoperative insulin therapy.

Results

The CABG group required a significantly higher insulin dose on postoperative days 2, 5, 6, and 7, and a significantly higher maximum postoperative insulin dose (24.6 U vs 9.7 U, P < 0.001) than the non-CABG group. Multivariate linear regression analyses showed that the independent determinants of the maximum postoperative insulin dose were HbA1c and duration of diabetes in the non-CABG group, and HbA1c in the CABG group.

Conclusion

CABG had a higher postoperative insulin requirement than other cardiovascular surgeries; early aggressive insulin therapy is indicated, especially for patients with higher HbA1c levels/longer duration of diabetes.

Cardiothoracic Critical Care

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.

A Perioperative Systems Design to Improve Intraoperative Glucose Monitoring Is Associated with a Reduction in Surgical Site Infections in a Diabetic Patient Population

BACKGROUND

Diabetic patients receiving insulin should have periodic intraoperative glucose measurement. The authors conducted a care redesign effort to improve intraoperative glucose monitoring.

METHODS

With approval from Vanderbilt University Human Research Protection Program (Nashville, Tennessee), the authors created an automatic system to identify diabetic patients, detect insulin administration, check for recent glucose measurement, and remind clinicians to check intraoperative glucose. Interrupted time series and propensity score matching were used to quantify pre- and postintervention impact on outcomes. Chi-square/likelihood ratio tests were used to compare surgical site infections at patient follow-up.

RESULTS

The authors analyzed 15,895 cases (3,994 preintervention and 11,901 postintervention; similar patient characteristics between groups). Intraoperative glucose monitoring rose from 61.6 to 87.3% in cases after intervention (P = 0.0001). Recovery room entry hyperglycemia (fraction of initial postoperative glucose readings greater than 250) fell from 11.0 to 7.2% after intervention (P = 0.0019), while hypoglycemia (fraction of initial postoperative glucose readings less than 75) was unchanged (0.6 vs. 0.9%; P = 0.2155). Eighty-seven percent of patients had follow-up care. After intervention the unadjusted surgical site infection rate fell from 1.5 to 1.0% (P = 0.0061), a 55.4% relative risk reduction. Interrupted time series analysis confirmed a statistically significant surgical site infection rate reduction (P = 0.01). Propensity score matching to adjust for confounders generated a cohort of 7,604 well-matched patients and confirmed a statistically significant surgical site infection rate reduction (P = 0.02).

CONCLUSIONS

Anesthesiologists add healthcare value by improving perioperative systems. The authors leveraged the one-time cost of programming to improve reliability of intraoperative glucose management and observed improved glucose monitoring, increased insulin administration, reduced recovery room hyperglycemia, and fewer surgical site infections. Their analysis is limited by its applied quasiexperimental design.

Clinical nurse specialists lead teams to impact glycemic control after cardiac surgery

PURPOSE

The purpose of this evidence-based practice improvement project was to improve patients' blood glucose control after cardiac surgery, specifically aiming to keep blood glucose levels less than 200 mg/dL.

BACKGROUND/RATIONALE

Glycemic control is essential for wound healing and infection prevention. Multiple factors including the use of corticosteroids and the stress of critical illness put cardiac surgery patients at greater risk for elevated blood glucose levels postoperatively. A Surgical Care Improvement Project measure related to infection prevention calls for the morning blood glucose level (closest to 6:00 AM) to be less than 200 mg/dL on postoperative days 0 to 2. Patients on our cardiothoracic surgery unit were experiencing blood glucose levels greater than benchmark goals.

DESCRIPTION

A practice improvement effort was designed to decrease the number of blood glucose results greater than 200 mg/dL after cardiac surgery. The clinical nurse specialists for diabetes and cardiac surgery worked with nursing staff and the interdisciplinary team to implement a 4-pronged approach to improve efficiency in care processes: (1) increase frequency of glucose monitoring, (2) improve accessibility of insulin orders, (3) develop delegation protocol to facilitate nurse-initiated insulin infusion, and (4) implement revised insulin infusion protocol.

OUTCOMES

Hyperglycemia was identified more quickly, and a nurse-initiated protocol prompted more timely use of revised insulin infusion orders and involvement of the diabetes specialty team. Clinically significant improvement in postoperative glycemic control was achieved.

CONCLUSIONS

Empowering nurses to initiate hyperglycemia treatment and consultation by diabetes specialists may greatly improve efficiency in care processes and clinical outcomes for cardiac surgery patients.

IMPLICATIONS

Clinical nurse specialists are well positioned to plan and implement interventions that facilitate an evidence-based approach to glycemic management after cardiac surgery.

Transitioning safely from intravenous to subcutaneous insulin

The transition from intravenous (IV) to subcutaneous (SQ) insulin in the hospitalized patient with diabetes or hyperglycemia is a key step in patient care. This review article suggests a stepwise approach to the transition in order to promote safety and euglycemia. Important components of the transition include evaluating the patient and clinical situation for appropriateness, recognizing factors that influence a safe transition, calculation of proper SQ insulin doses, and deciding the appropriate type of SQ insulin. This article addresses other clinical situations including the management of patients previously on insulin pumps and recommendations for patients requiring glucocorticoids and enteral tube feedings. The use of institutional and computerized protocols is discussed. Further research is needed regarding the transition management of subgroups of patients such as those with type 1 diabetes and end-stage renal disease.

Pharmacological and nonpharmacological treatment after cardiac surgery

Open-heart surgery has become a common procedure. Postcardiac surgery management is a critical issue and represents a crucial period in terms of physical recovery. Cardiac rehabilitation is increasingly considered as an integral component of the continuum of care for patients with cardiovascular disease. Its usefulness is now widely accepted, and therefore, it is recommended in most contemporary cardiovascular clinical practice guidelines. Similarly, early pharmacological management can modulate the pathophysiological alterations after cardiac surgery, leading to an improvement in the early and long-term outcome. In this review, we will present recent advances in postcardiac surgery management, focusing on the pathophysiology of the perioperative period and on recent evidences in pharmacological and rehabilitative strategies.

Blood glucose management in the patient undergoing cardiac surgery: A review

Both diabetes mellitus and hyperglycemia per se are associated with negative outcomes after cardiac surgery. In this article, we review these associations, the possible mechanisms that lead to adverse outcomes, and the epidemiology of diabetes focusing on those patients requiring cardiac surgery. We also examine outpatient and perioperative management of diabetes with the same focus. Finally, we discuss our own efforts to improve glycemic management of patients undergoing cardiac surgery at our institution, including keys to success, results of implementation, and patient safety concerns.

Glycemic Control during Coronary Artery Bypass Graft Surgery

Hyperglycemia, which occurs in the perioperative period during cardiac surgery, has been shown to be associated with increased morbidity and mortality. The management of perioperative hyperglycemia during coronary artery bypass graft surgery and all cardiac surgical procedures has been the focus of intensive study in recent years. This report will paper the pathophysiology responsible for the detrimental effects of perioperative hyperglycemia during cardiac surgery, show how continuous insulin infusions in the perioperative period have improved outcomes, and discuss the results of trials designed to determine what level of a glycemic control is necessary to achieve optimal clinical outcomes.