Glycemic control in cardiac surgery: implementing an evidence-based insulin infusion protocol

Effectiveness of blood glucose control protocol for open heart surgery patients

AIMS

To evaluate the effectiveness of a tailored blood glucose control protocol for postoperative cardiac surgery patients treated in intensive care.

DESIGN

Retrospective study.

METHODS

Data for the control group (non-tailored protocol) were collected from medical records at a tertiary hospital in Seoul, Korea between April-July 2015. Data for the experimental group (tailored protocol) were obtained from medical records between April-July 2016. After adjusting the target blood glucose range, eliminating single-dose insulin administration and extending the blood glucose measurement time interval, data for blood glucose measurements, time for reaching and maintaining target blood glucose, mean number of daily blood glucose measurements and insulin dose adjustments for the experimental group were collected.

RESULTS

In the experimental group (where the target blood glucose rate was increased) the hypoglycaemia rate and the variation in blood glucose decreased significantly compared with the control group. In particular, the experimental group maintained relatively stable blood glucose levels by retaining a small variation range in glucose, regardless of the presence of diabetes. Time required for maintaining target blood glucose, mean number of daily blood glucose measurements and insulin dose adjustments per patient decreased.

CONCLUSION

The tailored protocol contributes to the safe and effective control of blood glucose in critical care patients after cardiac surgery and to the efficiency of nurses administering it.

IMPACT

This study has two significant impacts. The application of the tailored protocol has a positive impact on patients' blood glucose management, a critical component of treatment for postoperative cardiac patients in intensive care units. It also has a positive impact on the efficiency of nurses applying it. The results of this study are thus expected to facilitate successful implementation of clinical protocols for critical care after heart surgery.

Prednosti in slabosti različnih protokolov vodenja vrednosti glukoze v krvi pri kritično bolnih pacientih

Uvod: Medicinske sestre v enotah intenzivne terapije uravnavajo ciljno vrednost glukoze v krvi pri kritično bolnih po sprejetih in veljavnih protokolih. Namen raziskave je bil raziskati prednosti in slabosti različnih protokolov vodenja  vrednosti glukoze v krvi pri kritično bolnih.Metode: Uporabljen je bil sistematični pregled znanstvene in strokovne literature. Iskanje literature je potekalo od 1. 2. 2017 do 8. 8. 2017. V pregled so bile vključene naslednje baze: COBIB.SI, Digitalna knjižnica Slovenije – Dlib.si, CINAHL, ProQuest, PubMed in Google Učenjak. Iskanje je potekalo z različnimi kombinacijami ključnih besed v slovenskem in angleškem jeziku: prednosti, slabosti, medicinske sestre, kritično bolni, glukoza v krvi in protokoli za vodenje vrednosti glukoze v krvi. Uporabljen je bil Boolov operater AND. Iz iskalnega nabora 1064 zadetkov je bilo v končno analizo  vključenih 15 člankov. Za obdelavo podatkov je bil uporabljen model analize konceptov.Rezultati: Identificirana so bila tri tematska področja: (1) primernost različnih protokolov za vodenje vrednosti glukoze v krvi, (2) delovne obremenitve medicinskih sester pri teh protokolih in (3) varnost protokolov. Prednosti računalniško podprtega protokola za vodenje vrednosti glukoze v krvi so v boljšem doseganju ciljne vrednosti koncentracije glukoze v krvi, slabosti pa v pojavu odstopanj v zvezi z načrtovanim časom za merjenje glukoze v krvi.Diskusija in zaključek: Nekatere raziskave ugotavljajo prednosti računalniško podprtih protokolov za vodenje vrednosti glukoze v krvi v smislu tehnoloških izboljšav, zmanjšanja delovnih obremenitev medicinskih sester in izboljšanja varnosti pacientov. Raziskava prispeva k izboljševanju klinične prakse pri delu s kritično bolnimi pacienti.

Hyperglycemic Episodes Are Associated With Postoperative Infections After Cardiac Surgery

BACKGROUND AND AIMS

To describe the incidence of and risk factors for postoperative infections and the correlation between postoperative hyperglycemia despite tight blood glucose control with infectious and other complications after contemporary cardiac surgery.

MATERIAL AND METHODS

The study comprised 1356 consecutive adult patients who underwent cardiac surgery between January 2013 and December 2014 and were followed up for 6 months. Patients surviving the first 2 days were included in the analysis. Preoperative demographic information, medical history, procedural details, and the postoperative course were recorded. The target range for blood glucose levels was 4-7 mmol/L and repeated arterial blood samples were obtained during the intensive care unit stay. The associations of blood glucose levels during the first postoperative day and the occurrence of postoperative infections and other significant complications were analyzed.

RESULTS

Of the study cohort, 9.8% developed infectious complications which were classified as major surgical site infections in 2.2%, minor surgical site infections in 1.1%, lung infections in 2.0%, unclear fever or bacteremia in 0.3%, cannula or catheter related in 2.6%, multiple in 1.5%, and other in 0.2%. The incidence of deep sternal wound infection was 2.0%. Repeated hyperglycemia occurred in 39.7% of patients and was associated with increased rates of postoperative infections, 12.1% versus 8.2%, p = 0.019; stroke, 4.9% versus 1.5%, p < 0.001; and mortality, 6.1% versus 2.1%, p < 0.001, when compared to patients with single or no hyperglycemia.

CONCLUSION

Every 10th patient develops infectious complications after cardiac surgery. Repeated hyperglycemia is associated with increased rates of infectious complications, stroke, and mortality.

Diabetes knowledge of nurses in different countries: An integrative review

OBJECTIVE

The aim of this study was to identify, critically appraise and synthesise evidence of nurses' knowledge of diabetes and identify factors that function as barriers to nurses' acquisition of diabetes knowledge.

DESIGN

An integrative review

METHODS

A systematic search was conducted for English-language, peer reviewed publications of any research design via CINAHL, Medline, EMBASE, and Education Research Complete databases from 2004 to 2014. Of 374 articles retrieved, after removal of duplicates and quality appraisal, 25 studies were included in the review and synthesised based on study characteristics, design and findings.

FINDINGS

Studies originated from developed and developing countries and applied a variety of research designs and tools to assess nurses' knowledge of diabetes. Assessed aspects of diabetes care included knowledge of diabetes medications (12 studies), nutrition (7), blood glucose monitoring (7), diabetes complications (6), and pathology, symptoms and diabetes management (9). Factors/barriers affecting nurses' acquisition of diabetes knowledge were identified (11). Overall, findings indicated wide-spread serious and sustained deficiencies in nurses' knowledge of diabetes and diabetes care.

CONCLUSION

With nurses demonstrating significant and long-standing knowledge deficits in many aspects of diabetes care, strategies are urgently required to overcome the identified barriers to knowledge acquisition.

Intensive care unit management of transcatheter aortic valve recipients

Severe aortic stenosis is an increasingly prevalent disease that continues to be associated with significant mortality. Transcatheter aortic valve replacements have been used as an alternative to surgical aortic valve replacement in high-risk patients with multiple comorbidities. In this review, we discuss postoperative considerations pertinent to the successful management of these complicated patients in the intensive care unit.

Effectiveness, safety and feasibility of an evidence-based insulin infusion protocol targeting moderate glycaemic control in intensive cardiac care units

OBJECTIVES

To assess the effectiveness, safety and feasibility of the revised, simplified nurse-managed version of our insulin infusion protocol, adapted to the new recommended glycaemic target of 140 to 180 mg/dL (Desio Diabetes Diagram i.v. 140-180).

METHODS

All clinical responses to the Desio Diabetes Diagram i.v. 140-180 in use for 3 years were recorded in patients with diabetes or hyperglycaemia admitted to our intensive cardiac care unit. To assess the feasibility, we asked nurses to complete an ad hoc questionnaire anonymously when the new insulin infusion protocol had been in use for 2 years.

RESULTS

From December 2010 to December 2013, 276 patients (173 men, median age 75 years) were treated according to the Desio Diabetes Diagram i.v. 140-180. The median time to reach glycaemic target was 4 h (Q1-Q3 2-8) in 128 patients with blood glucose >180 mg/dL and 2 h (Q1-Q3 1-4) in 82 patients with blood glucose <140 mg/dL. Once the target had been reached, insulin infusion was maintained for a median of 38 h (Q1-Q3 24-48) with blood glucose between 140 and 180 mg/dL for 58.3% of the infusion time. Over a total of 11,863 h of infusion, seven blood glucose <70 mg/dL occurred. The Desio Diabetes Diagram i.v. 140-180 protocol was considered easy to use by 93% of nurses.

CONCLUSIONS

The Desio Diabetes Diagram i.v. 140-180 protocol, fully managed by nurses, with insulin and glucose intravenous infusion proved effective, safe and feasible in maintaining blood glucose between 140 and 180 mg/dL in patients with diabetes or hyperglycaemia admitted to the intensive cardiac care unit for acute cardiac events.

Association of time in blood glucose range with outcomes following cardiac surgery

Background

The importance of optimal postoperative glycemic control in cardiac patients remains unclear. Various glycemic targets have been prescribed to reduce wound infection and overall mortality rates.

Aim of the work: To assess glucose control, as determined by time in range (TIR), in patients with glycemic targets of 6.0 to 8.1 mmol/L, and to determine factors related to poor control.

Methods

This prospective descriptive study evaluated 227 consecutive patients, 100 with and 127 without diabetes, after cardiac surgery. Patients received insulin to target glucose concentrations of 6.0 to 8.1 mmol/L. Data analyzed included patient age, gender, race, Euro score, cardiopulmonary bypass time (CPB), aortic cross clamp time (ACC), length of ventilation, stay in the intensive care unit (ICU) and stay in the hospital. Patients were divided into two groups, those who maintained > 80% and < 80% TIR. Outcome variables were compared in diabetics and non-diabetics.

Results

Patients with >80% and <80% TIR were matched in age, sex, gender, and Euro score. Failure to maintain target glycemia was significantly more frequent in diabetics (p = 0.001), in patients with glycated hemoglobin (HbA1c) > 8% (p = 0.0001), and in patients taking dopamine (p = 0.04) and adrenaline (p = 0.05). Times of CPB and ACC, length of stay in the ICU and ventilation were significantly higher in patients with TIR <80% than >80%. Rates of hypoglycemia, acute kidney injury, and in-hospital mortality were similar in the two groups, although the incidence of wound infection was higher in patients with TIR <80%. Both diabetics and non-diabetics with low TIR had poorer outcomes, as shown by length of stay and POAF. No significant differences were found between the two ethnic groups (Arabs and Asians).

Conclusion

Patients with >80% TIR, whether or not diabetics, had better outcomes than those with <80% TIR, as determined by wound infection, lengths of ventilation and ICU stay. Additionally, they were not subject to frequent hypoglycemic events. Preoperatively high HbA1C is likely a good predictor of poor glycemic control.

Recent advances in multidisciplinary critical care

The intensive care unit is a work environment where superior dedication is crucial for optimizing patients' outcomes. As this demanding commitment is multidisciplinary in nature, it requires special qualities of health care workers and organizations. Thus research in the field covers a broad spectrum of activities necessary to deliver cutting-edge care. However, given the numerous research articles and education activities available, it is difficult for modern critical care clinicians to keep up with the latest progress and innovation in the field. This article broadly summarizes new developments in multidisciplinary intensive care. It provides elementary information about advanced insights in the field via brief descriptions of selected articles grouped by specific topics. Issues considered include care for heart patients, mechanical ventilation, delirium, nutrition, pressure ulcers, early mobility, infection prevention, transplantation and organ donation, care for caregivers, and family matters.