Effect of Perioperative Insulin Infusion on Surgical Morbidity and Mortality: Systematic Review and Meta-analysis of Randomized Trials

Gandhi, Gunjan Y.; Murad, M. Hassan; Flynn, David N.; Erwin, Patricia J.; Cavalcante, Alexandre; Nielsen, Henning Bay; Capes, Sarah E.; Thorlund, Kristian; Montori, Víctor M.; Devereaux, P. J.

doi:10.4065/83.4.418

Cited by 75 publications

(48 citation statements)

References 67 publications

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“…223 Similarly, a more recent systematic review and meta-analysis suggested that perioperative insulin infusion versus control therapy may reduce perioperative mortality in patients undergoing any surgery, including a nearly significant benefit in patients with acute MI who did not receive reperfusion therapy, but at the "expense" of an increased risk of hypoglycemia. 224 Meta-analysis of 5 studies (3 randomized trials and 2 cohort) comparing intensive and conventional insulin in critically ill patients reported a reduction in the incidence of acute kidney injury by 38% with intensive therapy (RR, 0.62; 95% CI, 0.47 to 0.83). 225 These observations suggest potential benefit for intensive insulin in reducing delayed graft function after transplantation.…”

Section: Perioperative Medical Management Of Cardiovascular Risk Befomentioning

confidence: 99%

Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates

Lentine¹,

Costa²,

Weir³

et al. 2012

Circulation

287

159

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Section: Perioperative Medical Management Of Cardiovascular Risk Befomentioning

confidence: 99%

Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates

Lentine¹,

Costa²,

Weir³

et al. 2012

Circulation

287

159

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“…In a systematic review and meta-analysis of randomized controlled trials, Gandhi et al[ 27] showed that perioperative insulin infusion reduces mortality and increases hypoglycemia in patients undergoing surgery but without a significant effect on other important outcomes. No or greatly varying glycemic targets were set in the original studies, however, which is a major limitation for comparing the results obtained and to draw conclusions on the efficacy of strict glycemic control with intensive insulin therapy.…”

Section: Insulin Therapy In the Icumentioning

confidence: 99%

Insulin Treatment in Intensive Care Patients

Derde

Vanhorebeek²,

Berghe³

2008

Horm Res Paediatr

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Hyperglycemia is a major risk factor for increased morbidity and mortality in the intensive care unit. In two large randomized controlled single-center studies, the maintenance of strict normoglycemia with intensive insulin therapy has been shown to reduce morbidity and mortality. The benefits were more pronounced with at least a few days of treatment. Several implementation studies confirmed that blood glucose control with intensive insulin therapy is beneficial for critically ill patients. Two studies planned as large randomized controlled trials evaluating the effect of glycemic control in adults were stopped prematurely because of protocol violation and/or increased risk of hypoglycemia. The only multicenter trial designed with sufficient statistical power to assess the impact of strict blood glucose control with intensive insulin therapy on survival of a heterogeneous adult critically ill patient population is still ongoing. While awaiting these results, the current evidence favors strict control of blood glucose levels to normoglycemia below 110 mg/dl. Avoiding glucose toxicity appears crucial to obtain the clinical benefits of this therapy, although direct insulin effects may contribute as well.

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“…Given the inconsistent results from various randomized controlled trials and the variability in hypoglycemic outcomes, there were calls for a reevaluation of the risks and benefits of intensive glycemic control in critically ill medical and surgical patients (19,20). This led to a recommendation by the American Association of Clinical Endocrinologists and the American Diabetes Association for higher targets for glycemic control in inpatients (21).…”

mentioning

confidence: 99%

Comparison of Glycemic and Surgical Outcomes After Change in Glycemic Targets in Cardiac Surgery Patients

et al. 2014

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OBJECTIVE To compare perioperative glycemic and long-term surgical outcomes in patients undergoing cardiac surgery before and after the recommended 2009 changes in inpatient glycemic targets. RESEARCH DESIGN AND METHODS We performed a retrospective review of patients who underwent cardiac surgery between 4 September 2007 and 30 April 2011. Comparison was made of blood glucose (BG) outcomes 3 days after surgery, and 30-day cardiac outcomes before and after a change in insulin protocol that took place on 1 September 2009, which consisted of raising the glycemic targets during intravenous insulin infusions from 80–110 mg/dL (80–110 group) to 110–140 mg/dL (110–140 group). RESULTS When compared with the 80–110 group (n = 667), the 110–140 group (n = 658) had higher mean postoperative BG levels during the intravenous insulin infusion (141 ± 15 vs. 121 ± 15 mg/dL, P < 0.001) and the subcutaneous insulin period (134 ± 24 vs. 130 ± 23 mg/dL, P < 0.001), and for 3 days postoperatively (141 ± 17 vs. 127 ± 15 mg/dL, P < 0.001). Fewer patients in the 110–140 mg/dL group experienced moderate hypoglycemia (BG <70 mg/dL) (177 vs. 73, P = 0.04). Severe hypoglycemia (BG <40 mg/dL) occurred in only one patient in the 80–110 group and three patients in the 110–140 group. There were no significant differences in mortality or surgical complication rates (with the exception of reintubation) between the groups. CONCLUSIONS The higher glycemic target of 110–140 mg/dL resulted in similar mean glucose values, with significantly less hypoglycemia and no significant differences in mortality/morbidity compared with the more strict target of 80–110 mg/dL.

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Effect of Perioperative Insulin Infusion on Surgical Morbidity and Mortality: Systematic Review and Meta-analysis of Randomized Trials

Cited by 75 publications

References 67 publications

Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates

Cardiac Disease Evaluation and Management Among Kidney and Liver Transplantation Candidates

Insulin Treatment in Intensive Care Patients

Comparison of Glycemic and Surgical Outcomes After Change in Glycemic Targets in Cardiac Surgery Patients

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