Intraoperative Tight Glucose Control Using Hyperinsulinemic Normoglycemia Increases Delirium After Cardiac Surgery

Saager, Leif; Duncan, Andra E.; Yared, Jean-Pierre; Hesler, Brian D.; You, Jing; Deogaonkar, Anupa; Sessler, Daniel I.; Kurz, Andrea

doi:10.1097/01.sa.0000480666.39724.fd

Cited by 5 publications

(5 citation statements)

References 27 publications

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“…32 Another study indicated that intraoperative tight blood glucose control using hyperinsulinaemic normoglycaemia increases delirium after cardiac surgery. 33 In the present study, a higher baseline blood glucose level was an independent risk factor for PD in elderly patients undergoing THA for hip fracture. As a consequence, we would recommend tight blood glucose control during the perioperative and postoperative periods.…”

Section: Discussionsupporting

confidence: 49%

Prevalence and risk factors of postoperative delirium in elderly hip fracture patients

et al. 2016

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ObjectiveTo explore the risk factors associated with postoperative delirium (PD) in elderly patients following total hip arthroplasty (THA) for hip fracture.MethodsThis prospective study enrolled elderly patients (≥ 65 years) with hip fractures who underwent THA under general anaesthesia, and who had a complete set of postoperative observations. Detailed medical history and perioperative characteristics were recorded. During the postoperative period, patients were assessed twice daily for PD using the Confusion Assessment Method.ResultsA total of 572 patients were eligible for inclusion in the study. Of these, 120 patients (21.0%) were diagnosed with PD and 452 patients (79.0%) did not experience PD. Multivariate stepwise logistic regression analyses showed that older age, a history of stroke, lower albumin, higher blood glucose, higher total bilirubin, higher C-reactive protein, longer surgery duration and higher volume of red blood cell transfusions were independent risk factors for PD.ConclusionsCorrecting the modifiable risk factors might help prevent PD. Strategies might include nutritional support, tight blood glucose control, improvement of liver function, preoperative infection control and minimizing surgical injury or blood loss.

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Section: Discussionsupporting

confidence: 49%

Prevalence and risk factors of postoperative delirium in elderly hip fracture patients

et al. 2016

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“…80 Other strategies, including tight control of glucose levels and blood transfusions for delirium prevention in the perioperative setting, have shown varying degrees of benefit. 86,87 Moderate quality evidence suggests that adjusting the depth of anesthesia according to bispectral index monitoring can decrease the incidence of delirium. 60,88 Treatment Nonpharmacologic Approaches-Few recent studies have examined nonpharmacologic approaches for the treatment of delirium.…”

Section: Preventionmentioning

confidence: 99%

Delirium in Older Persons

Fong

Hshieh

et al. 2017

JAMA

691

306

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Importance-Delirium is defined as an acute disorder of attention and cognition. It is a common, serious, and often fatal condition among older patients. Although often underrecognized, delirium has serious adverse effects on the individual's function and quality of life, as well as broad societal effect with substantial health care costs.Objective-To summarize the current state of the art in diagnosis and treatment of delirium and to highlight critical areas for future research to advance the field.Evidence Review-We searched Ovid MEDLINE, Embase, and the Cochrane Library for the past 6 years, from January 1, 2011 until March 16, 2017 using a combination of controlled vocabulary and keyword terms. Since delirium is more prevalent in older adults, the focus was on studies in elderly populations; studies based solely in the intensive care unit (ICU) and non-English-language articles were excluded.Findings-Of 127 articles included, 25 were clinical trials, 42 cohort studies, 5 systematic reviews and meta-analyses, and 55 were other categories. A total of 11 616 patients were represented in the treatment studies. Advances in diagnosis have included the development of brief screening tools with high sensitivity and specificity, such as the 3-Minute Diagnostic Assessment, 4 A's test, and proxy-based measures such as the Family Confusion Assessment Method. Measures of severity, such as the Confusion Assessment Method-Severity Score, can aid in monitoring response to treatment, risk stratification, and assessing prognosis. Nonpharmacologic approaches focused on risk factors such as immobility, functional decline, visual or hearing impairment, dehydration, and sleep deprivation are effective for delirium prevention and also are recommended for delirium treatment. Current recommendations for pharmacologic treatment of

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“…In contrast, Gandhi et al found a higher risk of death and stroke after tight glycemic control for values of 80‐100 mg/dL. Saager et al even found a higher delirium rate after intraoperative tight glycemic control to maintain levels between 80 and110 mg/dL compared to conventional targets below 150 mg/dL. Overall, there is evidence that tight glycemic control may increase the incidence of hypoglycemia and mortality, which in turn can lead to irreversible brain damage .…”

Section: Discussionmentioning

confidence: 99%

Impact of Intraoperative Hyperglycemia on Brain Structures and Volumes

Lachmann

Spies

Windmann

et al. 2018

Journal of Neuroimaging

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BACKGROUND AND PURPOSE In hyperglycemic patients, who succumbed to septic shock, an increased rate of apoptosis of microglial cells and damaged neurons of the hippocampus were found. However, the influence of perioperative glucose levels on hippocampal brain structures has not yet been investigated. METHODS As part of the ongoing BIOCOG project, a subgroup of N = 65 elderly nondemented patients were analyzed who underwent elective surgery of ≥60 minutes. In these patients, at least one intraoperative blood glucose (BG) measurement was available from the medical charts. Intraoperative glucose maximum was determined in each patient. Preoperatively and at 3 months follow‐up, structural neuroimaging was performed with T1‐weighted magnetization prepared rapid gradient‐echo sequence (MP‐Rage) and a dedicated high‐resolution hippocampus magnetic resonance imaging (MRI). The MRI scans were analyzed to assess pre‐ or postoperative volume changes of the hippocampus as a whole and hippocampal subfields. We also assessed changes of frontal lobe volume and cortical thickness. RESULTS Overall, 173 intraoperative BG levels were obtained in 65 patients (median 2 per patient). A total of 18 patients showed intraoperative hyperglycemia (glucose maximum ≥150 mg/dL). Controlling for age and diabetes status, no significant impact of intraoperative hyperglycemia was found on the pre–post volume change of the hippocampus as a whole, hippocampal subfields, frontal lobe, and frontal cortical thickness. CONCLUSIONS This study found no effect of intraoperative hyperglycemia on postoperative brain structures and volumes including volumes of hippocampus and hippocampal subfields, frontal lobe, and frontal cortical thickness. Further studies investigating the impact of intraoperatively elevated glucose levels should consider a tighter or even continuous glycemic measurement and the determination of central microglial activation.

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Intraoperative Tight Glucose Control Using Hyperinsulinemic Normoglycemia Increases Delirium After Cardiac Surgery

Cited by 5 publications

References 27 publications

Prevalence and risk factors of postoperative delirium in elderly hip fracture patients

Prevalence and risk factors of postoperative delirium in elderly hip fracture patients

Delirium in Older Persons

Impact of Intraoperative Hyperglycemia on Brain Structures and Volumes

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