Reduction of Surgical Mortality and Morbidity in Diabetic Patients Undergoing Cardiac Surgery With a Combined Intravenous and Subcutaneous Insulin Glucose Management Strategy

Abstract

OBJECTIVE -To determine if glucose management in postcardiothoracic surgery patients with a combined intravenous (IV) and subcutaneous (SC) insulin regimen reduces mortality and morbidity in patients with diabetes and stress-induced hyperglycemia.RESEARCH DESIGN AND METHODS -Retrospective review of 614 consecutive patients who underwent cardiothoracic (CT) surgery in 2005 was performed to evaluate the incidence and treatment of postoperative hyperglycemia and operative morbidity and mortality. Hyperglycemic patients (glucose Ͼ6.05 mmol/l) were treated with IV insulin in the intensive care unit (ICU) followed by SC insulin (outside ICU). Subgroup analysis was performed on 159 coronary artery bypass grafting (CABG)-only patients.RESULTS -Among all CT surgeries, patients with a preoperative diagnosis of diabetes had higher rates of postoperative mortality (7.3 vs. 3.3%; P ϭ 0.03) and pulmonary complications (19.5 vs. 11.6%; P ϭ 0.02) but had similar rates of infections and cardiac, renal, and neurological complications on univariate analysis. However, on multivariate analysis, a preoperative diagnosis of diabetes was not a significant factor in postoperative mortality or pulmonary complications. In CABG-only patients, no significant differences were seen in outcomes between diabetic and nondiabetic patients. Independent of diabetic status, glucose Ն11 mmol/l on ICU admission was predictive of higher rates of mortality and renal, pulmonary, and cardiac postoperative complications.CONCLUSIONS -A combination of IV insulin (in the ICU) and SC insulin (outside the ICU), a less costly and less nursing-intensive therapy than 3 days of IV insulin postoperatively, results in a reduction of the increased surgical morbidity and mortality in diabetic patients after CT surgery. Diabetes Care 30:823-828, 2007

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

“…Furnary et al (11) have shown that patients who had mean glucose levels of .150 mg/dL in the first 3 days after cardiac surgery have twice the infection rate and 13 times the mortality compared with normoglycemic patients. In our previous studies at Northwestern University (22,23), using intravenous and subcutaneous insulin regimens with the previous target glucose level of 80-110 mg/dL with a GMS consultation, we have shown that the postoperative complication rates for patients undergoing cardiac surgery were similar in diabetic and nondiabetic subjects, unlike the very high levels of complications in diabetic patients found by others when glycemic control was not achieved (14). van den Berghe et al (10) first reported a 42% reduction in mortality in surgical ICU patients (87% without diabetes) when they were randomized to an intensive control group (BG level 80-110 mg/dL) versus a conventional group (BG level ,180 mg/dL).…”

“…This new guideline recommended a BG target of 140-180 mg/dL, with 110-140 mg/dL being marked as acceptable in certain centers with considerable experience with such management. Because of our prior extensive experience and studies at Northwestern Memorial Hospital (NMH) demonstrating the safety of intravenous insulin protocols with a BG target of 80-110 mg/dL (22,23), we decided to change to the 110-140 mg/dL target. As a result, the intravenous insulin infusion and subcutaneous injection protocols used by our Glucose Management Service (GMS) at NMH were modified in 2009, so that the target BG levels for the intravenous protocol would be 110-140 mg/dL instead of 80-110 mg/dL, and the fasting and preprandial glucose levels during the subcutaneous insulin protocol would be 110-180 mg/dL instead of 80-150 mg/dL.…”

“…On the day of conversion, this same 10% dose of rapid-acting insulin was given subcutaneously preprandially. On subsequent days, the doses of insulin glargine and lispro/aspart were generally reduced by ;20% per day, depending upon the clinical situation of the patient as judged by the GMS (22,23). The fasting and premeal targets during subcutaneous treatment were 80-150 mg/dL for the 80-110 group and 110-180 mg/dL for the 110-140 group.…”

Preoperative glucose as a screening tool in patients without diabetes

“…[1][2][3] Reduced morbidity and mortality from improved glycemic control in surgical patients also support the association between hyperglycemia and post-operative outcomes. [4][5][6][7][8][9] However, the risks of unrecognized hyperglycemia (in patients not known to have diabetes) prior to surgical operations remain unclear. Although Ramos et al have investigated associations between post-operative hyperglycemia and post-operative complications, 10 we were interested in using pre-operative blood glucose as a marker for post-operative complications in patients not known to have diabetes.…”

Preditores de infecção no pós-operatório de cirurgia de revascularização miocárdica

“…Once identified the association between diabetes and diabetes/infection with increased length of hospital stay, it is up to the managers the implementation of measures that are able to reduce these outcomes [21,23,30,31], aiming at cost reduction as already demonstrated in other institutions [22].…”