Postoperative outcome for hyperglycemic pediatric cardiac surgery patients

Effect of hyperglycemia treatment on complications rate after pediatric cardiac surgery

Introduction: The goal of this study was to elucidate harmful complications of intraoperative hyperglycemia following children cardiac surgery and benefits of insulin administration for accurate blood sugar controlling.

Methods: this study is a Randomized clinical trial. We conducted this study in the operating room of shahid madani hospital. Fifty patients who were children under 12 years old undergone cardiac surgery using cardiopulmonary bypass (CPB). Intraoperative insulin infusion was administered intravenously targeting blood sugar levels of 110-140 mg/dL. Blood sugar and arterial blood gas (ABG) were measured every 30 min during operation.

Results: Inotropes were used less in the study than the placebo group during surgery. The means of hospitalization and extubation time were more in the placebo group than the study group(P =0.03) and (P =0.005), respectively. However, the mean time of hospitalization in the ICU ward did not differ significantly between the two groups.

Conclusion: Hyperglycemia has a relation with long time of intubation and hospitalization in ICU. These findings suggest the positive effect of accurate blood sugar control on reducing complication and hospitalization time in children undergoing cardiac surgery.

Methylprednisolone in Pediatric Cardiac Surgery: Is There Enough Evidence?

Corticosteroids have been used to decrease the inflammatory response to cardiac surgery and cardiopulmonary bypass in children for decades. Sparse information is present concerning the pharmacokinetics and pharmacodynamics of corticosteroids in the context of pediatric cardiac surgery. There is large interindividual variability in plasma concentrations, with indications for a larger volume of distribution in neonates compared to other age groups. There is ample evidence that perioperative use of MP leads to a decrease in pro-inflammatory mediators and an increase in anti-inflammatory mediators, with no difference in effect between doses of 2 and 30 mg/kg. No differences in inflammatory mediators have been shown between different times of administration relative to the start of surgery in various studies. MP has been shown to have a beneficial effect in certain subgroups of patients but is also associated with side effects. In lower risk categories, the balance between risk and benefit may be shifted toward risk. There is limited information on short- to medium-term outcome (mortality, low cardiac output syndrome, duration of mechanical ventilation, length of stay in the intensive care unit or the hospital), mostly from underpowered studies. No information on long-term outcome, such as neurodevelopmental outcome, is available. MP may provide a small benefit that is easily abolished by patient characteristics, surgical techniques, and perfusion management. The lack of evidence leads to large differences in practice between and within countries, and even within hospitals, so there is a need for adequately powered randomized studies.

Antenatal and Perioperative Mechanisms of Global Neurological Injury in Congenital Heart Disease

Congenital heart defects (CHD) is one of the most common types of birth defects. Thanks to advances in surgical techniques and intensive care, the majority of children with severe forms of CHD survive into adulthood. However, this increase in survival comes with a cost. CHD survivors have neurological functioning at the bottom of the normal range. A large spectrum of central nervous system dysmaturation leads to the deficits seen in critical CHD. The heart develops early during gestation, and CHD has a profound effect on fetal brain development for the remainder of gestation. Term infants with critical CHD are born with an immature brain, which is highly susceptible to hypoxic-ischemic injuries. Perioperative blood flow disturbances due to the CHD and the use of cardiopulmonary bypass or circulatory arrest during surgery cause additional neurological injuries. Innate patient factors, such as genetic syndromes and preterm birth, and postoperative complications play a larger role in neurological injury than perioperative factors. Strategies to reduce the disability burden in critical CHD survivors are urgently needed.

Risk factors for postoperative hyperglycemia in neonates

OBJECTIVE

Postoperative hyperglycemia has been shown to be associated with higher morbidity and mortality in pediatric patients. Data on risk factors for neonatal patients is limited. The objective of this study was to identify pre- and intraoperative risk factors associated with postoperative glucose in neonates.

METHODS

We conducted a retrospective cohort study of neonates after surgical procedures between January and December 2016 in a quaternary neonatal intensive care unit. The primary outcome was hyperglycemia defined as serum glucose ≥8.3 mmol/L during the first 4 hours postoperatively. Secondary outcomes included death and length of stay. We assessed the association of risk factors with the postoperative glucose.

RESULTS

In total, 206 surgical procedures (171 patients) were evaluated, among which 178 had serum glucose values during the first 4 hours postoperatively available. The incidence of hyperglycemia was 54% (n = 96). The median (IQR) glucose during the first 4 hours in NICU was 8.4 (6.52-10.65) mmol/L. Risk factors for postoperative hyperglycemia were intraoperative glucose infusion rate (GIR) and gestational age. There was a non-linear relationship between gestational age and postoperative hyperglycemia. Mortality occurred in 6 (7%) in the no-hyperglycemia group and 3 (3%) in the hyperglycemia group (p = 0.31).

CONCLUSIONS

Among the risk factors, intraoperative GIR was identified as a modifiable factor that can reduce postoperative hyperglycemia. A non-linear relationship of gestational age with postoperative glucose provides new insights that may help advance our understanding of the complex mechanisms of glucose homeostasis in neonates.

Rapid Advancement in Enteral Nutrition Does Not Affect Systemic Inflammation and Insulin Homeostasis Following Pediatric Cardiopulmonary Bypass Surgery

OBJECTIVES

To determine impact of enteral nutrition delivery on the relationship among inflammation, insulin resistance, and outcomes following pediatric cardiopulmonary bypass surgery.

DESIGN

Pilot, randomized study analyzed according to intention-to-treat analysis.

SETTING

Pediatric cardiac ICU.

PATIENTS

Infants (≤ 6 mo) undergoing cardiopulmonary bypass.

INTERVENTIONS

Patients randomly assigned to receive rapid escalation to enteral nutrition reaching goal feeds by 27 hours or standard feeding practice reaching goal feeds by 63 hours. Feeds were initiated on the first postoperative day.

MEASUREMENTS AND MAIN RESULTS

Fifty patients were randomized equally to study arms. Patients were a median (interquartile range) of 16 days old (7-110 d old), undergoing biventricular surgery (88%) with a median cardiopulmonary bypass time of 125 minutes (105-159 min). Serial blood samples were drawn before and after cardiopulmonary bypass, cardiac ICU admission, and every 12 hours (up to 96 hr) for glucose, insulin, and cytokines (interleukin-1α, interleukin-6, interleukin-8, interleukin-10, and tumor necrosis factor-α) levels. Glucose-insulin ratio was calculated to quantify insulin resistance. Patient characteristics, time to enteral nutrition initiation, enteral nutrition interruptions, and insulin administration were similar across intervention arms. FF reached goal feeds at similar intervals as standard feeding (39 hr [30-60 hr] vs 60 hr [21-78 hr]; p = 0.75). No difference in cytokine, insulin, or glucose-insulin ratio was noted between groups. Higher inflammation was associated with increased glucose-insulin ratio and higher risk of adverse events. In multivariable models of interleukin-8, FF was associated with increased glucose-insulin ratio (estimate of effect [95% CI], 0.152 [0.033-0.272]; p = 0.013). Although higher interleukin-8 was associated with an elevated risk of adverse event, this relationship was possibly mitigated by FF (odds ratio [95% CI], 0.086 [0.002-1.638]; p = 0.13).

CONCLUSIONS

A FF strategy was not associated with changes to early enteral nutrition delivery. Inflammation, insulin resistance, and morbidity were similar, but FF may modify the relationship between inflammation and adverse event. Multicenter nutrition studies are possible and necessary in this vulnerable population.

Feeding May Modulate the Relationship Between Systemic Inflammation, Insulin Resistance, and Poor Outcome Following Cardiopulmonary Bypass for Pediatric Cardiac Surgery

BACKGROUND

Hyperglycemia is common following cardiopulmonary bypass (CPB) surgery and is associated with poor outcomes, often attributed to hyperinsulinemia and an acquired state of insulin resistance. This study examined the underpinnings of hyperglycemia and the effects of nutrition on the association with inflammation and clinical outcomes.

METHODS

This prospective, observational cohort study enrolled consecutive children (<18 years) undergoing CPB. Serial measurements of inflammatory cytokines, glucose, insulin, and nutrition delivery were obtained. Glucose-insulin ratio (G:I) was calculated for each time point as a measure of insulin resistance (lower G:I reflects higher resistance). Clinical outcomes were recorded using a composite morbidity score.

RESULTS

The 200 subjects studied were predominantly females (58%) undergoing biventricular repair (85%) at a median (interquartile range) age of 0.58 years (0.28, 3.4) and weight of 7.0 kg (3.1, 59.5). Hyperglycemia was common (49% of patients), coinciding with peak cytokine concentrations. Insulin levels were highest and G:I lowest immediately following separation from CPB but had no consistent relationship with cytokines. The morbidity outcome was reached by 23% of patients, with increased odds associated with higher interleukin (IL)6 and IL8 levels but not by glucose, insulin, or G:I. Providing higher feeding volumes attenuated this association between inflammation and morbidity. Higher feeds were not associated with G:I but appeared to decrease the strength of the relationship between cytokines and glycemic indices.

CONCLUSION

Postoperative morbidity is independently associated with increased inflammation but not with hyperglycemia or markers of insulin resistance. Higher feeding volume may modify these relationships and have a protective role.

A Comparison of the Sociodemographic and Clinical Characteristics of Patients Referring to a Pain Clinic with Subacute and Chronic Pain

OBJECTIVES

The aim of the present study was to assess and compare the sociodemographic characteristics and clinical features of patients referring to a university hospital's pain clinic with chronic ( ≥ 12 weeks) and subacute pain ( < 12 weeks).

METHODS

In this cross-sectional study, 426 patients were included. Demographic variables including education level, marital and employment status, and risk factors such as obesity, diabetes mellitus, hypertension, cigarette smoking, and opium addiction were recorded. Also, sites of pain, pain quality and associated symptoms, and pain severity were assessed using a numerical rating scale. Each one of these variables was compared between the chronic and subacute pain groups.

RESULTS

Of the 426 studied patients, 292 (69%) had chronic pain and 134 (31%) reported subacute pain. Patients with chronic pain were older and had higher body mass indices. Additionally, self-employment was less frequent among the chronic pain group. The patients with chronic pain had a higher prevalence of addiction. The most commonly reported site of pain in all patients was the lower back (62.4%), followed by pain in the leg and foot (39.9%), knee (24.4%), and hip (18.8%). There were no statistically significant differences in pain sites between the two groups, except for knee pain, which was more common among the chronic pain group. The patients with chronic pain had a higher incidence of obscure and persistent pain, while those with subacute pain experienced more night pain.

CONCLUSIONS

About one-third of the patients referring to the pain clinic had subacute pain. The patients with chronic pain were older and more obese, had a higher prevalence of addiction, had more cases of knee pain, and reported more instances of obscure and persistent pain than those with subacute pain.

Predisposing Factors for Hypoglycemia and Its Relation With Mortality in Critically Ill Patients Undergoing Insulin Therapy in an Intensive Care Unit

Background:

Hypoglycemia is a common and the most important complication of intensive insulin therapy in critically ill patients. Because of hypoglycemia’s impact on the cardinal organs as a fuel, if untreated it could results in permanent brain damage and increased mortality.

Objectives:

In this study, we aim to evaluate the incidence of hypoglycemia, its risk factors, and its relationship with mortality in critically ill patients.

Patients and Methods:

Five hundred adult patients who admitted to an intensive care unit (ICU) were enrolled in this study. A program of glycemic control with a target of 100 - 140 mg/dL was instituted. We used the threshold of 150 mg/dL for septic patients, which were monitored by point of care devices for capillary blood measurement. We detected hypoglycemia with a blood sugar of less than 50 mg/dL and with the detection of each episode of hypoglycemia, blood glucose measurement was performed every 30 minutes.

Results:

Five hundred patients experienced at least one episode of hypoglycemia, almost always on the third day. Of 15 expired patients who had one hypoglycemia episode, the most common causes were multiple trauma and sepsis. Increases in the sequential organ failure assessment (SOFA) number augmented the hypoglycemia risk to 52% (P < 0.001). Moreover, in patients with acute kidney injury (AKI), the risk of hypoglycemia is 10 times greater than in those without AKI (RR: 10.3, CI: 3.16 - 33.6, P < 0.001). ICU admission blood sugar has a significant relationship with mortality (RR: 1.01, CI: 1.004 - 1.02, P < 0.006). Hypoglycemia increased the mortality rate twofold, but it was not significant (RR: 1.2, CI: 0.927 - 1.58, P = 0.221).

Conclusions:

Our results showed that the SOFA score, AKI, and hemoglobin A1c are the independent risk factors for the development of hypoglycemia and demonstrated that ICU admission blood glucose, Hba1c, and hypoglycemia increased the risk of death, but only ICU admission blood glucose is significantly related to increased mortality.

Single Dose Corticosteroid Therapy After Surgical Repair of Fallot's Tetralogy; A Randomized Controlled Clinical Trial

Background:

Inflammatory reaction can produce several complications after cardiac surgery. Many attempts have been made to reduce these complications; perioperative corticosteroid therapy is one of the simplest methods.

Objectives:

We conducted a randomized study to evaluate the efficacy of single dose methylprednisolone, prescribed after surgery, for reducing the complications. Repair of Tetralogy of Fallot was chosen as a homogenous large group for the study.

Patients and Methods:

One hundred children who underwent total repair of Tetralogy of Fallot were enrolled in this study. After the surgery, all patients were transferred to pediatric ICU and were randomized (in a double-blind fashion) in 2 groups (A and B); a single dose of methylprednisolone (30 mg/kg of body weight) was injected to participants of group “A” just at the time of ICU entrance. Group “B” received no drug. Then, clinical outcomes and laboratory data were compared between the two groups.

Results:

The only significant differences were lower incidence of bacteremia and higher incidence of hyperglycemia in the group who were used methylprednisolone.

Conclusions:

Using a single postsurgical dose of methylprednisolone does not significantly alter the clinical outcome after repairing Tetralogy of Fallot.

Does tight glycemic control improve outcomes in pediatric patients undergoing surgery and/or those with critical illness?

This literature review examines the current evidence regarding the potential usefulness of tight glycemic control in pediatric surgical patients. In adults, fluctuations in glucose levels and/or prolonged hyperglycemia have been shown to be associated with poor outcomes with respect to morbidity and mortality. This review begins by summarizing the findings of key papers in adult patients and continues by investigating whether or not similar results have been seen in pediatric patients by performing a comprehensive literature review using Medline (OVID). A database search using the OVID interface and including the search terms (exp glucose) AND (exp surgery) AND (exp Paediatric/pediatric) AND (exp Hypoglycaemia/hypoglycemia) AND (exp Hyperglycaemia/hyperglycemia) yielded a total of 150+ papers, of which 24 fulfilled our criteria. We isolated papers utilizing pediatric patients who were hospitalized due to illness and/or surgery. Our review highlights several difficulties encountered in addressing this potentially useful clinical intervention. An absence of scientifically robust and randomized trials and the existence of several small-powered trials yielding conflicting results mean we cannot recommend tight glycemic control in these patients. Differences in study design and disagreements concerning the crucial stage of surgery where hyperglycemia becomes important are compounded by an over-reliance on the discretion of clinicians in the absence of well described treatment protocols. Closer inspection of key papers in adult patients identified fundamental discrepancies between exact definitions of both hyperglycemia and hypoglycemia. This lack of consensus, along with a fear of inducing iatrogenic hypoglycemia in pediatric patients, has resulted in professional bodies advising against this form of intervention. In conclusion, we cannot recommend use of tight glycemic control in pediatric surgical patients due to unclear glucose definitions, unclear thresholds for treatment, and the unknown long-term effects of iatrogenic hypoglycemia on the developing body and brain.

Control of serum glucose concentration in critical illness

PURPOSE OF REVIEW

Hyperglycemia is a significant problem for children in the ICU. Use of tight glycemic control (TGC) to manage hyperglycemia remains controversial, especially given the potential risk of insulin-induced hypoglycemia. This review will address the latest evidence regarding TGC in critically ill children.

RECENT FINDINGS

Two randomized controlled trials (RCT) involving primarily postoperative cardiac surgery patients demonstrated the feasibility and safety of TGC in pediatric patients. The trials, however, had discrepant results with regards to the benefit of TGC. There is also uncertainty about the generalizability of these results to nonpostoperative cardiac patients. There is only one published study addressing the long-term safety of TGC in children. In this study, hypoglycemia was not associated with adverse effects on neurocognitive development. In contrast, articles from adult studies demonstrate increased risk of death with hypoglycemia.

SUMMARY

Although the clinical benefit of TGC in critically ill children is still unclear, TGC can be done safely in this population.

Hyperglycemia or high hemoglobin A1C: Which one is more associated with morbidity and mortality after coronary artery bypass graft surgery?

PROPOSE

Our aim was to determine which criterion- hyperglycemia or high levels of glycosylated hemoglobin (HbA1C) is more associated with increased mortality and morbidity after coronary artery bypass graft (CABG).

METHODS

Two hundred and sixteen patients who underwent elective CABG were enrolled in this prospective study. In order to compare postoperative outcomes regarding HbA1c and fasting blood sugar (FBS) levels, the patients were divided into two groups based on plasma HbA1c levels >7% or ≤7% and FBS >126 mg/dl or ≤126 mg/dl.

RESULTS

Of 216 studied patients, 165 and 51 cases had levels of HbA1C ≤7% and HbA1c >7% respectively. Furthermore, 129 and 87 patients had levels of FBS of ≤126 mg/dl and FBS of >126 mg/dl respectively. Multivariate analyses revealed that patients with high HbA1C levels experienced significantly higher rates of postoperative re-intubation [P = 0.001, OR (95% CI) = 8.15 (2.88-23.09)], wound infection [P = 0.001, OR (95% CI) = 8.15 (2.88-23.09)] and bleeding [P = 0.027, OR (95% CI) = 2.18 (1.10-4.35)]. In addition, hyperglycemic patients had a higher frequency of arrhythmias [P = 0.001, OR (95% CI) = 3.07 (1.69-5.59)], atelectasis [P = 0.029, OR (95% CI) = 1.88 (1.07-3.30)] and wound infection [P = 0.001, OR (95% CI) = 8.75 (2.45-31.25)].

CONCLUSION

Higher levels of both HbA1C and FBS contribute to the increased risk of morbidity but not mortality rates in post-CABG surgery patients; yet further studies are required to distinguish "a better predictor" of postoperative adverse events.