Intensive Glycemic Control in Cardiac Surgery

Risk factors and clinical outcome of postoperative hyperglycemia after cardiac surgery with cardiopulmonary bypass

Background

There is a high incidence of postoperative hyperglycemia (PHG) in cardiac surgery with cardiopulmonary bypass (CPB), as well as increased morbidity and mortality. The purpose of this study was to evaluate the incidence of PHG after cardiac surgery with CPB, the independent risk factors, and its association with clinical outcomes.

Methods

This was a retrospective, observational study of patients who underwent cardiac surgery with CPB between January 2023 and March 2024 in West China Hospital of Sichuan University. A total of 1,008 consecutive postoperative cardiac surgery patients admitted to the cardiac surgery intensive care unit (ICU) were divided into a non-PHG group and a PHG group. Patients' blood glucose levels were evaluated immediately after cardiac surgery and every 3-4 h daily for 10days, until discharge from the ICU. For patients with PHG, intravenous insulin infusion was performed according to the institution's protocol, and perioperative risk factors for hyperglycemia and clinical outcomes were assessed.

Results

PHG, defined as random blood glucose ≥10.0 mmol/L (180 mg/dl) on two occasions within 24 h, occurred in 65.28% of cardiac surgery patients. Multivariable logistic regression analysis identified that age [odds ratio (OR) 1.054, 95% confidence interval (CI) 1.040-1.069; p < 0.001], female sex (OR 1.380, 95% CI 1.023-1.864; p = 0.035), diabetes (OR 13.101, 95% CI 4.057-42.310; p < 0.001), pulmonary infection (OR 1.918, 95% CI 1.129-3.258; p = 0.016), aortic cross-clamp time (OR 1.007, 95% CI 1.003-1.010; p < 0.001), and intraoperative highest glucose (OR 1.515, 95% CI 1.370-1.675; p < 0.001) emerged as independent risk factors for PHG. Moreover, PHG had higher rates of acute kidney injury (12.61% vs. 4.00%; p < 0.001), delirium (9.57% vs. 3.43%; p < 0.001), pulmonary infection (12.01% vs. 5.14%; p < 0.001), longer duration of mechanical ventilation (19 vs. 14 h; p < 0.001), length of ICU stay (74 vs. 58 h; p < 0.001), length of hospitalization (13 vs. 11 days; p < 0.001), and higher rate of self-discharge or death (3.95% vs. 0.57%; p = 0.002) compared with patients with non-PHG.

Conclusions

PHG occurs frequently in patients after cardiac surgery. Age, female, diabetes, pulmonary infection, aortic cross-clamp time, and intraoperative highest glucose were independent risk factors for PHG. PHG is associated with worse clinical outcomes, including a higher rate of acute kidney injury, delirium, and pulmonary infection, greater duration of mechanical ventilation, length of ICU stay, length of hospitalization, and higher rate of automatic discharge or death.

Electronic Glycemic Management System Improved Glycemic Control and Reduced Complications in Patients With Diabetes Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial

BACKGROUND

In-hospital hyperglycemia poses significant risks for patients with diabetes mellitus undergoing coronary artery bypass graft (CABG) surgery. Electronic glycemic management systems (eGMSs) like InsulinAPP offer promise in standardizing and improving glycemic control (GC) in these settings. This study evaluated the efficacy of the InsulinAPP protocol in optimizing GC and reducing adverse outcomes post-CABG.

METHODS

This prospective, randomized, open-label study was conducted with 100 adult type 2 diabetes mellitus (T2DM) patients post-CABG surgery, who were randomized into two groups: conventional care (gCONV) and eGMS protocol (gAPP). The gAPP used InsulinAPP for insulin therapy management, whereas the gCONV received standard clinical care. The primary outcome was a composite of hospital-acquired infections, renal function deterioration, and symptomatic atrial arrhythmia. Secondary outcomes included GC, hypoglycemia incidence, hospital stay length, and costs.

RESULTS

The gAPP achieved lower mean glucose levels (167.2 ± 42.5 mg/dL vs 188.7 ± 54.4 mg/dL; P = .040) and fewer patients-day with BG above 180 mg/dL (51.3% vs 74.8%, P = .011). The gAPP received an insulin regimen that included more prandial bolus and correction insulin (either bolus-correction or basal-bolus regimens) than the gCONV (90.3% vs 16.7%). The primary composite outcome occurred in 16% of gAPP patients compared with 58% in gCONV (P < .010). Hypoglycemia incidence was lower in the gAPP (4% vs 16%, P = .046). The gAPP protocol also resulted in shorter hospital stays and reduced costs.

CONCLUSIONS

The InsulinAPP protocol effectively optimizes GC and reduces adverse outcomes in T2DM patients' post-CABG surgery, offering a cost-effective solution for inpatient diabetes management.

The prognosis of patients with postoperative hyperglycemia after Stanford type A aortic dissection surgery and construction of prediction model for postoperative hyperglycemia

Objective

The mortality of type A aortic dissection (TAAD) is extremely high. The effect of postoperative hyperglycemia (PHG) on the prognosis of TAAD surgery is unclear. This study aims to investigate the prognosis of patients with PHG after TAAD surgery and construct prediction model for PHG.

Methods

Patients underwent TAAD surgery from January 2016 to December 2020 in Xiangya Hospital were collected. A total of 203 patients were included and patients were divided into non PHG group and PHG group. The occurrence of postoperative delirium, cardiac complications, spinal cord complication, cerebral complications, acute kidney injury (AKI), hepatic dysfunction, hypoxemia, and in-hospital mortality were compared between two groups. Data from MIMIC-IV database were further applied to validate the relationship between PHG and clinical outcomes. The prediction model for PHG was then constructed using Extreme Gradient Boosting (XGBoost) analysis. The predictive value of selected features was further validated using patient data from MIMIC-IV database. Finally, the 28-days survival rate of patient with PHG was analyzed using data from MIMIC-IV database.

Results

There were 86 patients developed PHG. The incidences of postoperative AKI, hepatic dysfunction, and in-hospital mortality were significant higher in PHG group. The ventilation time after surgery was significant longer in PHG group. Data from MIMIC-IV database validated these results. Neutrophil, platelet, lactic acid, weight, and lymphocyte were selected as features for prediction model. The values of AUC in training and testing set were 0.8697 and 0.8286 respectively. Then, five features were applied to construct another prediction model using data from MIMIC-IV database and the value of AUC in the new model was 0.8185. Finally, 28-days survival rate of patients with PHG was significantly lower and PHG was an independent risk factor for 28-days mortality after TAAD surgery.

Conclusion

PHG was significantly associated with the occurrence of AKI, hepatic dysfunction, increased ventilation time, and in-hospital mortality after TAAD surgery. The feature combination of neutrophil, platelet, lactic acid, weight, and lymphocyte could effectively predict PHG. The 28-days survival rate of patients with PHG was significantly lower. Moreover, PHG was an independent risk factor for 28-days mortality after TAAD surgery.

Postoperative Poor Oral Intake After Distal Pancreatectomy

OBJECTIVES

Poor oral intake (POI) without an identifiable cause is frequently observed after distal pancreatectomy (DP). This study was designed to investigate the incidence and risk factors of POI after DP, and its impact on the length of hospital stay.

METHODS

The prospectively collected data of patients who received DP were retrospectively reviewed. A diet protocol after DP was followed, and POI after DP was defined as the oral intake being less than 50% of the daily requirement and parenteral calorie supply being required on postoperative day 7.

RESULTS

Of the 157 patients, 21.7% (34) experienced POI after DP. The multivariate analysis revealed that the remnant pancreatic margin (head; hazard ratio, 7.837; 95% confidence interval, 2.111-29.087; P = 0.002) and postoperative hyperglycemia >200 mg/dL (hazard ratio, 5.643; 95% confidence interval, 1.482-21.494; P = 0.011) were independent risk factors for POI after DP. The length of hospital stay (median [range]) of the POI group was significantly longer than that of the normal diet group (17 [9-44] vs 10 [5-44] days; P < 0.001).

CONCLUSIONS

Patients undergoing pancreatic resection at pancreatic head portion should follow a postoperative diet, and postoperative glucose levels should be strictly regulated.

Association between intraoperative hyperglycemia and postoperative end-organ dysfunctions after cardiac surgery: a retrospective observational study

PURPOSE

Hyperglycemia has been associated with postoperative morbidity in patients who undergo cardiac surgery. However, it remains unclear whether the duration of hyperglycemia is as important as its magnitude in the development of postoperative end-organ dysfunction (PEOD). This retrospective study investigated the hypothesis that the intraoperative blood glucose (BG) exposure index (GE index), calculated by the product of the magnitude and duration of BG concentration ≥ 180 mg/dL, which is an integration of the severity and duration of hyperglycemia, is associated with the incidence of PEOD in patients undergoing cardiac surgery with cardiopulmonary bypass.

METHODS

The primary outcome in this study was PEOD within 72 h of surgery, which was defined as a composite of postoperative acute kidney injury, delirium, myocardial injury, and prolonged mechanical ventilation. The GE index (the magnitude of BG concentration deviation ≥ 180 mg/dL [Formula: see text] duration of BG concentration ≥ 180 mg/dL) of each patient was calculated based on the intraoperative BG concentration. The relationship between the GE index and the primary outcome was examined via logistic regression model with adjustment for potential confounders.

RESULTS

Within 72 h of surgery, 301 patients (54.5%) developed PEOD. PEOD was more common in patients with greater GE index quartiles (first versus third quartile; adjusted odds ratio, 5.65, 95% confidence interval (95% CI), 2.94-10.90; P < 0.001; first versus forth quartile, adjusted odds ratio, 20.80; 95% CI, 8.01-54.00; P < 0.001).

CONCLUSION

In patients undergoing cardiac surgery with cardiopulmonary bypass, the GE index was an independent predictor of PEOD.

Surgical Site Infections and Inflammatory Reaction After Cardiac Surgery; Bedside Artificial Pancreas Versus Conventional Insulin Therapy: A Propensity Score-Matched Analysis

OBJECTIVES

Perioperative hyperglycemia is associated with poor postoperative recovery, including compromised immune function and increased risk of infection. A closed-loop glycemic control system (artificial pancreas) has demonstrated strict safe perioperative glycemic control without hypoglycemia risk. The authors hypothesized that the artificial pancreas would reduce surgical site infections (SSIs) and postoperative inflammatory reactions. This study aimed to assess the effect of the artificial pancreas on SSIs and C-reactive protein (CRP) levels after cardiac surgery.

DESIGN

A single-center retrospective, propensity score-matched analysis.

SETTING

A university hospital.

PARTICIPANTS

In total, 295 patients who underwent cardiovascular surgery with cardiopulmonary bypass were included.

INTERVENTIONS

Patients were divided into two groups: artificial pancreas (target blood glucose: 120-150 mg/dL) and intravenous insulin infusion (conventional insulin therapy, target blood glucose: <200 mg/dL).

MEASUREMENTS AND MAIN RESULTS

The differences in the incidence of SSIs and CRP levels between the two groups were assessed. After 1:1 propensity score matching based on their covariates, 101 matched patients were selected from each group. The incidence of SSIs was reduced by 3%, 5% (conventional insulin therapy), and 2% (artificial pancreas), but the reduction was not statistically significant (p = 0.45). The postoperative maximum CRP level was significantly lower in the artificial pancreas group than in the conventional insulin therapy group, mean (standard deviation)14.53 (5.64) mg/dL v 16.57 (5.58) mg/dL; p = 0.01.

CONCLUSIONS

The artificial pancreas did not demonstrate a significant reduction in the incidence of SSIs. However, the artificial pancreas was safe and suppressed postoperative inflammation compared with conventional insulin therapy.

Factors associated with hypoglycemia in cardiovascular surgery

INTRODUCTION

An inadequate glycemic control in cardiovascular postoperative is a predictor of mortality, postoperative infections and a prolonged hospital stay. This study evaluates the incidence of hypoglycemia in the first 72 h of postoperative and its association with different factors, such as tissue perfusion parameters, and the administration of medicines that induct hypoglycemia during surgery, in patients that undergo cardiovascular surgery in a 4th level hospital in Bogota, Colombia.

METHODS AND MATERIALS

A nested cases and controls study was developed, taking as cases the patients that presented hypoglycemia episodes (<70 mg/dl) and the controls were the patients without this outcome. A systematic record of the glycemic control in the first 72 h of postoperative was registered. An univariate and multivariate analysis was conducted to determine the factor associated with hypoglycemia.

RESULTS

327 patients were evaluated (35% with coronary bypass and 27% with valvular replacement). 7.65% of the patients presented at least one episode of hypoglycemia <70 mg/dL (25 episodes). The multivariate analysis showed an association with chronic kidney failure in dialysis (OR6,21; IC:0,97-43.27,p:0.05), administration of preoperative steroids (OR4,41; IC:1,27-15,20,p:0.02), intraoperative insulin (OR2,61; IC:1.09-6,22, p:0.03), and postoperative hydrocortisone (OR 7,15; IC 1,46-34,9 p:0.01).

CONCLUSIONS

Hypoglycemia is frequent in patients that undergo a cardiovascular surgery. The associated factors were chronic kidney failure in dialysis, administration of preoperative steroids, intraoperative insulin and hydrocortisone during postoperative. Other factors such as tissue perfusion, administration of vasoactive or beta blockers substances, showed no association with hypoglycemia.

Effects of Isolated Impaired Fasting Glucose on Brain Injury During Cardiac Surgery Under Cardiopulmonary Bypass

Objective: To evaluate the effects of isolated impaired fasting glucose (IIFG) on brain injury in patients undergoing cardiopulmonary bypass (CPB) surgery. Methods: Patients with rheumatic heart valve disease who underwent elective mitral valve replacement were included and divided into control and IIFG groups. Pre-, intra-, and postoperative blood glucose levels, serum insulin levels, insulin resistance index (HOMA-IR), lactic acid levels, and neuron-specific enolase (NSE) and S100B levels were measured. The cerebral oxygen extraction ratio (OER) was calculated. Cognitive function was assessed via the Mini-Mental State Examination (MMSE). Results: HOMA-IR levels were higher in the IIFG group than the control group 30 min after the beginning of CPB, at the termination of CPB, and 2 h after the termination of CPB. Cerebral OER and lactic acid increased intraoperatively in both groups, especially in the IIFG group. NSE and S100B levels were higher in the IIFG group than in the control group at the termination of CPB, 2 h after the termination of CPB, and at 24 h postoperatively. The MMSE scores did not significantly differ between the two groups. Delirium occurred in two patients in the IIFG group, and one in the control group. No other signs and symptoms of brain injuries were detected in either group. Conclusions: The increased postoperative NSE and S100B levels in the IIFG group compared with controls may be associated with severe insulin resistance and stress hyperglycemia. However, the IIFG group did not have clinical manifestations of brain injuries, including cognitive impairment.

Impact of perioperative hyperglycemia in patients undergoing microvascular reconstruction

BACKGROUND

The effects of perioperative hyperglycemia on complications and outcomes in microvascular reconstruction have not been reported in the literature.

METHODS

A retrospective cohort of 203 patients undergoing microvascular reconstruction was generated. Perioperative glucose levels and clinical factors were tested for associations with complications using simple and multivariate analyses.

RESULTS

Hyperglycemia (blood glucose ≥ 180 mg/dL) occurred in 91 patients (44.8%) perioperatively, and was associated with increased rates of surgical complications, medical complications, surgical site infections, fistulas, and wound dehiscence. On univariate analysis, a more strict definition of hyperglycemia (blood glucose ≥ 165 mg/dL) was significantly associated with greater rates of venous thrombosis, although this lost statistical significance on multivariate analysis.

CONCLUSION

Perioperative hyperglycemia occurs commonly in patients undergoing microvascular reconstruction and is associated with higher rates of complications, independent of a preexisting diagnosis of diabetes mellitus. Further research is needed to define the ideal glycemic target in this population.

Effect of glycaemic control on complications following cardiac surgery: literature review

Introduction

No uniform consensus in the UK or Europe exists, for glycaemic management of patients with Diabetes or pre-diabetes undergoing cardiac surgery.

Objective

[i] Determine the relationship between glycaemic control and cardiac surgical outcomes; [ii] Compare current vs gold standard management of patients with Diabetes or pre-diabetes undergoing cardiac surgery.

Methods

Searches of MEDLINE, NHS Evidence and Web of Science databases were completed. Articles were limited to those in English, German and French. No date limit was enforced.13,232 articles were identified on initial literature review, and 50 relevant papers included in this review.

Results

No national standards for glycaemic control prior to cardiac surgery were identified. Upto 30% of cardiac surgical patients have undiagnosed Diabetes. Cardiac surgical patients without Diabetes with pre-operative hyperglycaemia have a 1 year mortality double that of patients with normoglyacemia, and equivalent to patients already diagnosed with Diabetes. Pre- and peri-operative hyperglycaemia is associated with worse outcomes. Evidence regarding tight glycaemic control vs moderate glycaemic control is conflicting. Tight control may be more effective in patients without Diabetes with pre−/peri-operative hyperglycaemia, and moderate control appears more effective in patients with pre-existing Diabetes. Patients with well controlled Diabetes may achieve comparable outcomes to patients without Diabetes with similar glycaemic control.

Conclusions

Pre / peri-operative hyperglycaemia is associated with worse outcomes in both patients with, and without Diabetes undergoing CABG. This review supports the pre-operative screening, and optimisation of glycaemic control in patients undergoing cardiac surgery. Optimal glycaemic management remains unclear and clear guidelines are needed.