Postoperative Hypoglycemia Is Associated With Worse Outcomes After Cardiac Operations

A distributional reinforcement learning model for optimal glucose control after cardiac surgery

This study introduces Glucose Level Understanding and Control Optimized for Safety and Efficacy (GLUCOSE), a distributional offline reinforcement learning algorithm for optimizing insulin dosing after cardiac surgery. Trained on 5228 patients, tested on 920, and externally validated on 649, GLUCOSE achieved a mean estimated reward of 0.0 [-0.07, 0.06] in internal testing and -0.63 [-0.74, -0.52] in external validation, outperforming clinician returns of -1.29 [-1.37, -1.20] and -1.02 [-1.16, -0.89]. In multi-phase human validation, GLUCOSE first showed a significantly lower mean absolute error (MAE) in insulin dosing, with 0.9 units MAE versus clinicians' 1.97 units (p < 0.001) in internal testing and 1.90 versus 2.24 units (p = 0.003) in external validation. The second and third phases found GLUCOSE's performance as comparable to or exceeding that of senior clinicians in MAE, safety, effectiveness, and acceptability. These findings suggest GLUCOSE as a robust tool for improving postoperative glucose management.

Real-time continuous glucose monitoring improves postoperative glucose control in people with type 2 diabetes mellitus undergoing coronary artery bypass grafting: A randomized clinical trial

BACKGROUND

Effective glycaemic control following cardiac surgery improves clinical outcomes, and continuous glucose monitoring (CGM) might be a valuable tool in achieving this objective. We investigated the effect of real-time CGM and telemonitoring on postoperative glycaemic control in people with type 2 diabetes (T2D) after coronary artery bypass grafting (CABG).

METHODS

In this randomized clinical trial (RCT), adults with T2D undergoing CABG were assigned to either a test group utilizing real-time CGM (Dexcom G6) and telemetry for glycaemic control, or a control group with blinded CGM measures, relying on point-of-care measures. The primary outcome was the percentage of time in range (TIR) of blood glucose between 70 and 180 mg/dL (3.9-10.0 mmol/L), measured by CGM.

RESULTS

Among 91 subjects, 48 were in the test group and 43 were in the control group. The least squares (LS) mean ± standard error of TIR was 60.3 ± 2.7%, 50.3 ± 2.9% in the test and control group, respectively. The test group had significantly higher TIR when adjusted with age, sex, body mass index, baseline fasting blood glucose and baseline glycated haemoglobin (LS mean difference, 10.0%; 95% confidence interval, 2.1-18.0; p = 0.014). The test group also had lower time above range and mean glucose levels, with no differences in time below range or hypoglycaemic events.

CONCLUSIONS

In this RCT, real-time CGM and telemonitoring improved glycaemic control during postoperative period without increasing hypoglycaemia risk. Given the benefits of effective glycaemic control on perioperative outcomes, CGM may be helpful in managing T2D after CABG.

Reality of post-gastrectomy stress hyperglycemia revealed by continuous glucose monitoring: a prospective study

PURPOSES

Postoperative stress hyperglycemia is reported to be associated with increased postoperative complications (PCs) following various surgical procedures. However, most reports of postoperative hyperglycemia are based on conventional, point blood glucose measurements. We sought to clarify trends in post-gastrectomy glucose levels using continuous glucose monitoring (CGM) and investigate the relationship between postoperative hyperglycemia and stress-related factors such as PCs and the degree of surgical invasiveness.

METHODS

The subjects of this prospective study were 40 patients who underwent gastrectomy between November, 2022 and September, 2023. We recorded their glucose levels by CGM immediately after surgery until discharge (up to 2 weeks postoperatively).

RESULTS

There was no increase in glucose levels caused by open gastrectomy, a strong inflammatory response, or PCs. Hyperglycemia, defined as the percentage of time that the glucose level was > 140 mg/dL, was associated only with the preoperative HbA1c value (P = 0.039). Patients with an HbA1c ≥ 6% had a significantly longer duration of hyper- and hypo-glycemia and greater glycemic variability than those with an HbA1c < 6% (glucose level < 70 mg/dL, P = 0.027; > 140 mg/dL, P = 0.001, coefficient of variation P = 0.024).

CONCLUSIONS

No association was observed between stress hyperglycemia during the acute phase following gastrectomy and PCs. Only patients with an elevated HbA1c had high rates of hypo- and hyper-glycemia and large glycemic variability, despite perioperative glucose management.

Association of triglyceride-glucose-body mass index with all-cause mortality among individuals with cardiovascular disease: results from NHANES

Background

The objective of this study was to explore the relationship between the triglyceride-glucose-body mass index (TyG-BMI) and all-cause mortality rate and to determine valuable predictive factors for the survival status of patients with cardiovascular disease (CVD).

Methods

Conduct a study on CVD patients in the NHANES database from 2007 to 2016. Patients were divided into four groups based on the weighted quartiles of TyG-BMI. Kaplan-Meier curves, Cox regression, and restricted cubic spline (RCS) were used to analyze the correlation between this index and all-cause mortality. Receiver operating characteristic (ROC) curves were used to evaluate its predictive ability, sensitivity, and specificity.

Results

This study included 1085 patients, and revealed significant differences in survival rates among patients with different TyG-BMI levels. Patients in the higher TyG-BMI group have a lower mortality risk, yet there is no evident non-linear relationship. The ROC curve indicates that this indicator can serve as a predictive value for mortality in CVD patients, demonstrating good sensitivity and specificity.

Conclusion

This study found a significant association between TyG-BMI index and all-cause mortality in patients with CVD. TyG-BMI can be used as a predictive indicator of all-cause mortality in CVD patients.

Consensus Considerations and Good Practice Points for Use of Continuous Glucose Monitoring Systems in Hospital Settings

Continuous glucose monitoring (CGM) systems provide frequent glucose measurements in interstitial fluid and have been used widely in ambulatory settings for diabetes management. During the coronavirus disease 2019 (COVID-19) pandemic, regulators in the U.S. and Canada temporarily allowed for CGM systems to be used in hospitals with the aim of reducing health care professional COVID-19 exposure and limiting use of personal protective equipment. As such, studies on hospital CGM system use have been possible. With improved sensor accuracy, there is increased interest in CGM usage for diabetes management in hospitals. Laboratorians and health care professionals must determine how to integrate CGM usage into practice. The aim of this consensus guidance document is to provide an update on the application of CGM systems in hospital, with insights and opinions from laboratory medicine, endocrinology, and nursing.

Noniatrogenic hypoglycemia: A universal marker for poor outcomes

Objective

Previous retrospective studies have established a relationship between postoperative hypoglycemia and adverse outcomes after cardiac surgery, but none have accounted for the cause of hypoglycemia.

Methods

A retrospective review was performed of patients who underwent cardiac surgery at a single institution between 2016 and 2021. Patients were categorized as hypoglycemic if they had 1 or more postoperative blood glucose measurement less than 70 mg/dL and normoglycemic otherwise. Hypoglycemia was subcategorized as noniatrogenic (underlying liver failure, adrenal insufficiency, sepsis, or shock) or iatrogenic (insulin infusion continued while nil per os or infusion protocol violated) via manual chart review. Baseline characteristics were compared between groups using Pearson χ2, analysis of variance, and Kruskal-Wallis testing, and outcomes were compared using multivariable logistic regression.

Results

In total, 5373 patients and 183,346 glucose measurements were included. Hypoglycemia occurred in 5% (267) of patients, of whom 63% (169) were iatrogenic and 37% (98) were noniatrogenic. In a multivariate analysis adjusting for age, sex, case urgency, pre-existing diabetes, and bypass time, both iatrogenic and noniatrogenic hypoglycemia were associated with greater odds of renal failure, prolonged ventilation, and prolonged intensive care unit length of stay relative to normoglycemia, but the magnitude was substantially lower in iatrogenic hypoglycemia. Patients with noniatrogenic hypoglycemia had 68.6 times greater odds of mortality relative to patients who were normoglycemic (odds ratio, 68.6; confidence interval, 39.5-119), but patients with iatrogenic hypoglycemia had no increased odds of mortality (odds ratio, 1.45; confidence interval, 0.77-2.73).

Conclusions

When excluding patients with conditions known to cause hypoglycemia from the analysis, the morbidity and mortality of iatrogenic hypoglycemia from tight postoperative glycemic control is dramatically attenuated.

Endocrine Care for the Surgical Patient: Diabetes Mellitus, Thyroid and Adrenal Conditions

Patients with hyperglycemia, thyroid dysfunction, and adrenal insufficiency face increased perioperative risk, which may be mitigated by appropriate management. This review addresses preoperative glycemic control, makes evidence-based recommendations for the increasingly complex perioperative management of noninsulin diabetes medications, and provides guideline-supported strategies for the perioperative management of insulin, including suggested indications for continuous intravenous insulin. The authors propose a strategy for determining when surgery should be delayed in patients with thyroid dysfunction and present a matrix for managing perioperative stress dose corticosteroids based on the limited evidence available.

Impact of Diabetes Mellitus on Outcomes in Patients with Left Ventricular Assist Devices

Heart failure (HF) represents a significant health burden in the United States, resulting in substantial mortality and healthcare costs. Through the array of treatment options available, including lifestyle modifications, medications, and implantable devices, HF management has evolved. Left ventricular assist devices (LVADs) have emerged as a crucial intervention, particularly in patients with advanced HF. However, the prevalence of comorbidities such as diabetes mellitus (DM) complicates treatment outcomes. By elucidating the impact of DM on LVAD outcomes, this review aims to inform clinical practice and enhance patient care strategies for individuals undergoing LVAD therapy. Patients with DM have higher rates of hypertension, dyslipidemia, peripheral vascular disease, and renal dysfunction, posing challenges to LVAD management. The macro/microvascular changes that occur in DM can lead to cardiomyopathy and HF. Glycemic control post LVAD implantation is a critical factor affecting patient outcomes. The recent literature has shown significant decreases in hemoglobin A1c following LVAD implantation, representing a possible bidirectional relationship between DM and LVADs; however, the clinical significance of this decrease is unclear. Furthermore, while some studies show increased short- and long-term mortality in patients with DM after LVAD implantation, there still is no literature consensus regarding either mortality or major adverse outcomes in DM patients.

Low preoperative hemoglobin A1c level is a predictor of perioperative infectious complications after esophagectomy: A retrospective, single-center study

This retrospective, single-center study aimed to evaluate the impact of blood glucose (BG) markers on perioperative complications after esophagectomy in a cohort of 176 patients. Study analyses included the correlation of daily maximum BG level and hemoglobin A1c (HbA1c) with clinicopathological factors. Maximum BG levels were significantly higher on postoperative day (POD) 0 than on PODs 2, 3, 5, and 7 (p < 0.05). Additionally, maximum BG levels on PODs 1, 2, and 7 were significantly higher in patients with preoperative HbA1c levels of ≥ 5.6% than in those with preoperative HbA1c levels of < 5.6% (p < 0.05 for all). The rates of any complications and infectious complications were higher in patients with preoperative HbA1c levels of < 5.6% than in those with preoperative HbA1c levels of ≥ 5.6% (p < 0.05 for both). A preoperative HbA1c level of < 5.6% was a significant predictor of infectious complications after esophagectomy by logistic regression analysis (p < 0.05). Maximum BG level after esophagectomy remained high in patients with high preoperative HbA1c levels, whereas a normal HbA1c level was an independent risk factor for infectious complications.

Perioperative Glycemic Management in Cardiac Surgery: A Narrative Review

Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.

Continuous Glucose Monitoring Reveals Perioperative Hypoglycemia in Most Patients With Diabetes Undergoing Major Surgery: A Prospective Cohort Study

OBJECTIVE

To investigate the frequency and duration of hypo- and hyperglycemia, assessed by continuous glucose monitoring (CGM) during and after major surgery, in departments with implemented diabetes care protocols.

SUMMARY BACKGROUND DATA

Inadequate glycemic control in the perioperative period is associated with serious adverse events, but monitoring currently relies on point blood glucose measurements, which may underreport glucose excursions.

METHODS

Adult patients without (A) or with diabetes [non-insulin-treated type 2 (B), insulin-treated type 2 (C) or type 1 (D)] undergoing major surgery were monitored using CGM (Dexcom G6), with an electrochemical sensor in the interstitial fluid, during surgery and for up to 10 days postoperatively. Patients and health care staff were blinded to CGM values, and glucose management adhered to the standard diabetes care protocol. Thirty-day postoperative serious adverse events were recorded. The primary outcome was duration of hypoglycemia (glucose <70 mg/dL). Clinicaltrials.gov: NCT04473001.

RESULTS

Seventy patients were included, with a median observation time of 4.0 days. CGM was recorded in median 96% of the observation time. The median daily duration of hypoglycemia was 2.5 minutes without significant difference between the 4 groups (A-D). Hypoglycemic events lasting ≥15 minutes occurred in 43% of all patients and 70% of patients with type 1 diabetes. Patients with type 1 diabetes spent a median of 40% of the monitoring time in the normoglycemic range 70 to 180 mg/dL and 27% in the hyperglycemic range >250 mg/dL. Duration of preceding hypo- and hyperglycemia tended to be longer in patients with serious adverse events, compared with patients without events, but these were exploratory analyses.

CONCLUSIONS

Significant duration of both hypo- and hyperglycemia was detected in high proportions of patients, particularly in patients with diabetes, despite protocolized perioperative diabetes management.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

Practical approach to clinical controversies in glycemic control for hospitalized surgical patients

The importance of glycemic management in surgical patient populations stems from an association between hyperglycemia and increased rates of surgical site infections, sepsis, and mortality. Various guidelines provide recommendations regarding target glucose concentrations, but all stress the importance of avoiding hypoglycemia as well. Within the surgical patient population, glycemic targets may vary further depending on the surgical service, such as cardiac surgery, neurosurgery, or reconstructive burn surgery. Glycemic management in critically ill surgical patients is achieved primarily through the use of intravenous insulin infusion protocols. These protocols can include fixed protocols, multiplication factor protocols, and computerized algorithms. In contrast, noncritically ill surgical patients are generally managed through the utilization of subcutaneous insulin with a combination of basal, bolus, and sliding scale insulin. Insulin protocols should be effective at maintaining glucose concentrations within the specified target range with minimal hypoglycemic events. Monitoring glucose concentrations while on either an intravenous or subcutaneous insulin protocol is essential. Point-of-care testing is the primary method for monitoring glucose concentrations in both critically ill and noncritically ill surgical patients and allows for adjustment of the insulin regimen. As patients move between units and to the outpatient setting, ensuring adequate follow-up is essential to maintaining control of hyperglycemia.

Effect of early hypoglycaemia on hospitalization outcomes in patients undergoing coronary artery bypass grafting

OBJECTIVE

To investigate the effect of early postoperative hypoglycaemia on hospitalization outcomes including major cardiovascular complications and in-hospital mortality among patients undergoing coronary artery bypass grafting (CABG).

METHODS

Data from an observational study of 9583 patients in the intensive care unit (ICU) who underwent CABG were analyzed. Hypoglycaemia was defined as a nadir blood glucose level <70 mg/dL (3.9 mmol/L). One-to-one propensity score matching (PSM) was used to identify 251-balanced pairs of patients to compare outcomes.

RESULTS

A total of 306 (3.2%) patients experienced hypoglycaemia, of whom, 133 had diabetes, 173 hadn't diabetes. Patients who were hypoglycaemia had higher incidences of compositeoutcomes than those without hypoglycaemia (12.1% versus 6.0%, P < 0.0001). Postoperative length of ICU stay was longer in patients with hypoglycaemia [2.8 (0.8-21.0) versus 2.0 (0.25-36.0) days, P < 0.0001]. After PSM, the compositeoutcomes and length of ICU stay remained significantly increased for the patients with hypoglycaemia [compositeoutcomes: odd ratio (OR) 2.78, 95% CI, 1.30-5.88, P = 0.01; length of ICU stay: OR 1.60, 95% CI, 1.14-2.26, P = 0.007].

CONCLUSION

Postoperative hypoglycaemia was an independent associated factor of adverse composite outcomes and a lengthened ICU stay after CABG. Hypoglycaemia should be avoided for both postoperative patients with and without diabetes.

Reference Ranges of Glycemic Variability in Infants after Surgery—A Prospective Cohort Study

We aimed to define reference ranges of glycemic variability indices derived from continuous glucose monitoring data for non-diabetic infants during post-operative intensive care treatment after cardiac surgery procedures. We performed a prospective cohort intervention study in a pediatric intensive care unit (PICU). Non-diabetic infants aged 0–12 months after corrective cardiovascular surgery procedures were fitted upon arrival to the PICU with a continuous glucose monitoring system (iPro2, Medtronic, Minneapolis, MN, USA). Thirteen glycemic variability indices were calculated for each patient. Complete recordings of 65 patients were collected on the first postoperative day. During the first three postsurgical days 5%, 24% and 43% of patients experienced at least one hypoglycemia episode, and 40%, 10% and 15%—hyperglycemia episode, respectively, in each day. Due to significant differences between the first postoperative day (mean glycemia 130 ± 31 mg/dL) and the second and third day (105 ± 18 mg/dL, 101 ± 22.2 mg/dL; p < 0.0001), we proposed two separate reference ranges—for the acute and steady state patients. Thus, for individual glucose measurements, we proposed a reference range between 85 and 229 mg/dL and 69 and 149 mg/dL. For the mean daily glucose level, ranges between 122 and 137 mg/dL and 95 and 110 mg/dL were proposed. In conclusion, rt-CGM revealed a very high likelihood of hyperglycemia in the first postsurgical day. The widespread use of CGM systems in a pediatric ICU setting should be considered as a safeguard against dysglycemic episodes; however, reference ranges for those patients should be different to those used in diabetes care.

Dynamic changes in insulin requirements with post-operative time using bedside artificial pancreas to maintain normoglycemia without hypoglycemia after cardiac surgery

It is difficult to manage postoperative blood glucose levels without hyperglycemia and hypoglycemia in cardiac surgery patients even if continuous intravenous insulin infusion is used. Therefore, the insulin requirements for maintaining normoglycemia may be difficult to evaluate and need to be elucidated. In this single-center retrospective study, 30 adult patients (age 71.5 ± 9.0 years old, men 67%, BMI 22.0 ± 3.1 kg/m², diabetes 33%) who underwent cardiac surgery and used bedside artificial pancreas (STG-55) as a perioperative glycemic control were included. We investigated the insulin and glucose requirements to maintain normoglycemia until the day after surgery. The bedside artificial pancreas achieved intensive glycemic control without hypoglycemia under fasting conditions for 15 h after surgery (mean blood glucose level was 103.3 ± 3.1 mg/dL and percentage of time in range (70-140 mg/dL) was 99.4 ± 2.0%). The total insulin requirement for maintaining normoglycemia differed among surgical procedures, including the use of cardiopulmonary bypass during surgery, while it was not affected by age, body mass index, or the capacity of insulin secretion. Moreover, the mean insulin requirement and the standard deviation of the insulin requirements were variable and high, especially during the first several hours after surgery. Treatment using the bedside artificial pancreas enabled intensive postoperative glycemic control without hypoglycemia. Furthermore, the insulin requirements for maintaining normoglycemia after cardiac surgery vary based on surgical strategies and change dynamically with postoperative time, even in the short term.

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.

Effectiveness and safety of the Space GlucoseControl system for glycaemia control in caring for postoperative cardiac surgical patients

BACKGROUND

Hyperglycaemia is a very common complication in post-cardiac surgical patients, and as such, it must be properly managed. For this purpose, the enhanced Model Predictive Control algorithm for glycaemia control has been implemented into a nurse-led device called Space GlucoseControl (SGC) that aims to achieve a safe and effective blood glucose control in a better way than the traditional "paper-based" protocols.

PURPOSE

The aim of the study was to know the effectiveness and safety of the SGC in glycaemia control in cardiosurgical adult patients in the immediate postoperative period in the intensive care unit.

METHODS

A prospective before-and-after intervention study was conducted. One hundred sixty cardiosurgical adult patients with hyperglycaemia were selected: 80 in the control group from May to November 2018 and 80 in the intervention group (use of the SGC device) from January to December 2019. The primary outcome was the percentage of time within the target range (140-180 mg/dL in the control group and 100-160 mg/dL in the intervention group).

RESULTS

The percentage of time within the target range was significantly higher in the SGC group than in the control group (70.5% [58.25-80] vs 54.83% [36.09-75], p < 0.001). The range was also achieved earlier with the SGC (5 [3-6.875] hours vs 7 [4-11] hours; p < 0.05). The first blood glucose value after reaching the target range was higher in the control group, with statistical significance (p < 0.05). There were no hypoglycaemia episodes in the control group. However, during SGC treatment, six episodes of hypoglycaemia occurred, and all of them were nonsevere (mean value = 61 mg/dL).

CONCLUSION

The SGC is useful to achieve a faster tight glycaemic control, with a higher percentage of time within the target range, although episodes of nonsevere hypoglycaemia could be observed.

Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery

BACKGROUND

Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery.

METHODS

All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs.

RESULTS

A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%.

CONCLUSION

Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.

Surgical Site Infections in Cardiac Surgery

Surgical site infection (SSI) can be a significant complication of cardiac surgery, delaying recovery and acting as a barrier to enhanced recovery after cardiac surgery. Several risk factors predisposing patients to SSI including smoking, excessive alcohol intake, hyperglycemia, hypoalbuminemia, hypo- or hyperthermia, and Staphylococcus aureus colonization are discussed. Various measures can be taken to abolish these factors and minimize the risk of SSI. Glycemic control should be optimized preoperatively, and hyperglycemia should be avoided perioperatively with the use of intravenous insulin infusions. All patients should receive topical intranasal Staphylococcus aureus decolonization and intravenous cephalosporin if not penicillin allergic.

Perioperative intensive glycemic control for liver transplant recipients to prevent surgical site infection: A systematic review and meta-analysis

BACKGROUND

Surgical Site Infections (SSIs) are common among liver transplant recipients and result in adverse patient outcomes. Standard glycemic control is effective in reducing SSIs. Some studies suggest intensive glycemic control reduces the risk of SSI further.

METHODS

For this systematic review, were searched for studies comparing perioperative intensive and standard glycemic control in liver transplant recipients. Clinical trials registries and reference lists of included studies were also searched. No date or language restrictions were applied. Randomized controlled trials (RCTs) were assessed using Cochrane risk of bias tool and GRADE method. Cohort studies were assessed using the Newcastle-Ottawa Scale.

RESULTS

Two RCTs and three cohort studies met the inclusion criteria. Low-quality evidence from the two RCTs in a meta-analysis with 264 recipients found it was uncertain whether the risk of SSI was reduced by having intensive glycemic control (Risk Ratio [RR] 1.52, 95% CI 0.66-3.51). However, there was an increased risk of hypoglycemia among recipients having intensive glycemic control (RR 2.34, 95% CI 1.40-3.92) n = 264. Meta-analyses found it uncertain whether secondary outcomes, allograft rejection and death, were reduced among recipients having intensive glycemic control; (RR 0.85, 95% CI 0.48-1.50) and (RR 0.92, 95% CI 0.44-1.95), respectively. The two cohort studies were poor quality and presented conflicting outcomes on the effects of intensive blood glucose control on SSI.

CONCLUSION

There is insufficient evidence to recommend the use of intensive glycemic control among liver transplant recipients to reduce SSIs.

The use of GLP-1 receptor agonists in hospitalised patients: An untapped potential

In the outpatient setting, glucagon-like peptide-1 (GLP-1) receptor agonists have proved to be highly efficacious drugs that provide glycaemic control with a low risk of hypoglycaemia. These characteristics make GLP-1 receptor agonists attractive agents to treat dysglycaemia in perioperative or high-dependency hospital settings, where glycaemic variability and hyperglycaemia are associated with poor prognosis. GLP-1 also has a direct action on the myocardium and vasculature-which may be advantageous in the immediate aftermath of a vascular insult. This is a narrative review of the work in this area. The aim was to determine the populations of hospitalised patients being evaluated and the clinical and mechanistic end-points tested, with the institution of GLP-1 therapy in hospital. We searched the PubMed, Embase, and Google scholar databases, combining the term "glucagon-like peptide 1" OR "GLP-1" OR "incretin" OR "liraglutide" OR "exenatide" OR "lixisenatide" OR "dulaglutide" OR "albiglutide" AND "inpatient" OR "hospital" OR "perioperative" OR "postoperative" OR "surgery" OR "myocardial infarction" OR "stroke" OR "cerebrovascular disease" OR "transient ischaemic attack" OR "ICU" OR "critical care" OR "critical illness" OR "CCU" OR "coronary care unit." Pilot studies were reported in the fields of acute stroke, cardiac resuscitation, coronary care, and perioperative care that showed advantages for GLP-1 therapy, with normalisation of glucose, lower glucose variability, and lower risk of hypoglycaemia. Animal and human studies have reported improvements in myocardial performance when given acutely after vascular insult or surgery, but these have yet to be translated into randomised clinical trials.

PROACTIVE PROTOCOL-BASED MANAGEMENT OF HYPERGLYCEMIA AND DIABETES IN COLORECTAL SURGERY PATIENTS

OBJECTIVE

The management of diabetic patients undergoing elective abdominal surgery continues to be unsystematic, despite evidence that standardized perioperative glycemic control is associated with fewer postoperative surgical complications. We examined the efficacy of a pre-operative diabetes optimization protocol implemented at a single institution in improving perioperative glycemic control with a target blood glucose of 80 to 180 mg/dL.

METHODS

Patients with established and newly diagnosed diabetes who underwent elective colorectal surgery were included. The control group comprised 103 patients from January 1, 2011, through December 31, 2013, before protocol implementation. The glycemic-optimized group included 96 patients following protocol implementation from January 1, 2014, through July 31, 2016. Data included demographic information, blood glucose levels, insulin doses, hypoglycemic events, and clinical outcomes (length of stay, re-admissions, complications, and mortality).

RESULTS

Patients enrolled in the glycemic optimization protocol had significantly lower glucose levels intra-operatively (145.0 mg/dL vs. 158.1 mg/dL; P = .03) and postoperatively (135.6 mg/dL vs. 145.2 mg/dL; P = .005). A higher proportion of patients enrolled in the protocol received insulin than patients in the control group (0.63 vs. 0.48; P = .01), but the insulin was administered less frequently (median [interquartile range] number of times, 6.0 [2.0 to 11.0] vs. 7.0 [5.0 to 11.0]; P = .04). Two episodes of symptomatic hypoglycemia occurred in the control group. There was no difference in clinical outcomes.

CONCLUSION

Improved peri-operative glycemic control was observed following implementation of a standardized institutional protocol for managing diabetic patients undergoing elective colorectal surgery.

ABBREVIATIONS

HbA1c = glycated hemoglobin A1c; IQR = interquartile range.

The Association Between Common Clinical Characteristics and Postoperative Morbidity and Overall Survival in Patients with Glioblastoma

BACKGROUND

The impact of noncancerous factors on the morbidity and mortality of glioblastoma multiforme (GBM) has not been well studied. Using a large surgical cohort, we examined the association between multiple clinical characteristics and postoperative morbidities and survival in patients with GBM.

MATERIALS AND METHODS

The study included 404 consecutive GBM patients who underwent initial tumor resection at MD Anderson Cancer Center between January 1, 2010, and December 31, 2014. Data about clinical characteristics, treatments, and postoperative complications were collected. The associations between clinical parameters and postoperative complications and survival were analyzed.

RESULTS

Charlson Comorbidity Index was positively related to a higher incidence of postoperative total (odds ratio [OR] = 1.20; p = .002) and neurological (OR = 1.18; p = .011) complications. Preoperative systolic blood pressure (SBp) over 140 mmHg was associated with a higher incidence of postoperative intracranial hemorrhage (OR = 4.42; p = .039) and longer hospital stay (OR = 2.48; p = .015). Greater postoperative fluctuation of SBp (OR = 1.14; p = .025) and blood glucose (mmol/L; OR = 1.48; p = .023) were related to a higher incidence of neurological complications, whereas higher postoperative blood glucose (OR = 0.64; p < .001) was related to a lower incidence. Long-term lower SBp (<124 mmHg; hazard ratio [HR] = 1.47; p = .010) and higher blood glucose (HR = 1.12; p < .001) were associated with shorter survival. Long-term serum albumin level (g/dL; HR = 0.32; p < .001) was positively associated with survival.

CONCLUSION

Short-term SBp and blood glucose levels and fluctuations are associated with postoperative complications in GBM patients. Their long-term optimization may impact survival of these patients. Future clinical trials are needed to confirm the benefit of optimizing medical comorbidities on GBM patients' outcomes.

IMPLICATIONS FOR PRACTICE

Glioblastoma multiforme (GBM) is one of the most feared cancer diagnoses because of its limited survival and treatment. This study revealed significant associations of noncancerous factors on the morbidity and mortality of GBM. The complexity of medical comorbidities, as well as short-term postoperative levels and fluctuations of blood pressure and blood glucose, was associated with postoperative complications, but not overall survival. However, long-term levels of these common clinical parameters were significantly associated with survival. Optimization of medical conditions may be critical for reducing the morbidity and mortality of GBM patients. Future clinical trials are needed to validate the observed associations in an independent cohort.

Clinical Effectiveness of Intravenous Exenatide Infusion in Perioperative Glycemic Control after Coronary Artery Bypass Graft Surgery

Background

We aimed to assess the clinical effectiveness of intravenous exenatide compared to insulin in perioperative blood glucose control in coronary artery bypass grafting surgery patients.

Methods

Patients more than 18 yr old admitted for elective coronary artery bypass grafting were included in a phase II/III nonblinded randomized superiority trial. Current insulin use and creatinine clearance of less than 60 ml/min were exclusion criteria. Two groups were compared: the exenatide group, receiving exenatide (1-h bolus of 0.05 µg/min followed by a constant infusion of 0.025 µg/min), and the control group, receiving insulin therapy. The blood glucose target range was 100 to 139 mg/dl. The primary outcome was the proportion of patients who spent at least 50% of the study period within the target range. The consumption of insulin (Cinsulin) and the time to start insulin (Tinsulin) were compared between the two groups.

Results

In total, 53 and 51 patients were included and analyzed in the exenatide and control groups, respectively (age: 70 ± 9 vs. 68 ± 11 yr; diabetes mellitus: 12 [23%] vs. 10 [20%]). The primary outcome was observed in 38 (72%) patients in the exenatide group and in 41 (80%) patients in the control group (odds ratio [95% CI] = 0.85 [0.34 to 2.11]; P = 0.30). Cinsulin was significantly lower (60 [40 to 80] vs. 92 [63 to 121] U, P &lt; 0.001), and Tinsulin was significantly longer (12 [7 to 16] vs. 7 [5 to 10] h, P = 0.02) in the exenatide group.

Conclusions

Exenatide alone at the dose used was not enough to achieve adequate blood glucose control in coronary artery bypass grafting patients, but it reduces overall consumption of insulin and increases the time to initiation of insulin.