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Intensive Glycemic Control in Cardiac Surgery

  • Hospital Management of Diabetes (GE Umpierrez, Section Editor)
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Abstract

Hyperglycemia has been found to be associated with increased morbidity and mortality in surgical patients, yet, the optimal glucose management strategy during the perioperative setting remains undetermined. While much has been published about hyperglycemia and cardiac surgery, most studies have used widely varying definitions of hyperglycemia, methods of insulin administration, and the timing of therapy. This has only allowed investigators to make general conclusions in this challenging clinical scenario. This review will introduce the basic pathophysiology of hyperglycemia in the cardiac surgery setting, describe the main clinical consequences of operative hyperglycemia, and take the reader through the published material of intensive and conservative glucose management. Overall, it seems that intensive control has modest benefits with adverse effects often outweighing these advantages. However, some studies have indicated differing results for certain patient subgroups, such as non-diabetics with acute operative hyperglycemia. Future studies should focus on distinguishing which patient populations, if any, would optimally benefit from intensive insulin therapy.

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References

Papers of particular interest, published recently, have been highlighted as: •• Of major importance

  1. Schmeltz LR, DeSantis AJ, Thiyagarajan V, et al. Reduction of surgical mortality and morbidity in diabetic patients undergoing cardiac surgery with a combined intravenous and subcutaneous insulin glucose management strategy. Diabetes Care. 2007;30(4):823–8.

    Article  CAS  PubMed  Google Scholar 

  2. van den Berghe G, Wouters P, Weekers F, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–67.

    Article  PubMed  Google Scholar 

  3. Kosiborod M, Inzucchi SE, Krumholz HM, et al. Glucometrics in patients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation. 2008;117(8):1018–27.

    Article  CAS  PubMed  Google Scholar 

  4. Halkos ME, Kilgo P, Lattouf OM, et al. The effect of diabetes mellitus on in-hospital and long-term outcomes after heart valve operations. Ann Thorac Surg. 2010;90(1):124–30.

    Article  PubMed  Google Scholar 

  5. Halkos ME, Puskas JD, Lattouf OM, et al. Elevated preoperative hemoglobin A1c level is predictive of adverse events after coronary artery bypass surgery. J Thorac Cardiovasc Surg. 2008;136(3):631–40.

    Article  PubMed  Google Scholar 

  6. Halkos ME, Lattouf OM, Puskas JD, et al. Elevated preoperative hemoglobin A1c level is associated with reduced long-term survival after coronary artery bypass surgery. Ann Thorac Surg. 2008;86(5):1431–7.

    Article  PubMed  Google Scholar 

  7. Thourani VH, Weintraub WS, Stein B, et al. Influence of diabetes mellitus on early and late outcome after coronary artery bypass grafting. Ann Thorac Surg. 1999;67(4):1045–52.

    Article  CAS  PubMed  Google Scholar 

  8. Umpierrez GE, Kosiborod M. Inpatient dysglycemia and clinical outcomes: association or causation? J Diabet Complications. 2014;28(4):427–9.

    Article  Google Scholar 

  9. Ito N, Iwaya T, Ikeda K, et al. Hyperglycemia 3 days after esophageal cancer surgery is associated with an increased risk of postoperative infection. J Gastrointest Surg. 2014;18(9):1547–56.

    Article  PubMed  Google Scholar 

  10. Girish G, Agarwal S, Satsangi DK, et al. Glycemic control in cardiac surgery: rationale and current evidence. Ann Card Anaesth. 2014;17(3):222–8.

    Article  CAS  PubMed  Google Scholar 

  11. Gerstein HC, Miller ME, Ismail-Beigi F, et al. ACCORD Study Group. Effects of intensive glycaemic control on ischaemic heart disease: analysis of data from the randomised, controlled ACCORD trial. Lancet. 2014;384(9958):1936–41.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Mulla I, Schmidt K, Cashy J, et al. Comparison of glycemic and surgical outcomes after change in glycemic targets in cardiac surgery patients. Diabetes Care. 2014;37(11):2960–5.

    Article  CAS  PubMed  Google Scholar 

  13. Reddy P, Duggar B, Butterworth J. Blood glucose management in the patient undergoing cardiac surgery: a review. World J Cardiol. 2014;6(11):1209–17.

    Article  PubMed  PubMed Central  Google Scholar 

  14. Lazar HL, McDonnell M, Chipkin SR, et al. Society of thoracic surgeons blood glucose guideline task force. The society of thoracic surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87(2):663–9.

    Article  PubMed  Google Scholar 

  15. Corsino L, Dhatariya K, Umpierrez G. Management of Diabetes and Hyperglycemia in Hospitalized Patients. [Updated 2014 Oct 4]. In: De Groot LJ, Beck-Peccoz P, Chrousos G, et al., editors. Endotext [Internet]. South Dartmouth (MA): MDText.com, Inc.; 2000.

  16. Mizock BA. Alterations in carbohydrate metabolism during stress: a review of the literature. Am J Med. 1995;98(1):75–84. Review.

    Article  CAS  PubMed  Google Scholar 

  17. Tiruvoipati R, Chiezey B, Lewis D, et al. Stress hyperglycemia may not be harmful in critically ill patients with sepsis. J Crit Care. 2012;27(2):153–8.

    Article  CAS  PubMed  Google Scholar 

  18. Furnary AP, Gao G, Grunkemeier GL, et al. Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2003;125(5):1007–21.

    Article  CAS  PubMed  Google Scholar 

  19. Lazar HL. Glycemic control during coronary artery bypass graft surgery. ISRN Cardiol. 2012;2012:292490. doi:10.5402/2012/292490.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Hoedemaekers CW, Pickkers P, Netea MG, et al. Intensive insulin therapy does not alter the inflammatory response in patients undergoing coronary artery bypass grafting: a randomized controlled trial [ISRCTN95608630]. Crit Care. 2005;9(6):R790–7.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Sawin G, Shaughnessy AF. Glucose control in hospitalized patients. Am Fam Physician. 2010;81(9):1121–4.

    PubMed  Google Scholar 

  22. Punke MA, Goepfert MS, Kluge S, et al. Perioperative glycemic control with a computerized algorithm versus conventional glycemic control in cardiac surgical patients undergoing cardiopulmonary bypass with blood cardioplegia. J Cardiothorac Vasc Anesth. 2014;28(5):1273–7.

    Article  PubMed  Google Scholar 

  23. Gandhi GY, Nuttall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med. 2007;146(4):233–43.

    Article  PubMed  Google Scholar 

  24. Thiessen S, Vanhorebeek I, Van den Berghe G. Glycemic control and outcome related to cardiopulmonary bypass. Best Pract Res Clin Anaesthesiol. 2015;29(2):177–87.

    Article  PubMed  Google Scholar 

  25. Knapik P, Nadziakiewicz P, Urbanska E, et al. Cardiopulmonary bypass increases postoperative glycemia and insulin consumption after coronary surgery. Ann Thorac Surg. 2009;87(6):1859–65.

    Article  PubMed  Google Scholar 

  26. Anderson RE, Brismar K, Barr G, et al. Effects of cardiopulmonary bypass on glucose homeostasis after coronary artery bypass surgery. Eur J Cardiothorac Surg. 2005;28(3):425–30.

    Article  PubMed  Google Scholar 

  27. Kohl BA, Deutschman CS. The inflammatory response to surgery and trauma. Curr Opin Crit Care. 2006;12(4):325–32. Review.

    Article  PubMed  Google Scholar 

  28. Palermo RA, Palac HL, Wald EL, et al. Metabolic Uncoupling Following Cardiopulmonary Bypass. Congenit Heart Dis. 2015 Jul 29.

  29. Floh AA, Manlhiot C, Redington AN, et al. Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg. 2015 Jun 25.

  30. Whitcomb BW, Pradhan EK, Pittas AG, et al. Impact of admission hyperglycemia on hospital mortality in various intensive care unit populations. Crit Care Med. 2005;33(12):2772–7.

    Article  PubMed  Google Scholar 

  31. Gandhi GY, Nuttall GA, Abel MD, et al. Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc. 2005;80(7):862–6.

    Article  PubMed  Google Scholar 

  32. Umpierrez GE, Isaacs SD, Bazargan N, et al. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab. 2002;87(3):978–82.

    Article  CAS  PubMed  Google Scholar 

  33. Kwon S, Thompson R, Dellinger P, et al. Importance of perioperative glycemic control in general surgery: a report from the Surgical Care and Outcomes Assessment Program. Ann Surg. 2013;257(1):8–14.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Doenst T, Wijeysundera D, Karkouti K, et al. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. J Thorac Cardiovasc Surg. 2005;130(4):1144.

    PubMed  Google Scholar 

  35. Lleva RR, Inzucchi SE. Hospital management of hyperglycemia. Curr Opin Endocrinol Diabet Obes. 2011;18(2):110–8.

    Article  CAS  Google Scholar 

  36. Fish LH, Weaver TW, Moore AL, et al. Value of postoperative blood glucose in predicting complications and length of stay after coronary artery bypass grafting. Am J Cardiol. 2003;92(1):74–6.

    Article  PubMed  Google Scholar 

  37. Eiland L, Goldner W, Drincic A, et al. Inpatient hypoglycemia: a challenge that must be addressed. Curr Diab Rep. 2014;14(1):445.

    Article  PubMed  Google Scholar 

  38. Brunkhorst FM, Engel C, Bloos F, et al. German Competence Network Sepsis (SepNet). Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125–39.

    Article  CAS  PubMed  Google Scholar 

  39. Preiser JC, Devos P, Ruiz-Santana S, et al. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med. 2009;35(10):1738–48.

    Article  CAS  PubMed  Google Scholar 

  40. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360(13):1283–97.

    Article  Google Scholar 

  41. Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest. 2010;137(3):544–51.

    Article  CAS  PubMed  Google Scholar 

  42. Yuan J, Liu T, Zhang X, et al. Intensive Versus Conventional Glycemic Control in Patients with Diabetes During Enteral Nutrition After Gastrectomy. J Gastrointest Surg. 2015;19(8):1553–8.

    Article  PubMed  Google Scholar 

  43. Cao S, Zhou Y, Chen D, et al. Intensive versus conventional insulin therapy in nondiabetic patients receiving parenteral nutrition after D2 gastrectomy for gastric cancer: a randomized controlled trial. J Gastrointest Surg. 2011;15(11):1961–8.

    Article  PubMed  Google Scholar 

  44. Al-Niaimi AN, Ahmed M, Burish N, et al. Intensive postoperative glucose control reduces the surgical site infection rates in gynecologic oncology patients. Gynecol Oncol. 2015;136(1):71–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  45. Hermayer KL, Egidi MF, Finch NJ, et al. A randomized controlled trial to evaluate the effect of glycemic control on renal transplantation outcomes. J Clin Endocrinol Metab. 2012;97(12):4399–406.

    Article  CAS  PubMed  Google Scholar 

  46. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–31.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Qaseem A, Humphrey LL, Chou R, et al. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2011;154(4):260–7.

    Article  PubMed  Google Scholar 

  48. Jacobi J, Bircher N, Krinsley J, et al. Guidelines for the use of an insulin infusion for the management of hyperglycemia in critically ill patients. Crit Care Med. 2012;40(12):3251–76.

    Article  PubMed  Google Scholar 

  49. Inzucchi SE. Clinical practice. Management of hyperglycemia in the hospital setting. N Engl J Med. 2006;355(18):1903–11.

    Article  CAS  PubMed  Google Scholar 

  50. Boreland L, Scott-Hudson M, Hetherington K, et al. The effectiveness of tight glycemic control on decreasing surgical site infections and readmission rates in adult patients with diabetes undergoing cardiac surgery: A systematic review. Heart Lung. 2015 Jun 29.

  51. Bláha J, Mráz M, Kopecký P, et al. Perioperative tight glucose control reduces postoperative adverse events in non-diabetic cardiac surgery patients. J Clin Endocrinol Metab. 2015 Jun 16:jc20151959.

  52. Saager L, Duncan AE, Yared JP, et al. Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery. Anesthesiology. 2015;122(6):1214–23.

    Article  CAS  PubMed  Google Scholar 

  53. Desai SP, Henry LL, Holmes SD, et al. Strict versus liberal target range for perioperative glucose in patients undergoing coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg. 2012;143(2):318–25.

    Article  CAS  PubMed  Google Scholar 

  54. Pezzella AT, Holmes SD, Pritchard G, et al. Impact of perioperative glycemic control strategy on patient survival after coronary bypass surgery. Ann Thorac Surg. 2014;98(4):1281–5.

    Article  PubMed  Google Scholar 

  55. Lazar HL, McDonnell MM, Chipkin S, Fitzgerald C, Bliss C, Cabral H. Effects of aggressive versus moderate glycemic control on clinical outcomes in diabetic coronary artery bypass graft patients. Ann Surg. 2011;254(3):458–63. discussion 463–4.

    Article  PubMed  Google Scholar 

  56. Umpierrez G, Cardona S, Pasquel F, et al. Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial. Diabetes Care. 2015 Jul 15. Recent randomized study of CABG patients indicating no significant difference in clinical outcomes between intensive and conventional control.

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Authors and Affiliations

  1. Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA

    Lillian L. Tsai, Hanna A. Jensen & Vinod H. Thourani

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  1. Lillian L. Tsai
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  2. Hanna A. Jensen
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  3. Vinod H. Thourani
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Correspondence to Vinod H. Thourani.

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Lillian L. Tsai, Hanna A. Jensen, and Vinod H. Thourani declare that they have no conflict of interest.

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This article does not contain any studies with human or animal subjects performed by any of the authors.

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This article is part of the Topical Collection on Hospital Management of Diabetes

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Tsai, L.L., Jensen, H.A. & Thourani, V.H. Intensive Glycemic Control in Cardiac Surgery. Curr Diab Rep 16, 25 (2016). https://doi.org/10.1007/s11892-016-0719-5

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