Effects of intensive glycemic control on outcomes of cardiac surgery

Giakoumidakis, Konstantinos; Eltheni, Rokeia; Patelarou, Evridiki; Theologou, Stavros; Patris, Vasileios; Michopanou, Nektaria; Mikropoulos, Theodoros; Brokalaki, Hero

doi:10.1016/j.hrtlng.2012.12.007

Cited by 37 publications

(24 citation statements)

References 39 publications

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“…[22][23][24][25][26] Some evidence supports implementing glycemic control prior to surgery, 27,28 which suggests that delaying surgery for better glycemic control in the cases of elective surgeries may be a useful option. A randomized prospective study would be needed to address the best course of action once patients without known diabetes are pre-operatively screened for glucose.…”

Section: Discussionmentioning

confidence: 99%

Preoperative glucose as a screening tool in patients without diabetes

Wang

Panizales

Hudson

et al. 2014

Journal of Surgical Research

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Section: Discussionmentioning

confidence: 99%

Preoperative glucose as a screening tool in patients without diabetes

Wang

Panizales

Hudson

et al. 2014

Journal of Surgical Research

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“…These findings are supported by a large and growing body of evidence that includes clinical trials 1–3 and systematic reviews 4 as well as observational cohorts. 5,6 Consequently, adequate glycemic control remains an important quality measure for cardiac care teams, and is outlined in Society for Thoracic Surgery (STS) guidelines.…”

mentioning

confidence: 57%

“…This would seem to be contradicted by the results of Giakoumiadakis et al in 2013, who conclude based on their prospective trial that “intensive” glucose control was favorable when compared to their control group. 3 They assigned 212 patients quasi-randomly to intensive or standard glucose control strategies, and found a significant decrease in in-hospital mortality during the study period. However, they defined intensive control as a goal of 120–160 mg/dL, which in fact is more in line with Desai’s liberal protocol rather than the strict protocol.…”

Section: Commentmentioning

confidence: 99%

“…The ideal or appropriate level of postoperative glycemic control following cardiac surgery has been a moving target for several years as data accumulate to support both intensive 3,8 and more permissive 9,10 glycemic management strategies. The use of intra- and postoperative insulin infusions to maintain serum glucose less than 180 mg/dL, and less than 150 mg/dL in select patients, is supported by level B evidence and STS guidelines, but the ideal level and duration of control remains undetermined.…”

mentioning

confidence: 99%

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Postoperative Hypoglycemia Is Associated With Worse Outcomes After Cardiac Operations

Johnston

Kirby

Downs

et al. 2017

The Annals of Thoracic Surgery

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Background Hypoglycemia is a known risk of intensive postoperative glucose control in cardiac surgery patients. However, neither the consequences of hypoglycemia relative to hyperglycemia, nor the possible interaction effects, have been well described. We examined the effects of postoperative hypoglycemia, hyperglycemia, and their interaction on short-term morbidity and mortality. Methods Single institution Society of Thoracic Surgeons (STS) database patient records from 2010–2014 were merged with clinical data, including blood glucose values measured in the intensive care unit (ICU). Exclusion criteria included fewer than 3 glucose measurements and absence of a STS predicted risk of morbidity or mortality score. Primary outcomes were operative mortality and composite major morbidity (permanent stroke, renal failure, prolonged ventilation, pneumonia or myocardial infarction). Secondary outcomes included ICU and postoperative length of stay. Hypoglycemia was defined as <70 mg/dL, and hyperglycemia as >180 mg/dL. Simple and multivariable regression models were used to evaluate outcomes. Results A total of 2,285 patient records met selection criteria for analysis. The mean postoperative glucose was 140.8 ± 18.8 mg/dL. Overall, 21.4% of patients experienced a hypoglycemic episode (n=488), and 1.05% (n=24) had a severe hypoglycemic episode (<40 mg/dL). The unadjusted odds ratio (UOR) for operative mortality for patients with any hypoglycemic episode compared to those without was 5.47 (95% CI 3.14–9.54), and the UOR for major morbidity was 4.66 (95% CI 3.55–6.11). After adjustment for predicted risk of morbidity or mortality and other significant covariates, the adjusted odds (AOR) of operative mortality are significant for patients with any hypoglycemia (AOR 4.88, 95% CI 2.67–8.92) and patients with both events (AOR 8.29 95% CI 1.83–37.5) but not hyperglycemia alone (AOR 1.62, 95% CI 0.56–4.69). The AOR of major morbidity for patients with both hypo- and hyperglycemic events is 14.3 (95% CI 6.50–31.4). Conclusions Postoperative hypoglycemia is associated with both mortality and major morbidity after cardiac surgery. The combination of both hyperglycemia and hypoglycemia represents a substantial increase in risk. Although it remains unclear whether hypoglycemia is a cause, an early warning sign, or a result of adverse events, this study suggests hypoglycemia may be an important event in the postoperative period after cardiac surgery.

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“…11,12,71 There have been many studies investigating optimal perioperative glycemic targets in major surgery. Whereas several early interventional studies have shown a beneficial effect of tight intraoperative glycemic control, 33,72,73 most recent studies do not support these findings. [74][75][76][77] In a recent meta-analysis of six studies, 75 a moderate glycemic target (between 5.6 and 8.3 mmol L −1 ) was found to be most beneficial in terms of postoperative complications and mortality as lower targets (less than 5.6 mmol L −1 ) did not lead to improved outcomes.…”

Section: Blood Glucose Target Rangementioning

confidence: 93%

Ambulatory anesthesia: optimal perioperative management of the diabetic patient

Polderman¹,

Wilpe²,

Eshuis³

et al. 2016

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Given the growing number of patients with diabetes mellitus (DM) and the growing number of surgical procedures performed in an ambulatory setting, DM is one of the most encountered comorbidities in patients undergoing ambulatory surgery. Perioperative management of ambulatory patients with DM requires a different approach than patients undergoing major surgery, as procedures are shorter and the stress response caused by surgery is minimal. However, DM is a risk factor for postoperative complications in ambulatory surgery, so should be managed carefully. Given the limited time ambulatory patients spend in the hospital, improvement in management has to be gained from the preanesthetic assessment. The purpose of this review is to summarize current literature regarding the anesthesiologic management of patients with DM in the ambulatory setting. We will discuss the risks of perioperative hyperglycemia together with the pre-, intra-, and postoperative considerations for these patients when encountered in an ambulatory setting. Furthermore, we provide recommendations for the optimal perioperative management of the diabetic patient undergoing ambulatory surgery.

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Effects of intensive glycemic control on outcomes of cardiac surgery

Cited by 37 publications

References 39 publications

Preoperative glucose as a screening tool in patients without diabetes

Preoperative glucose as a screening tool in patients without diabetes

Postoperative Hypoglycemia Is Associated With Worse Outcomes After Cardiac Operations

Ambulatory anesthesia: optimal perioperative management of the diabetic patient

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