Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery

Gandhi, Gunjan Y.; Nuttall, Gregory A.; Abel, Martin

doi:10.7326/0003-4819-147-7-200710020-00019

Cited by 136 publications

(180 citation statements)

References 4 publications

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“…1 Since then, however, multicenter randomized trials have been unable to replicate these findings. [2][3][4][5][6][7][8][9] Their failure has been ascribed by some to be secondary to the significantly higher incidence of severe hypoglycemia (SH) (< 40 mg/dL) that accompanies intensive glucose management with intravenous insulin. It is important to note that the efficacy and safety of the protocols utilized in the trials were not previously reported or critically evaluated.…”

Section: Introductionmentioning

confidence: 99%

Computerization of the Yale Insulin Infusion Protocol and Potential Insights into Causes of Hypoglycemia with Intravenous Insulin

Marvin

Inzucchi

Besterman³

2013

Diabetes Technology & Therapeutics

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Background: The management of critically ill hyperglycemic patients in the intensive care unit (ICU) has been fraught with recent controversy. Only one randomized trial has demonstrated a mortality benefit to intensive glycemic control, with all subsequent studies failing to confirm this benefit and revealing a markedly increased risk of severe hypoglycemia (SH) in intensively treated patients. In most of these trials, adherence to the protocols were neither tracked nor reported. Methods: A retrospective analysis of all patients admitted to an ICU who were treated with an insulin infusion directed by the GlucoCareÔ IGC System, an FDA-cleared insulin-dosing calculator (Yale 100-140 mg/dL protocol). Mean blood glucose (BG) levels, time to target range and incidence of SH ( < 40 mg/dL) and moderate hypoglycemia (MH) (40-69 mg/dL) were determined, and potential causes of hypoglycemic episodes were assessed. Results: Mean post-target BG was approximately 123 mg/dL. Of > 55,000 readings in 1,657 patients, overall incidence of SH was 0.01% of readings and 0.3% of patients. MH occurred in 1.1% of readings and 17.6% of patients. The top potential causes of MH were: (1) Protocol-directed recommendations including continuation of insulin with BG < 100 mg/dL and decreases in the frequency of BG checks (63.7%), and (2) Staff non-adherence to protocol directives (15.3%). Conclusions:The results of the GlucoCare-directed Yale 100-140 mg/dL protocol experience revealed an extremely low incidence of SH and an incidence of MH of 1.1%. The incidence of SH in this study was lower than the control group of the NICE-SUGAR study and are supportive of the new Society of Critical Care guidelines to target BG levels of 100-150 mg/dL in critically ill patients. Further refinements to the original protocol and emphasis on staff adherence to protocol directives could potentially further reduce these very low hypoglycemia rates.

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Section: Introductionmentioning

confidence: 99%

Computerization of the Yale Insulin Infusion Protocol and Potential Insights into Causes of Hypoglycemia with Intravenous Insulin

Marvin

Inzucchi

Besterman³

2013

Diabetes Technology & Therapeutics

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“…Indeed, some potential flaws in these links between hyperglycemia and other adverse outcomes have recently been demonstrated. 26 This reinforces the concept of the difference between temporal association and causation, in essence, asking whether hyperglycemia can cause POCD, or if the two are only epiphenomena. One often incorrectly extrapolates data from such association studies assuming that addressing the associated factor will result in improvement of the adverse clinical outcome.…”

mentioning

confidence: 64%

Hyperglycemia and postoperative cognitive dysfunction: another call for better glycemic control?

Grocott

2008

Can J Anesth/J Can Anesth

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“…Although an alternative strategy would be to design such a study around composite outcomes, the clinical relevance of such an approach has been called into question. 30,31 The physiologic rationale for limiting tidal volume in the absence of lung injury deserves some discussion. For example, if large tidal volumes themselves could cause lung injury, then one would predict that exercising athletes would be subject to similar risk.…”

Section: Discussionmentioning

confidence: 99%

Influence of Low Tidal Volume Ventilation on Time to Extubation in Cardiac Surgical Patients

Sundar¹,

Novack²,

Jervis³

et al. 2011

Survey of Anesthesiology

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Background-Low tidal volumes have been associated with improved outcomes in patients with established acute lung injury. The role of low tidal volume ventilation in patients without lung injury is still unresolved. We hypothesized that such a strategy in patients undergoing elective surgery would reduce ventilator-associated lung injury and that this improvement would lead to a shortened time to extubation

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Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery

Cited by 136 publications

References 4 publications

Computerization of the Yale Insulin Infusion Protocol and Potential Insights into Causes of Hypoglycemia with Intravenous Insulin

Computerization of the Yale Insulin Infusion Protocol and Potential Insights into Causes of Hypoglycemia with Intravenous Insulin

Hyperglycemia and postoperative cognitive dysfunction: another call for better glycemic control?

Influence of Low Tidal Volume Ventilation on Time to Extubation in Cardiac Surgical Patients

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