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Report
Perioperative Glucose
Management in
Cardiothoracic Surgery
Kelly Grogan, MD
Associate Professor
Medical University of South Carolina
Department of Anesthesiology and Perioperative Medicine
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Disclosures
• No conflict of interest
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Discussion
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Review of the literature
Moderate versus intensive glucose control
Current guidelines/ recommendations
Review of new quality measure
Are you there already?
Questions
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Hyperglycemia and Cardiac Surgery –
Observational Data - Postoperative
• Observational studies have suggested that hyperglycemia
(>200 mg/dL) after cardiothoracic surgery is associated with a
2-fold increased risk of wound infection
• Reducing serum glucose reduces surgical site infection rates
and cardiac-related mortality
• Elevates risk of poor outcomes in the setting of hyperglycemia
has been reported repeatedly, independent of diabetes status
• Direct correlation between the risk and degree of
hyperglycemia
• Fish and colleagues predicted 10 fold increase in complications
from post-op glucose level of >250 mg/dL
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Latham R et al. Infect Control Hosp Epidemiol 2001;22:607-612.
Zerr KJ et al. Ann Thorac Surg 1997;63:356-61.
Furnary AP et al. Ann Thorac Surg 1999;67:352-62.
Ascione R et al. Circulation 2008;118:113-123.
Jones KW et al. J Diabetes Complications 2008;22:365-70.
Fish LH et al. Am J Cardiol 2003;92:74-6.
Hyperglycemia and Cardiac Surgery –
Observational Data - Intraoperative
• Mounting evidence regarding the importance of
intraoperative glucose control
• Higher glucose levels during surgery are an independent
predictor of mortality in patients with and without diabetes
• Duncan et al found that:
• Severe intraoperative hyperglycemia (average glucose >200
mg/dL) increased morbidity and mortality following cardiac
surgery
• Patients with glucose <140 mg/dL had similar worse outcomes
• Glucose between 141-170 mg/dL had best outcomes
Doenst T et al. J Thorac Cardiovasc Surg 2005;130:1144.
Ouattara A et al. Anesthesiology 2005;103:687-94.
Gandhi GY et al. Mayo Clin Proc 2005;80:862-6.
Duncan AE et al. Anesthesiology 2010;112:860-71.
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Hyperglycemia and Cardiac Surgery:
Observational - Preoperative
• Poor preoperative glucose control has been associated with
increased morbidity, including increased DSWI and prolonged
LOS
• Abnormal glucose values prior to surgery may also be
predictors of decreased survival postoperatively
• Anderson and colleagues:
• 1375 CABG patients
• Elevated preop fasting glucose had:
• 1-year mortality that was twice as great as patients with normal
fasting
• 1-year mortality equal to that of patients with diabetes
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Furnary Ap et al. Endocr Pract 2004;10(suple)2:21-33.
Lazar HL et al. Circulation 2004;109:1497-502.
Anderson et al. Eur J Cardiothorac Surg 2005;28:425-30.
Hyperglycemia and Cardiac Surgery –
Interventions
• Portland Diabetic Project
• Prospective, nonrandomized, interventional study investigating
relationship between hyperglycemia and M&M since 1987
• Implemented in graded steps initiated in ICU and now continues
until 7:00 am of the 3rd postoperative day
• Continuous insulin infusion resulted in significantly lower mean
glucose levels than intermittent SQ insulin
• Most recent update includes data on 4864 diabetic patients who
underwent open heart surgery
• Increasing blood glucose levels were found to be independently and
directly associated with increasing rates of death, DSWIs, length of
stay and hospital cost
• Concluded that both a target blood glucose level of less than 150
mg/dL and a 3-day postoperative duration were important variables
in improving outcome
Furnary AP et al. J Thorac Cardiovasc Surg 2003;125:1007-21.
Furnary AP et al. Endocr Pract 2004;10:21-33.
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Hyperglycemia and Cardiac Surgery –
Interventions
• Lazar and colleagues
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141 CABG pts with DM
Modified glucose-insulin-potassium solution
Goal 120-180 mg/dL versus <250 mg/dL with SSI
GIP had better glucose control, higher cardiac indices, lower
infections, less arrhythmias, shorter hospital LOS, and 5 year
survival advantage
• Van den Bergue et al
• 1548 ventilated ICU patients; 62% cardiac surgery; 12% diabetics
• Conventional (180-200 mg/dL) vs intensive (80-110 mg/dL)
• Mortality reduction in pts requiring >3 days ICU care
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Lazar et al. Circulation 2004;109:1497-502.
Van den Bergue G et al. N Engl J Med 2001;345:1359-67.
Moderate vs Intensive Therapy
Randomized Control Trials
• NICE SUGAR
• Finfer S et al.NEJM. 2009;360:1283-97.
• 6100 critically ill subjects in randomized, prospective, and blinded
evaluation of IIT versus conventional management
• Mortality from cardiovascular causes was more common in the
IIT group (42% vs 36%, p<0.02) as was severe hypoglycemia (6.8%
vs 0.5%, p<0.001)
• Concluded that glucose <180 mg/dL or less resulted in lower
mortality that did target 81-108 mg/dL
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Higher incidence of mortality and severe hypoglycemia associated with intensive insulin therapy raise the
possibility that serious adverse events may, at least in part, outweigh benefit derived from strict glycemic control.
Moderate vs Intensive Therapy
Randomized Control Trials
• VISEP
• Brunkhorst FM et al. NEJM 2008;358:12539.
• Used the Leuven protocol and attempted to evaluate role of IIT
versus conventional therapy in patients with severe sepsis
• Discontinued early due to high rates of severe hypoglycemia in IIT
vs conventional group (17.0% vs 4.1%, p<0.001)
• Glucontrol
• Preiser J et al. Intensive Care Med 2009;35:1738-48.
• Also stopped early due to increased rates of hypoglcemia (8.7% vs
2.7%, p<0.001)
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Higher incidence of mortality and severe hypoglycemia associated with intensive insulin therapy raise the
possibility that serious adverse events may, at least in part, outweigh benefit derived from strict glycemic control.
Moderate vs Intensive Therapy
Meta Analysis/Systematic Reviews
• Weiner RS et al
• JAMA 2008;300:933-44.
• Meta analysis of RCTs comparing IIT (80-110 mg/dL) vs less
intensive targets (180-200 mg/dL) in critically ill patients
• 8432 pts in 29 RCTs, no difference in mortality (21.6 vs 23.3%,
respectively)
• Griesdale DE et al
• CMAJ 2009;180:821-7.
• Meta analysis of 13567 critically ill patients, IIT was shown to
significantly increase risk of hypoglycemia (6 fold increase)
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Higher incidence of mortality and severe hypoglycemia associated with intensive insulin therapy raise the
possibility that serious adverse events may, at least in part, outweigh benefit derived from strict glycemic control.
Moderate versus Intensive Therapy
Cardiac Surgery
• Haga KK et al. Cardiothorac Surg 2011;6:3.
• Systematic review and meta analysis
• “there may be some benefit to tight glycemic control during and
after cardiac surgery”
• Results were limited by few eligible trials, small patient numbers,
poorly defined outcomes
• D’Ancona G et al. Eur J Cardiothorac Surg 2011;40:360-6.
• Iatrogenic hypoglycemia secondary to tight glucose control was
independent determinant for mortality and cardiac morbidity
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Comparison of Glycemic Control
Recommendations and Guidelines
• American Association of Clinical Endocrinologists and American
Diabetes Association Consensus Statement on Inpatient Glycemic
Control (Moghessi et al, Endocr Pract 2009;15:353-69)
• Consensus statement recommendations for inpatient glucose
management based on degree of illness
• Society of Thoracic Surgeons Practice Guidelines Series: Blood
Glucose Management During Adult Cardiac Surgery (Lazar et al, Ann
Thorac Surg 2009;87:663-9)
• Evidence-based recommendations for all patients undergoing cardiac
surgery
• American College of Cardiology Foundation and American Heart
Association Guidelines for Coronary Artery Bypass Grafting (Hillis et
al, Circulation 2011;124:2610-2642)
• Recommendations for all patients undergoing CABG
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Intraoperative
STS Practice
Guideline Series
• Diabetics – A glucose
level ≤180 mg/dL is
best achieved with IV
insulin (level of
evidence A)
• Nondiabetics – IV
insulin is not
necessary provided
glucose levels remain
≤180 mg/DL (Class I;
level of evidence B)
AACE/ADA Consensus
Statement
No specific
recommendations for
intraoperative
management
ACCF/AHA
CABG Guideline
Use of continuous IV
insulin to achieve a
glucose level ≤140
mg/dL has uncertain
effectiveness
(Class IIb; level of
evidence B)
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Postoperative/Inpatient Management –
General Comments
STS Practice Guidelines
Series
• Diabetics should have
a glucose ≤180 mg/dL
for at least 24 hrs
postop; best achieved
with IV insulin
infusion
• Non-diabetics with
persistently elevated
blood glucose levels
(≥180 mg/dL) treat
with IV insulin
infusion and obtain
endocrinology consult
(Class I; level of
evidence B)
AACE/ADA Consensus
Statement
ACCF/AHA CABG
Guideline
Use of continuous IV
insulin to achieve early
postoperative glucose
level ≤180 mg/dL while
avoiding hypoglycemia is
indicated to reduce the
incidence of adverse
events, including deep
sternal wound infection
after CABG
(Class I; level of evidence
B)
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Prolonged ICU Stay of Critically Ill
STS Practice Guidelines
Series
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All patients with
persistently elevated
glucose levels (≥180
mg/dL) should receive IV
insulin infusions to
maintain serum glucose
≤180 mg/dL for the
duration of their IV care
(Class I; level of evidence
A)
All patients who require
>3 days in ICU* should
have a continuous IV
insulin infusion to
maintain serum glucose
≤150 mg/dL (Class I; level
of evidence B)
AACE/ADA Consensus
Statement
ACCF/AHA CABG
Guideline
Critically ill patients in the
ICU should have IV insulin
initiated for glucose levels
≤180 mg/dL with the goal of
140-180 mg/dL; target levels
<110 mg/dL are not
recommended
*Vent dependency; inotropes; IABP; LVAD; antiarrhythmics; dialysis; CVVH
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Stepdown and Floor Status
STS Practice Guidelines
Series
AACE/ADA Consensus
Statement
• A target blood
glucose level ≤180
mg/dL should be
achieved in peak
postprandial state
(Class I; level of
evidence B)
• A target blood
glucose level ≤110
mg/dL should be
achieved in the
fasting and premeal
states (Class I; level of
evidence C)
Based on clinical
experience and
judgment, premeal
glucose levels should
generally be ≤140 mg/dL
with random glucose
levels ≤180 mg/dL
ACCF/AHA CABG
Guideline
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New Quality Measure
• Performance Metric Name: Cardiac Surgery Patients with
Controlled Postoperative Blood Glucose
• Description: Cardiac surgery patients with controlled
postoperative blood glucose (less than or equal to 180 mg/dL)
in the timeframe of 18-24 hours after Anesthesia End Time
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Rationale
• STS Workforce guidelines that recommend that all cardiac
surgery patients, with and without diabetes, maintain serum
glucose of <180 mg/dL
• Controlling glucose in the immediate time period after surgery
may be challenging
• Cardiac surgery care teams should be able to reasonably
control the blood glucose to levels of 180 mg/dL or less within
the 18-24 hour post-operative time frame
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Definitions
Type of Measure
Process
Improvement Noted As
An increase in the percentage
Numerator Statement
Cardiac surgery patients with
controlled postoperative blood glucose
(<180 mg/dL) in the timeframe of 1824 hours after Anesthesia End Time
Denominator Statement
Cardiac surgery patients with no
evidence of prior infection
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Included Populations
• An ICD-9-CM Principal Procedure Code of selected surgeries
(as defined in Appendix A, Table 5.10 for ICD-9-CM codes)
• An ICD-9-CM Principal Procedure Code of selected surgeries
(as defined in Appendix A, Table 5.11 for ICD-9-CM codes)
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Excluded Populations
• Patients less than 18 years of age
• Patients who have a length of stay greater than 120 days
• Patients who had a principal diagnosis suggestive of
preoperative infectious disease (as defined in Appendix A,
Table 5.09 for ICD-9-CM codes)
• Burn and transplant patients (as defined in Appendix A, Table
5.14 and 5.15 for ICD-9-CM codes)
• Patients enrolled in clinical trials
• Patients whose ICD-9-CM principal procedure occurred prior
to the date of admission
• Patients with physician/APN/PA documented infection prior to
surgical procedure of interest
• Patients who undergo CPR or surgery, discharge, expire, or
leave AMA prior to 24 hours after Anesthesia End Time
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Data Elements
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Anesthesia Start Date
Admission Date
Birthdate
Clinical Trial
Discharge Date
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
Infection Prior to Anesthesia
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Where to begin?
The Framework
Administrative
support
Identify
Modify
Stakeholders
Define working
groups
Evaluate
Assess Current
State
Implement
Education
Create/Identify
Protocols and
Algorithms
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Assessment of Current Processes
• What is the current level of glycemic control?
• How many measurements fall within goal?
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Assessment of Current Processes
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What are the current practices and policies?
Are they used consistently/ appropriately?
Is glucose being measured sufficiently frequently?
Insulin use patterns
Incidence of hypoglycemic and it’s sequelae
• What are YOUR identified barriers to obtaining glycemic
control?
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Questions?
Comments?
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