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Perioperative Glucose Management in Cardiothoracic Surgery

Perioperative Glucose Management in Cardiothoracic Surgery. Kelly Grogan, MD Associate Professor Medical University of South Carolina Department of Anesthesiology and Perioperative Medicine. Disclosures. No conflict of interest. Discussion. Review of the literature

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Perioperative Glucose Management in Cardiothoracic Surgery

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  1. Perioperative Glucose Management in Cardiothoracic Surgery Kelly Grogan, MD Associate Professor Medical University of South Carolina Department of Anesthesiology and Perioperative Medicine

  2. Disclosures • No conflict of interest

  3. Discussion • Review of the literature • Moderate versus intensive glucose control • Current guidelines/ recommendations • Review of new quality measure • Are you there already? • Questions

  4. 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 Latham R et al. Infect Control HospEpidemiol 2001;22:607-612. Zerr KJ et al. Ann ThoracSurg 1997;63:356-61. Furnary AP et al. Ann ThoracSurg 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.

  5. 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 ThoracCardiovascSurg 2005;130:1144. Ouattara A et al. Anesthesiology 2005;103:687-94. Gandhi GY et al. Mayo ClinProc 2005;80:862-6. Duncan AE et al. Anesthesiology 2010;112:860-71.

  6. 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 FurnaryAp et al. EndocrPract 2004;10(suple)2:21-33. Lazar HL et al. Circulation 2004;109:1497-502. Anderson et al. Eur J CardiothoracSurg 2005;28:425-30.

  7. 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 ThoracCardiovascSurg 2003;125:1007-21. Furnary AP et al. EndocrPract 2004;10:21-33.

  8. Hyperglycemia and Cardiac Surgery –Interventions • Lazar and colleagues • 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 Lazar et al. Circulation 2004;109:1497-502. Van den Bergue G et al. N Engl J Med 2001;345:1359-67.

  9. Moderate vs Intensive TherapyRandomized 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 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.

  10. Moderate vs Intensive TherapyRandomized 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) 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.

  11. Moderate vs Intensive TherapyMeta 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) 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.

  12. Moderate versus Intensive TherapyCardiac Surgery • Haga KK et al. CardiothoracSurg 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 CardiothoracSurg 2011;40:360-6. • Iatrogenic hypoglycemia secondary to tight glucose control was independent determinant for mortality and cardiac morbidity

  13. 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, EndocrPract 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 ThoracSurg 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

  14. Intraoperative

  15. Postoperative/Inpatient Management – General Comments

  16. Prolonged ICU Stay of Critically Ill *Vent dependency; inotropes; IABP; LVAD; antiarrhythmics; dialysis; CVVH

  17. Stepdown and Floor Status

  18. 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

  19. 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

  20. Definitions

  21. 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)

  22. 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

  23. Data Elements • 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

  24. Where to begin?The Framework

  25. Assessment of Current Processes • What is the current level of glycemic control? • How many measurements fall within goal?

  26. Assessment of Current Processes • What are the current practices and policies? • Are they used consistently/ appropriately? • Is glucose being measured sufficiently frequently? • Insulin use patterns • Incidence of hypoglycemicand it’s sequelae • What are YOUR identified barriers to obtaining glycemic control?

  27. Questions?Comments?

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