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SSI Glucose Control: Cardiac Surgery


SSI Glucose Control: Cardiac Surgery. Betty Anne Whelan RN, ... Based on the Van den ... was initiated and then vetted through our cardiac surgery ... – PowerPoint PPT presentation

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Title: SSI Glucose Control: Cardiac Surgery

SSI Glucose Control Cardiac Surgery
  • Betty Anne Whelan RN, BScN, MN(c),CCRN
  • Sandra Skerratt, RN(EC), MN/NP-Adult
  • March 12, 2009

  • Review History
  • Identify Stakeholders
  • Examine Barriers implementing Glucose Control
  • Discuss the implementation of data collection for
  • Discuss future plans

Key Stakeholders
  • Anesthesia
  • Cardiac Surgeons
  • Endocrinologists
  • Nursing
  • Pharmacy
  • Administration

  • Cardiac Surgery program began _at_ Southlake
    Regional in 2003
  • Based on the Van den Berghe Study (2001). The
    evidence pointed to the fact that there was a
    reduction in sternal infections directly related
    to tight glucose control
  • Our goal to implement pre-printed orders in
    CVICU to control Blood Glucose greater than 10

  • Biggest challenge was creating the protocol
  • Key issues identified were
  • Selection of the trigger glucose for the
    initiation of insulin
  • The change in nursing care processes to
    accommodate frequent glucose measurement
  • Frequent measurement played a critical role in
    maintaining control

  • Constant Glucose Measurement
  • Feedback and dialogue facilitated adjustments to
    the protocol and adherence by the nursing staff.
  • Dispute between anesthesia and nursing regarding
    how to collect the blood glucose( art-line versus
    finger poke)
  • Occasional periods of hypoglycemia due to tight
    control and a missed glucose check . This
    reinforced the nurses mistaken impression that
    the protocol was too rigid.

Early Changes Implemented
  • Developed low and high risk protocols
  • The low risk protocol was directed at the patient
    who were previously not a known diabetic but had
    developed high BS from the stress of cardiac
  • The high risk protocol was developed and defined
    for patients that we had difficulty
    controlling(as stated on the insulin orders)
  • In the high risk patients the potential for an
    initial bolus of insulin according to blood sugar
    was developed

Early Changes Implemented (cont)
  • The insulin infusion was to be started
    immediately after the bolus given the infusion
    should start to work approx the time the bolus
    half life is over.
  • The BS was to be measured in 1 hour if bolus
    given but the actual infusion rate was not to be
    increased until after the 2 hour results.
  • Without the bolus the 1st results would be
    obtained in 2 hrs and adjustments made.

  • The insulin infusion rate was not to be increased
    more than q2hr even if BS repeated in 1 hr and
    elevated from previous measurement
  • In the data collected, nurses were increasing the
    infusion rate with every BS done leading to the
    necessity of D50.
  • The low risk protocol needed to be revisited as
    it was not really effective in controlling the
    BS levels.

  • A great deal of time was spent educating the
    nurses and physicians regarding insulin and the
    protocol application
  • Education of effects of hyper hypoglycemia and
    the value of tight BS control was included in the

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Safer HealthCare Now
  • Implemented data collection in 2005.
  • By this time, glucose control had already been
    established and the only challenge was collecting
    the data
  • Began with small sample groups (n 20)
  • The second post-op day glucose was rarely
    collected, therefore the data reflected
    poor-glucose control
  • Implemented a change in the pre-printed transfer
    orders to the CVS unit from CVICU

No data collected
BG POD 2 not routinely collected
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Future Goals
  • Glucose control was a collaborative effort that
    was initiated and then vetted through our cardiac
    surgery committee
  • The hurdles as with any project were engaging all
    the stakeholders at the same meeting.
  • The team was large with CV surgeons, Endo,
    Nursing etc.
  • Everyone required time to review, input comments,
    then meet. Ultimately, this process was time
  • It was decided that although we felt we were
    advanced in the concept of glucose control on the
    immediate post-op period we needed to address
    our patients within the post-op period on the CVS

Future Initiatives
Ann Thorac Surg 2009 87663-9
Preoperative Management and Assessment for
Patients with Diabetes Recommendations
  • Hemaglobin A1c on all preoperative patients (lt
  • All oral diabetes medications should be withheld
    within the 24 hours prior to surgery (IV insulin
    infusion morning of surgery)
  • Insulin requiring diabetics should continue basal
    insulin but hold their nutritional insulin after
    dinner the evening prior to surgery
  • IV insulin therapy or SC basal plus rapid-acting
  • Maintain glucose lt 10 mmol/L in all pre-op

Intraoperative Control Recommendations
  • Glycemic control lt 10 mmol/L in patients with
    diabetes during cardiac surgery
  • Continuous IV insulin infusion intraoperatively
  • Continue for at least 24 hours postoperatively to
    maintain serum glucose lt 10mmol/L

Intraoperative Control Recommendations
  • Intravenous glycemic control using IV insulin
    infusions is not necessary in cardiac surgery
    patients without diabetes provided that glucose
    values remain lt 10 mmol/L
  • Single or intermittent dose of IV insulin if
    levels remain lt 10 mmol/L
  • Persistent elevated glucose levels gt 10 mmol/L
    continuous IV insulin infusion
  • Endocrinology consult
  • Continue postoperatively for 24 hours to maintain
    serum glucose lt 10 mmol/L

Glycemic Control in the ICU
  • Patients with and without diabetes with
    persistently elevated serum glucose (gt 10 mmol/L)
    should receive IV insulin infusions to maintain
    serum glucose lt 10 mmol/L for the duration of
    their ICU care
  • Before IV insulin infusions are discontinued,
    patients should be transitioned to a subcutaneous
    insulin schedule
  • Need basal and bolus insulin
  • Daily insulin requirements can be estimated by
    extrapolating the amount of insulin required in
    the preceding 24 hours and considering
    nutritional intake

Glycemic Control in the ICU (cont)
  • All patients who require gt 3 days in the ICU
    because of…
  • Ventilatory dependency
  • Requiring the need for inotropes
  • Intra-aortic balloon pump
  • Left ventricular device support
  • Dialysis
  • … Should have a continuous insulin infusion to
    keep blood glucose lt 8.3 mmol / L, regardless of
    diabetes status

Glycemic Control in the Stepdown Units and on the
Floor Recommendations
  • A target blood glucose level lt 10 mmol/L should
    be achieved in the peak postprandial state
  • A target blood glucose level lt 6.1 mmol/L should
    be achieved in the fasting and pre-meal states
    after transfer to the floor
  • Scheduled subcutaneous basal (long acting) and
    bolus (short acting) insulin
  • Oral hypoglycemic medications should be restarted
    in patients who have achieved target blood
    glucose levels (if there are no
    contraindications) and are eating a regular diet

Preparation for Hospital Discharge
  • Prior to discharge, all patients with diabetes
    and those who have started a new glycemic control
    regimen, should receive in-patient education
  • Glucose monitoring
  • Medication administration
  • Nutrition, and lifestyle modification
  • Upon discharge, changes in therapy for glycemic
    control should be communicated to primary care
    physicians, and follow-up appointments should be
    arranged with an endocrinologist when appropriate

Questions ??