SSI Glucose Control: Cardiac Surgery

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SSI Glucose Control Cardiac Surgery

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

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Objectives

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

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Key Stakeholders

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

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History

• 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

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Challenges

• 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

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Barriers

• 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.

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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
  surgery
• 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

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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.

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Changes

• 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.

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Changes

• 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
  education

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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

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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
  intensive.
• 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
  unit

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Future Initiatives
Ann Thorac Surg 2009 87663-9
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Preoperative Management and Assessment for
Patients with Diabetes Recommendations

• Hemaglobin A1c on all preoperative patients (lt
  7)
• 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
  insulin
• Maintain glucose lt 10 mmol/L in all pre-op
  patients

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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

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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

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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

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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

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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

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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
  regarding
• 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

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Questions ??