Title: Impact of Hyperglycemia and Intravenous Insulin on Cardiac Surgery Outcomes
1Impact of Hyperglycemia and Intravenous Insulin
on Cardiac Surgery Outcomes
2Surgery and Hyperglycemia Overview
- Patients with diabetes comprise 29 of surgical
population - Associated with
- Longer stay
- Greater infection rate
- Higher operative mortality
- Worse long-term prognosis
American Association of Clinical
Endocrinologists. Available athttp//www.aace.co
m/pub/ICC/inpatientStatement.php. Accessed March
17, 2004.
3Hyperglycemia and Risk of Infection in General
Surgery and Medical Patients
- Glucose gt 220 mg/dL on postoperative day 1 is
- A sensitive predictor of nosocomial infection
- Associated with
- 2.7 times higher rate of infection
- 5.9 times higher rate of severe infection
Pomposelli JJ, et al. J Parenter Enteral Nutr.
1998227781.
4Portland Diabetic ProjectRate of Deep Sternal
Wound Infection Rates With Different Insulin
Protocols
2.0
P 0.01
Deep Wound Infection Rate ()
0.8
SQI subcutaneous insulin CII continuous
insulin infusion.
Furnary AP, et al. Ann Thorac Surg.
199967352362.
5Glucose Control Lowers Risk of Wound Infection
in Patients With Diabetes After Cardiac Surgery
67
P 0.002
Deep Wound Infection Rate ()
25
16
13
Day 1 Blood Glucose (mg/dL)
Reprinted from Zerr KJ, et al. Ann Thorac Surg.
199763356361 with permission from Society of
Thoracic Surgeons.
6Open Heart Surgery in DiabetesPortland St.
Vincent Medical Center2467 diabetic
patients
- Control Group
- N 968
- 19871991
- SubQ Insulin q 4 h
- Goal 200 mg/dL
- All Mean BGs lt 200 47
- Study Group
- N 1499
- 19911997
- IV Insulin
- Goal 150200 mg/dL
- All Mean BGs lt 200 84
Furnary et al, The 34th Meeting of The Society of
Thoracic Surgeons New Orleans, LA January 26,
1998
7Portland Diabetic Project Incidence of DSWI and
Impact of Implementation of Insulin Infusion
Protocols
4.0
CII
3.0
Patients with diabetes
DSWI()
2.0
Patients without
diabetes
1.0
0.0
87
88
89
90
91
92
93
94
95
96
97
Year
DSWI deep sternal wound infection CII
continuous insulin infusion.
Reprinted from Furnary AP, et al. Ann Thorac
Surg. 199967352362 with permission from
Society of Thoracic Surgeons.
8CII Reduces Mortality in Patients With Diabetes
Undergoing Cardiovascular Surgery
14.5
Cardiac-related mortality
Noncardiac-related mortality
Mortality()
6.0
4.1
2.3
1.3
0.9
Average Postoperative Glucose (mg/dL)
CII continuous insulin infusion.
Reprinted from Furnary AP, et al. J Thorac
Cardiovasc Surg. 200312510071021 with
permission from American Association for Thoracic
Surgery.
9Portland Diabetes ProjectMortality Versus
Hyperglycemia
(N 2,110)
Glucose goal lt 200 mg/dL
6.1
4.9
P 0.001
3.7
Mortality()
2.4
1.2
0.0
Furnary AP, et al. Circulation. 1999183113
(abstract).
10Portland Diabetes Project Postoperative
Mortality
Glucose Level (mg/dL)
Mortality Rate ( for quartile)
- lt 150 1.4
- 150175 1.7
- 175200 2.1
- 200225 3.8
- 225250 5.8
- gt 250 8.6
-
- Patients with a blood glucose level gt 200 mg/dL
had a higher mortality than those with a blood
glucose level lt 200 mg/dL (5.0 vs. 1.8 P lt
0.001)
Furnary AP, et al. Circulation. 1999183117
(abstract).
11Portland Diabetes Project Mortality
10
CII
8
Patients with diabetes
6
Mortality()
Patients without
4
diabetes
2
0
87
88
89
90
91
92
93
94
98
99
00
95
96
97
01
Year
Reprinted from Furnary AP, et al. J Thorac
Cardiovasc Surg. 200312510071021 with
permission from American Association for Thoracic
Surgery.
12Impact of Deep Sternal Wound Infection
- Additional cost per patient was 26,400
- Additional length of stay was 16 days
- Mortality increase 5 times
Furnary AP, et al. Ann Thorac Surg.
199967352360.
13Tight Glycemic Control With GIK in CABG Patients
With Diabetes Improves Outcomes
5.0
4.5
4.0
3.5
GIK
Cardiac Index(L/min/m2)
3.0
2.5
No GIK
2.0
1.5
P lt 0.001
1.0
0.5
0.0
PreCPB
Pool
0 Hr
6 Hrs
12 Hrs
18 Hrs
Cumulative 5 Year Survival
100
GIK
No GIK
75
Survival()
Log Rank Test P 0.04
50
25
0
0
1
2
3
4
5
Years
Lazar HL, et al. Circulation. 200410914971502.
Reprinted with permission (http//lww.com).
14Hyperglycemia and Insulin Infusion in Cardiac
Surgery Patients Summary
- Diabetes mellitus is a risk factor for mortality
after cardiac surgery - Preoperative hyperglycemia is an independent
predictor of deep sternal wound infection and
total length of hospital stay after open heart
surgery - Incidence of deep wound infection is reduced
after insulin protocol implementation to maintain
mean blood glucose levels lt 200 mg/dL in
postoperative period - CII should be standard of care for glycometabolic
control in patients with diabetes undergoing
cardiac surgery
CII continuous insulin infusion.