Impact of Hyperglycemia and Intravenous Insulin on Cardiac Surgery Outcomes

1
Impact of Hyperglycemia and Intravenous Insulin
on Cardiac Surgery Outcomes
2
Surgery 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.
3
Hyperglycemia 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.
4
Portland 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.
5
Glucose 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.
6
Open 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
7
Portland 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.
8
CII 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.
9
Portland 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).
10
Portland 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).
11
Portland 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.
12
Impact 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.
13
Tight 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).
14
Hyperglycemia 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.