Implementation of an intraoperative glycemic control protocol for cardiac surgery in a high-acuity academic medical center: an observational study

• Published in: Journal of clinical anesthesia Vol. 25; no. 2; pp. 121 - 128
• Main Authors: Kohl, Benjamin A., MD, FCCM, Hammond, Mary S., BSN, Ochroch, E. Andrew, MD
• Format: Journal Article
• Language: English
• Published: New York, NY Elsevier Inc 01-03-2013; Elsevier; Elsevier Limited
• Subjects: Academic Medical Centers; Aged; Aged, 80 and over; Anesthesia; Anesthesia & Perioperative Care; Anesthesia depending on type of surgery; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Blood Glucose - metabolism; Body mass index; Cardiac Surgical Procedures - mortality; Cardiopulmonary Bypass; Clinical Protocols; Diabetes; Diabetes Mellitus - blood; Diabetes Mellitus - drug therapy; Drug Administration Schedule; Female; Humans; Hyperglycemia; Hyperglycemia - prevention & control; Hypoglycemic Agents - administration & dosage; Hypoglycemic Agents - therapeutic use; Infusions, Intravenous; Insulin - administration & dosage; Insulin - therapeutic use; Insulin protocol; Intraoperative Care - methods; Intraoperative glycemic control, perioperative glycemic control; Kidney Failure, Chronic - blood; Kidney Failure, Chronic - prevention & control; Male; Medical sciences; Middle Aged; Mortality; Pain Medicine; Pennsylvania - epidemiology; Prognosis; Retrospective Studies; Thoracic and cardiovascular surgery. Cardiopulmonary bypass; Pennsylvania; Intraoperative glycemic control, perioperative glycemic control; Insulin protocol; Heart; Human; Prognosis; Intravenous administration; Mortality; Cardiovascular disease; Intraoperative; Insulin; Biological monitoring; Cardiopulmonary bypass; Surgery; Glycemia
• ISSN: 0952-8180; 1873-4529
• DOI: 10.1016/j.jclinane.2012.06.019

Abstract Study Objective To examine the effect on morbidity and mortality of an established intraoperative insulin protocol in cardiac surgical patients. Design Retrospective observational study. Setting Single-center, 782 bed, metropolitan academic hospital. Patients 1,616 adult patients undergoing cardiac surgical procedures with cardiopulmonary bypass (CPB). Interventions An intraoperative, intravenous (IV) insulin protocol designed to maintain blood glucose values less than 150 mg/dL was implemented. Measurements Blood glucose was evaluated on entry to the operating room, every 30 minutes during CPB, and at least once after discontinuation of CPB. Blood glucose values were followed postoperatively, as dictated by institutional policy. Main Results Intraoperative predictors of 30-day mortality using multivariate logistic regression included hyperglycemia on initiation of CPB (OR 1.0, P = 0.05). The strongest predictor of 30-day mortality was the development of postoperative renal failure requiring hemodialysis (OR 3.26, P = 0.001). Conclusions Implementation of an intraoperative IV insulin protocol, while associated with improved glycemic control, was not associated with improved outcomes. While improved glycemic control on initiating CPB was associated with decreased 30-day mortality, the effect was small. Implementation of our insulin protocol was highly associated with decreased renal failure postoperatively. Further prospective studies are warranted to better establish causality.