Perioperative Glucose Management in Cardiothoracic Surgery

Kelly Grogan, MDAssociate ProfessorMedical University of South CarolinaDepartment of Anesthesiology and Perioperative Medicine

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Disclosures• No conflict of interest

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Discussion• Review of the literature• Moderate versus intensive glucose control• Current guidelines/ recommendations• Review of new quality measure• Are you there already?• Questions

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Hyperglycemia and Cardiac Surgery –Observational Data - Postoperative

• Observational studies have suggested that hyperglycemia (>200 mg/dL) after cardiothoracic surgery is associated with a 2-fold increased risk of wound infection

• Reducing serum glucose reduces surgical site infection rates and cardiac-related mortality

• Elevates risk of poor outcomes in the setting of hyperglycemia has been reported repeatedly, independent of diabetes status

• Direct correlation between the risk and degree of hyperglycemia• Fish and colleagues predicted 10 fold increase in complications

from post-op glucose level of >250 mg/dL

Latham R et al. Infect Control Hosp Epidemiol 2001;22:607-612.Zerr KJ et al. Ann Thorac Surg 1997;63:356-61.Furnary AP et al. Ann Thorac Surg 1999;67:352-62.

Ascione R et al. Circulation 2008;118:113-123.Jones KW et al. J Diabetes Complications 2008;22:365-70.Fish LH et al. Am J Cardiol 2003;92:74-6.

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Hyperglycemia and Cardiac Surgery –Observational Data - Intraoperative

• Mounting evidence regarding the importance of intraoperative glucose control

• Higher glucose levels during surgery are an independent predictor of mortality in patients with and without diabetes

• Duncan et al found that:• Severe intraoperative hyperglycemia (average glucose >200

mg/dL) increased morbidity and mortality following cardiac surgery

• Patients with glucose <140 mg/dL had similar worse outcomes• Glucose between 141-170 mg/dL had best outcomes

Doenst T et al. J Thorac Cardiovasc Surg 2005;130:1144.Ouattara A et al. Anesthesiology 2005;103:687-94.Gandhi GY et al. Mayo Clin Proc 2005;80:862-6.Duncan AE et al. Anesthesiology 2010;112:860-71.

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Hyperglycemia and Cardiac Surgery:Observational - Preoperative

• Poor preoperative glucose control has been associated with increased morbidity, including increased DSWI and prolonged LOS

• Abnormal glucose values prior to surgery may also be predictors of decreased survival postoperatively

• Anderson and colleagues:• 1375 CABG patients• Elevated preop fasting glucose had:

• 1-year mortality that was twice as great as patients with normal fasting

• 1-year mortality equal to that of patients with diabetes

Furnary Ap et al. Endocr Pract 2004;10(suple)2:21-33.Lazar HL et al. Circulation 2004;109:1497-502.Anderson et al. Eur J Cardiothorac Surg 2005;28:425-30.

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Hyperglycemia and Cardiac Surgery –Interventions

• Portland Diabetic Project• Prospective, nonrandomized, interventional study investigating

relationship between hyperglycemia and M&M since 1987• Implemented in graded steps initiated in ICU and now continues

until 7:00 am of the 3rd postoperative day • Continuous insulin infusion resulted in significantly lower mean

glucose levels than intermittent SQ insulin• Most recent update includes data on 4864 diabetic patients who

underwent open heart surgery• Increasing blood glucose levels were found to be independently and

directly associated with increasing rates of death, DSWIs, length of stay and hospital cost

• Concluded that both a target blood glucose level of less than 150 mg/dL and a 3-day postoperative duration were important variables in improving outcome

Furnary AP et al. J Thorac Cardiovasc Surg 2003;125:1007-21.

Furnary AP et al. Endocr Pract 2004;10:21-33.

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Hyperglycemia and Cardiac Surgery –Interventions

• Lazar and colleagues• 141 CABG pts with DM• Modified glucose-insulin-potassium solution• Goal 120-180 mg/dL versus <250 mg/dL with SSI• GIP had better glucose control, higher cardiac indices, lower

infections, less arrhythmias, shorter hospital LOS, and 5 year survival advantage

• Van den Bergue et al• 1548 ventilated ICU patients; 62% cardiac surgery; 12% diabetics• Conventional (180-200 mg/dL) vs intensive (80-110 mg/dL)• Mortality reduction in pts requiring >3 days ICU care

Lazar et al. Circulation 2004;109:1497-502.Van den Bergue G et al. N Engl J Med 2001;345:1359-67.

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Moderate vs Intensive TherapyRandomized Control Trials

• NICE SUGAR• Finfer S et al.NEJM. 2009;360:1283-97.• 6100 critically ill subjects in randomized, prospective, and blinded

evaluation of IIT versus conventional management• Mortality from cardiovascular causes was more common in the

IIT group (42% vs 36%, p<0.02) as was severe hypoglycemia (6.8% vs 0.5%, p<0.001)

• Concluded that glucose <180 mg/dL or less resulted in lower mortality that did target 81-108 mg/dL

Higher incidence of mortality and severe hypoglycemia associated with intensive insulin therapy raise the possibility that serious adverse events may, at least in part, outweigh benefit derived from strict glycemic control.

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Moderate vs Intensive TherapyRandomized Control Trials

• VISEP• Brunkhorst FM et al. NEJM 2008;358:12539.• Used the Leuven protocol and attempted to evaluate role of IIT

versus conventional therapy in patients with severe sepsis• Discontinued early due to high rates of severe hypoglycemia in IIT

vs conventional group (17.0% vs 4.1%, p<0.001)• Glucontrol• Preiser J et al. Intensive Care Med 2009;35:1738-48.• Also stopped early due to increased rates of hypoglcemia (8.7%

vs 2.7%, p<0.001)

Higher incidence of mortality and severe hypoglycemia associated with intensive insulin therapy raise the possibility that serious adverse events may, at least in part, outweigh benefit derived from strict glycemic control.

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Moderate vs Intensive TherapyMeta Analysis/Systematic Reviews

• Weiner RS et al• JAMA 2008;300:933-44.• Meta analysis of RCTs comparing IIT (80-110 mg/dL) vs less

intensive targets (180-200 mg/dL) in critically ill patients• 8432 pts in 29 RCTs, no difference in mortality (21.6 vs 23.3%,

respectively)• Griesdale DE et al• CMAJ 2009;180:821-7.• Meta analysis of 13567 critically ill patients, IIT was shown to

significantly increase risk of hypoglycemia (6 fold increase)

Higher incidence of mortality and severe hypoglycemia associated with intensive insulin therapy raise the possibility that serious adverse events may, at least in part, outweigh benefit derived from strict glycemic control.

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Moderate versus Intensive TherapyCardiac Surgery

• Haga KK et al. Cardiothorac Surg 2011;6:3.• Systematic review and meta analysis• “there may be some benefit to tight glycemic control during and

after cardiac surgery”• Results were limited by few eligible trials, small patient numbers,

poorly defined outcomes• D’Ancona G et al. Eur J Cardiothorac Surg 2011;40:360-6.• Iatrogenic hypoglycemia secondary to tight glucose control was

independent determinant for mortality and cardiac morbidity

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Comparison of Glycemic Control Recommendations and Guidelines

• American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control (Moghessi et al, Endocr Pract 2009;15:353-69)• Consensus statement recommendations for inpatient glucose

management based on degree of illness• Society of Thoracic Surgeons Practice Guidelines Series: Blood

Glucose Management During Adult Cardiac Surgery (Lazar et al, Ann Thorac Surg 2009;87:663-9)• Evidence-based recommendations for all patients undergoing cardiac

surgery• American College of Cardiology Foundation and American Heart

Association Guidelines for Coronary Artery Bypass Grafting (Hillis et al, Circulation 2011;124:2610-2642)• Recommendations for all patients undergoing CABG

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IntraoperativeSTS Practice

Guideline SeriesAACE/ADA Consensus

StatementACCF/AHA

CABG Guideline • Diabetics – A glucose

level ≤180 mg/dL is best achieved with IV insulin (level of evidence A)

• Nondiabetics – IV insulin is not necessary provided glucose levels remain ≤180 mg/DL (Class I; level of evidence B)

No specific recommendations for intraoperative management

Use of continuous IV insulin to achieve a glucose level ≤140 mg/dL has uncertain effectiveness (Class IIb; level of evidence B)

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Postoperative/Inpatient Management – General CommentsSTS Practice Guidelines

SeriesAACE/ADA Consensus

StatementACCF/AHA CABG

Guideline• Diabetics should have

a glucose ≤180 mg/dL for at least 24 hrs postop; best achieved with IV insulin infusion

• Non-diabetics with persistently elevated blood glucose levels (≥180 mg/dL) treat with IV insulin infusion and obtain endocrinology consult (Class I; level of evidence B)

Use of continuous IV insulin to achieve early postoperative glucose level ≤180 mg/dL while avoiding hypoglycemia is indicated to reduce the incidence of adverse events, including deep sternal wound infection after CABG(Class I; level of evidence B)

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Prolonged ICU Stay of Critically IllSTS Practice Guidelines

Series AACE/ADA Consensus

StatementACCF/AHA CABG

Guideline

• All patients with persistently elevated glucose levels (≥180 mg/dL) should receive IV insulin infusions to maintain serum glucose ≤180 mg/dL for the duration of their IV care (Class I; level of evidence A)

• All patients who require >3 days in ICU* should have a continuous IV insulin infusion to maintain serum glucose ≤150 mg/dL (Class I; level of evidence B)

Critically ill patients in the ICU should have IV insulin initiated for glucose levels ≤180 mg/dL with the goal of 140-180 mg/dL; target levels <110 mg/dL are not recommended

*Vent dependency; inotropes; IABP; LVAD; antiarrhythmics; dialysis; CVVH

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Stepdown and Floor StatusSTS Practice Guidelines

SeriesAACE/ADA Consensus

StatementACCF/AHA CABG

Guideline• A target blood

glucose level ≤180 mg/dL should be achieved in peak postprandial state (Class I; level of evidence B)

• A target blood glucose level ≤110 mg/dL should be achieved in the fasting and premeal states (Class I; level of evidence C)

Based on clinical experience and judgment, premeal glucose levels should generally be ≤140 mg/dL with random glucose levels ≤180 mg/dL

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New Quality Measure• Performance Metric Name: Cardiac Surgery Patients with

Controlled Postoperative Blood Glucose• Description: Cardiac surgery patients with controlled

postoperative blood glucose (less than or equal to 180 mg/dL) in the timeframe of 18-24 hours after Anesthesia End Time

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Rationale• STS Workforce guidelines that recommend that all cardiac

surgery patients, with and without diabetes, maintain serum glucose of <180 mg/dL

• Controlling glucose in the immediate time period after surgery may be challenging

• Cardiac surgery care teams should be able to reasonably control the blood glucose to levels of 180 mg/dL or less within the 18-24 hour post-operative time frame

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Definitions

Type of Measure Process

Improvement Noted As An increase in the percentage

Numerator Statement Cardiac surgery patients with controlled postoperative blood glucose (<180 mg/dL) in the timeframe of 18-24 hours after Anesthesia End Time

Denominator Statement Cardiac surgery patients with no evidence of prior infection

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Included Populations• An ICD-9-CM Principal Procedure Code of selected surgeries

(as defined in Appendix A, Table 5.10 for ICD-9-CM codes)• An ICD-9-CM Principal Procedure Code of selected surgeries

(as defined in Appendix A, Table 5.11 for ICD-9-CM codes)

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Excluded Populations• Patients less than 18 years of age• Patients who have a length of stay greater than 120 days• Patients who had a principal diagnosis suggestive of preoperative

infectious disease (as defined in Appendix A, Table 5.09 for ICD-9-CM codes)

• Burn and transplant patients (as defined in Appendix A, Table 5.14 and 5.15 for ICD-9-CM codes)

• Patients enrolled in clinical trials• Patients whose ICD-9-CM principal procedure occurred prior to the

date of admission• Patients with physician/APN/PA documented infection prior to

surgical procedure of interest• Patients who undergo CPR or surgery, discharge, expire, or leave

AMA prior to 24 hours after Anesthesia End Time23

Data Elements• Anesthesia Start Date• Admission Date• Birthdate• Clinical Trial• Discharge Date• ICD-9-CM Principal Diagnosis Code• ICD-9-CM Principal Procedure Code• Infection Prior to Anesthesia

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Administrative support

IdentifyStakeholders

Define working groups

Assess Current State

Create/Identify Protocols and

AlgorithmsEducation

Implement

Evaluate

Modify

Where to begin?The Framework

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Assessment of Current Processes• What is the current level of glycemic control?

• How many measurements fall within goal?

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Assessment of Current Processes• What are the current practices and policies?• Are they used consistently/ appropriately?• Is glucose being measured sufficiently frequently?• Insulin use patterns• Incidence of hypoglycemic and it’s sequelae

• What are YOUR identified barriers to obtaining glycemic control?

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Questions?Comments?

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