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Submitted: 23 January 2017 Modified: 26 January 2017
HERDIN Record #: NCR-PHC-17012310304876

A comparison of outcomes among diabetic patients undergoing cardiac surgery using insulin infusion versus insulin bolus in glucose management.

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Background. Perioperative hyperglycemia during on-pump cardiac surgery is associated with increased incidence of postoperative complications such as deep sternal wound infection, cardiac, renal, neurologic complications, prolonged intubation and longer stay in the intensive care unit, particularly among diabetic patients. Intraoperative glycemic control can be difficult to control because the stress response of cardiac surgery and cardiopulmonary bypass can induce profound hyperglycemia. Intraoperative blood glucose control significantly reduces postoperative morbidity and mortality in cardiac patients under cardiopulmonary bypass. This study was done to determine and compare outcomes of diabetic patients undergoing open heart surgery receiving insulin bolus versus insulin infusion for glucose control.


Methods. This is a prospective randomized controlled study involving 86 adult diabetic patients who underwent on-pump cardiac surgery. Patients were randomly assigned to receive insulin bolus or insulin infusion to maintain glucose levels between 80-120mg/dl. Insulin therapy was initiated according to modified Portland protocol. Intraoperative blood glucose levels were measured hourly and titrated accordingly. Postoperative blood glucose levels were also determined and titrated with insulin until 12 hours. Outcomes of glucose management were followed up for in-hospital events thru chart review and interview from patients and relatives. The primary outcome was a composite of death, stroke, coma, sternal wound infection, cardiac arrhythmias (new onset atrial fibrillation, heart block, and cardiac arrest), and prolonged ventilation. The secondary outcomes were episodes hyperglycemia and hypoglycemia.


Results. Twenty of 43 patients in the bolus group and 20 of 43 patients had an in-hospital event. More deaths (0 vs. 2, [P=0.49]) occurred in the infusion group. Mean glucose concentrations were lower in the bolus group than in the infusion group during induction of anesthesia (171.2±87.5 vs. 158.4 ± 89.81, [P=0.504]), on bypass 396.3±80.33 vs. 398.9 ± 103.5, [P=0.89]), rewarming (399.1±81.14 vs. 402.1 ± 85.21, [P=0.84]), and postbypass (360 ± 10 vs. 386.7 ± 31, [P= 0.59] were not statistically significant. Mean glucose concentrations postoperatively taken upon arrival at ICU (290 ± 93.87 vs. 291.28 ± 116.53, P=0.97]) were similar in both groups. The average 12 hours glucose concentrations were lower in the infusion group but not significantly (214.57 ± 43.15 vs. 206.47 ± 62.58, {P=0.48]). The frequency of intraoperative hypoglycemia was low. Increased episodes of hyperglycemia was noted in both groups (41 vs. 38, [P=0.43]). Postoperative hypoglycemia was low in both groups. Postoperative hyperglycemia was seen in 27 patients in bolus group and 25 patients in the infusion group.


Conclusions. Intraoperative hyperglycemia under cardiopulmonary bypass is an independent risk factor for mortality and complications in diabetic patients. Although this pilot study showed no difference in clinical outcomes among the two study groups, the sample size was not large enough to allow for any definite conclusions or recommendations on the effect of glucose control on the outcomes of surgery. Insulin bolus can be used  intraoperatively and postoperatively with similar outcome in the infusion group.

Publication Type
Journal
Publication Sub Type
Journal Article, Original
Title
Philippine Heart Center Journal
Frequency
Semi-Annual
Publication Date
January-June 2013
Volume
17
Page(s)
34-42
LocationLocation CodeAvailable FormatAvailability
Philippine Heart Center Medical Library Fulltext Print Format