1. Perioperative Glucose Management in Cardiothoracic Surgery
Kelly Grogan, MD
Associate Professor
Medical University of South Carolina
Department of Anesthesiology and Perioperative Medicine

2. Disclosures
No conflict of interest

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

5. 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
Fish – retrospectively reviewed the importance of blood glucose levels in the intraoperative and immediate postoperative period to predict the morbitiy in 200 consecutive CABG patients
Latham R et al. Infect Control Hosp Epidemiol 2001;22:
Zerr KJ et al. Ann Thorac Surg 1997;63:
Furnary AP et al. Ann Thorac Surg 1999;67:
Ascione R et al. Circulation 2008;118:
Jones KW et al. J Diabetes Complications 2008;22:
Fish LH et al. Am J Cardiol 2003;92:74-6.

6. 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 mg/dL had best outcomes
Doenst – effects of hyperglycemia on the clinical outcomes of 6280 patients undergoing cardiac surgery
Gahdhi – performed retrospective, observational study of 409 cardiac surgery patients; intraoperative hyperglycemia was an independent predictor of complications including death
Doenst T et al. J Thorac Cardiovasc Surg 2005;130:1144.
Ouattara A et al. Anesthesiology 2005;103:
Gandhi GY et al. Mayo Clin Proc 2005;80:862-6.
Duncan AE et al. Anesthesiology 2010;112:

7. 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:
Anderson et al. Eur J Cardiothorac Surg 2005;28:

8. 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:
Furnary AP et al. Endocr Pract 2004;10:21-33.

9. Hyperglycemia and Cardiac Surgery – Interventions
Lazar and colleagues
141 CABG pts with DM
Modified glucose-insulin-potassium solution
Goal 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 ( mg/dL) vs intensive ( mg/dL)
Mortality reduction in pts requiring >3 days ICU care
Lazar et al. Circulation 2004;109:
Van den Bergue G et al. N Engl J Med 2001;345:

10. Moderate vs Intensive Therapy Randomized Control Trials
NICE SUGAR
Finfer S et al.NEJM. 2009;360:
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 mg/dL
Recent trials in critically ill patients have failed to show a significant improvement in mortality with intensive glycemic control and have highlighted the risks of severe hypoglycemia
NICE SUGAR – 6100 subjects randomized, prospective, and blinded evaluation of IIT vs conventional; mortality (42 vs 36%) and severe hypoglycemia (6.8 vs 0.5%); concluded that IIT increased mortality and that glucose target <180 mg/dl or less resulted in less mortality
VISEP – attempted to evaluate role of IIT in pts with severe sepsis using Leuven Protocol – stopped early cause of hypoglycemia (17 vs 4.1%)
Glucontrol – 8.7 vs 2.7& hypoglycemia; stopped early cause of rate of hypoglycemia
D’Ancona – Iatrogenic hypoglycemia secondary to tight glucose control was an independent determinant for mortality and cardiac morbidity
Weiner – 8432 critically ill patients in 29 RCTs; no significant difference in mortality
Griesdale – critically ill patients; significantly increased incidence of hypoglycemia. In the 14 of 26 that reported hypoglycemia, there was a 6 fold increase in the rate of occurrence
Haga – Systematic review and meta-analysis of the cardiac surgery patient population found that there may be some benefit to tight glycemic control during and after cardiac surgery, results limited by few eligible trials and comparable outcomes that could be reviewed, small pt numbers, and poorly defined outcomes
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.

11. Moderate vs Intensive Therapy Randomized 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:
Also stopped early due to increased rates of hypoglcemia (8.7% vs 2.7%, p<0.001)
Recent trials in critically ill patients have failed to show a significant improvement in mortality with intensive glycemic control and have highlighted the risks of severe hypoglycemia
NICE SUGAR – 6100 subjects randomized, prospective, and blinded evaluation of IIT vs conventional; mortality (42 vs 36%) and severe hypoglycemia (6.8 vs 0.5%); concluded that IIT increased mortality and that glucose target <180 mg/dl or less resulted in less mortality
VISEP – attempted to evaluate role of IIT in pts with severe sepsis using Leuven Protocol – stopped early cause of hypoglycemia (17 vs 4.1%)
Glucontrol – 8.7 vs 2.7& hypoglycemia; stopped early cause of rate of hypoglycemia
D’Ancona – Iatrogenic hypoglycemia secondary to tight glucose control was an independent determinant for mortality and cardiac morbidity
Weiner – 8432 critically ill patients in 29 RCTs; no significant difference in mortality
Griesdale – critically ill patients; significantly increased incidence of hypoglycemia. In the 14 of 26 that reported hypoglycemia, there was a 6 fold increase in the rate of occurrence
Haga – Systematic review and meta-analysis of the cardiac surgery patient population found that there may be some benefit to tight glycemic control during and after cardiac surgery, results limited by few eligible trials and comparable outcomes that could be reviewed, small pt numbers, and poorly defined outcomes
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.

12. Moderate vs Intensive Therapy Meta Analysis/Systematic Reviews
Weiner RS et al
JAMA 2008;300:
Meta analysis of RCTs comparing IIT ( mg/dL) vs less intensive targets ( 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 critically ill patients, IIT was shown to significantly increase risk of hypoglycemia (6 fold increase)
Recent trials in critically ill patients have failed to show a significant improvement in mortality with intensive glycemic control and have highlighted the risks of severe hypoglycemia
NICE SUGAR – 6100 subjects randomized, prospective, and blinded evaluation of IIT vs conventional; mortality (42 vs 36%) and severe hypoglycemia (6.8 vs 0.5%); concluded that IIT increased mortality and that glucose target <180 mg/dl or less resulted in less mortality
VISEP – attempted to evaluate role of IIT in pts with severe sepsis using Leuven Protocol – stopped early cause of hypoglycemia (17 vs 4.1%)
Glucontrol – 8.7 vs 2.7& hypoglycemia; stopped early cause of rate of hypoglycemia
D’Ancona – Iatrogenic hypoglycemia secondary to tight glucose control was an independent determinant for mortality and cardiac morbidity
Weiner – 8432 critically ill patients in 29 RCTs; no significant difference in mortality
Griesdale – critically ill patients; significantly increased incidence of hypoglycemia. In the 14 of 26 that reported hypoglycemia, there was a 6 fold increase in the rate of occurrence
Haga – Systematic review and meta-analysis of the cardiac surgery patient population found that there may be some benefit to tight glycemic control during and after cardiac surgery, results limited by few eligible trials and comparable outcomes that could be reviewed, small pt numbers, and poorly defined outcomes
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.

13. Moderate versus Intensive Therapy Cardiac 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

14. 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: )
Recommendations for all patients undergoing CABG
There is evolving literature that moderate glucose control provides the same benefit as tight glucose control but with a lower risk of hypoglycemic complications.

15. Intraoperative STS Practice Guideline Series AACE/ADA Consensus
Statement
ACCF/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)

16. Postoperative/Inpatient Management – General Comments
STS Practice Guidelines Series
AACE/ADA Consensus Statement
ACCF/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)

17. Prolonged ICU Stay of Critically Ill
STS Practice Guidelines Series
AACE/ADA Consensus Statement
ACCF/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 mg/dL; target levels <110 mg/dL are not recommended
*Vent dependency; inotropes; IABP; LVAD; antiarrhythmics; dialysis; CVVH

18. Stepdown and Floor Status
STS Practice Guidelines Series
AACE/ADA Consensus Statement
ACCF/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

19. 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 hours after Anesthesia End Time
Is replacing the goal of controlled 6:00 am glucose of less than 200 mg/dl on postoperative day 1 and 2 with anesthesia end date being postoperative day zero (POD 0)

20. 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 hour post-operative time frame

21. 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 hours after Anesthesia End Time
Denominator Statement
Cardiac surgery patients with no evidence of prior infection
A measure used to assess a goal directed, interrelated series of
actions, events, mechanisms, or steps, such as measure of performance that
describes what is done to, for, or by patients, as in performance of a procedure.

22. 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)

23. 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 Time

24. 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

26. UTD – unable to determine
Surgery days – equal to the Anesthesia start date minus the admission date
Glucose equals a 3 or 4, the case will proceed to a Measure Category assignment of D and will be in the measure population
Glucose equals a 1 or 2, the case will proceed to a measure catetory assignment of E and will be in the numerator population

27. Where to begin? The Framework
Administrative support
Stakeholders
Identify
Define working groups
Assess Current State
Create/Identify Protocols and Algorithms
Education
Implement
Evaluate
Modify

28. Assessment of Current Processes
What is the current level of glycemic control?
How many measurements fall within goal?

29. 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?

30. Questions? Comments?