1. JOURNAL CLUB M.CAIRNEY

2. Anesthesiology 2009; 110:970–7 Continuous Perioperative Insulin Infusion Decreases Major Cardiovascular Events in Patients Undergoing Vascular Surgery A Prospective, Randomized Trial Balachundhar Subramaniam, M.B.B.S., M.D.,* Peter J. Panzica, M.D.,† Victor Novack, M.D., Ph.D.,‡Feroze Mahmood, M.D.,† Robina Matyal, M.B.B.S.,† John D. Mitchell, M.D.,† Eswar Sundar, M.B.B.S., Ruma Bose, M.B.B.S.,† Frank Pomposelli, M.D., Judy R. Kersten, M.D.,_ Daniel S. Talmor, M.D., M.P.H.

3. AIM To show that a strategy of tight perioperative blood glucose control using a continuous insulin infusion in patients undergoing vascular surgery decreases major cardiovascular events when compared with conventional management.

4. BACKGROUND Hyperglycaemia is an independent predictor of increased cardiovascular risk Aggressive glycaemic control in the intensive care decreases mortality The benefit of glycaemic control in non cardiac surgery is unknown

5. BACKGROUND Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, Vlasselaers D, Ferdinande P, Lauwers P, Bouillon R Intensive insulin therapy in the critically ill patients. N Engl J Med 2001; 345:1359–67 Intensive insulin therapy significantly decreased in-hospital deaths, from 10.9% to 7.2%, in critically ill surgical patients Carr JM, Sellke FW, Fey M, Doyle MJ, Krempin JA, de la Torre R, Liddicoat JR: Implementing tight glucose control after coronary artery bypass surgery. Ann Thorac Surg 2005; 80:902–9 Continuous intravenous insulin infusion to maintain blood glucose concentrations less than 150 mg/dl showed a decrease in deep sternal wound infections in cardiac surgical patients

6. BACKGROUND Ouattara A, Lecomte P, Le Manach Y, Landi M, Jacqueminet S, Platonov I, Bonnet N, Riou B, Coriat P: Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. ANESTHESIOLOGY 2005; 103:687–94 Poor intraoperative glycaemic control was significantly more frequent in patients with severe postoperative morbidity (37% vs. 10%; P < 0.001). Lazar HL, Chipkin SR, Fitzgerald CA, Bao Y, Cabral H, Apstein CS: Tight glycemic control in diabetic coronary artery bypass graft patients improves perioperative outcomes and decreases recurrent ischemic events. Circulation 2004; 109:1497–502 Patients on a GKI showed a survival advantage over 2 years after surgery (P=0.04) and decreased episodes of ischemia (5% versus 19%; P=0.01) and developed fewer recurrent wound infections (1% versus 10%, P=0.03)

7. METHOD This was a single-centre, prospective, randomized, nonblinded, active-control study 236 patients It compared the efficacy and safety of perioperative tight blood glucose control (target glucose 100–150 mg/dl) in patients undergoing peripheral vascular bypass surgery, abdominal aortic aneurysm surgery, or below- or above-knee amputation

8. METHOD Inclusion criteria: all patients, both diabetic and non diabetic, aged 18 yr or older had an ASA status of I–IV Undergoing peripheral vascular bypass surgery, abdominal aortic surgery, or major lower extremity amputation (above or below the knee) expected to stay in the hospital for at least 48 h

9. METHOD Exclusion criteria: Patients with brittle diabetes varicose vein ligation continuous insulin infusion pumps planned stent procedures for vascular disease ASA V

10. METHOD Intervention group – continuous insulin infusion (CII) protocol the target blood glucose concentration was 100–150 mg/dl. If exceeded 150 mg/dl, a continuous insulin infusion was initiated Blood glucose levels were measured every hour until stable, then 2 hourly if 3 consecutive levels stable then 4 hourly until 48 hours Adjustments to the insulin infusion were determined by both the current blood glucose concentrations and insulin infusion rates. Changes in the rate were made by the anesthesiologist in theatre and by the nurse in the post anesthetic care unit and intensive care unit Validated protocol to achieve target in 70% half of their standard baseline long acting insulin regimen on the morning of surgery and at the time of transition

11. METHOD Control group – intermittent sliding-scale insulin bolus (IIB) protocol blood glucose concentrations were monitored every 4 h (until 48 h postoperatively) and blood glucose concentrations exceeding 150 mg/dl were treated with standardized intermittent intravenous regular insulin boluses on the morning of surgery, diabetic patients received half of their baseline long-acting insulin, and their normal insulin regimen was resumed 48 h postoperatively

12. PRIMARY OUTCOME All-cause death Myocardial infarction Acute congestive heart failure

13. SECONDARY OUTCOME Blood glucose levels at 4-h intervals starting from 4 h after the procedure and ending at 48 h Rate of hypoglycemia Rate of glucose concentrations greater than 150mg/dl Graft failure or a need for reintervention Surgical site infection Acute renal insufficiency Hospital duration of stay

14. RESULTS

15. RESULTS – PT CHARACTERISTICS IIB Group, n =122 CII Group, n=114 P Value Age, yr 71+- 11 67 +- 10 0.02 Male sex, n (%)66 (54)67 (59)0.47 Height, cm169 _ 11169 _ 100.98 Weight, kg81 _ 2484 _ 230.34 BMI, kg/m 2 28 _830_ 8.00.13 Preexisting conditions, n (%) Diabetes64 (53)62 (54)0.80 Hypertension)95 (7892 (81)0.59 CAD71 (58)58 (51)0.26 CHF11 (9)13 (11)0.54 CABG36 (30)24 (21)0.14 CRF15 (12)15 (13)0.84 Stroke11 (9)9 (8)0.76 COPD31 (25)23 (20)0.34 Statin, n (%)70 (57)76 (67)0.14 Aspirin, n (%)102 (84)97 (85)0.75 ACE inhibitor, n (%)69 (57)64 (56)1.00 BBlocker, n (%)98 (80)83 (73)0.17 Chronic hypoglycemic therapy,* n (%) Insulin34 (53)40 (65)0.20 Metformin12 (19)9 (15)0.63 Glyburide19 (30)23 (37)0.45

16. RESULTS

17. IIB Group, n =122 CII Group, n =114 Relative Risk for Continuous Infusion (95% CI) P Value Composite (MI and CHF), n (%)15 (12.3)4 (3.5)0.29 (0.10–0.83)0.013* MI, n (%)7 (5.7)0—0.015* CHF decompensation, n (%)9 (7.4)4 (3.5)0.48 (0.15–1.50)0.19 Wound infection, n (%)29 (23.8)35 (30.7)1.29 (0.85–1.97)0.23 Graft failure or need for reintervention, n (%) 18 (14.8)14 (12.3)0.83 (0.43–1.59)0.58 Creatinine increase > 25% above baseline, n (%) 22 (18.2)23 (20.5)0.89 (0.52–1.50)0.65 Hypoglycemia (level < 60 mg/dl) recorded at least once, n (%) 5 (4.1)10 (8.8)2.14 (0.75–6.07)0.14 Glucose level> 150 mg/dl, No. of events (IQR) 1.0 (0.0–3.0)1.0 (0.0–2.0)—0.11 Total No. of events235167 Hospital duration of stay, median (IQR), days 7.0 (5.0–9.0)6.0 (4.0–8.0)—0.06

18. RESULTS No mortality in either group

19. DISCUSSION Decreases major cardiovascular events in a population of patients undergoing vascular surgery. The moderate glycaemic target (100–150 mg/dl) avoided severe hypoglycaemia whilst providing beneficial cardioprotective effects. Studies show blood glucose variability was a stronger predictor of intensive care unit mortality than absolute blood glucose values Continuous IV administration of insulin is likely to be associated with less variability of blood glucose concentrations

20. DISCUSSION No statistical difference between diabetics and non diabetics

21. LIMITATIONS Only 236 patients randomised. Planned for over 900. Underpowered to detect mortality difference No differences shown in secondary outcomes either. Van den Berghe et al, suggested tighter control needed Unblinded Baseline insulin given in both groups More frequent monitoring in intervention group

22. QUESTIONS?