Report from STS Workforce on Evidence Based Surgery
The Society of Thoracic Surgeons Practice Guideline Series: Blood Glucose Management During Adult Cardiac Surgery

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Key Points: Poor Perioperative Glycemic Control is Associated With Increased Morbidity and Mortality

Doenst and coworkers [4] retrospectively reviewed the effects of hyperglycemia on the clinical outcomes of 6,280 patients undergoing cardiac surgical procedures. Higher glucose levels during surgery were found to be an independent predictor of mortality in patients with and without diabetes. Fish and coworkers [5] retrospectively reviewed the importance of blood glucose levels in the intraoperative and immediate postoperative period to predict morbidity in 200 consecutive coronary artery bypass

Key Points: Glycemic Control (< 180 mg/dL) in Patients With Diabetes During Cardiac Surgery

  • Reduces mortality

  • Reduces morbidity

  • Lowers the incidence of wound infections

  • Reduces hospital length of stay

  • Enhances long-term survival

One of the earliest studies to examine the effects of glycemic control during cardiac surgery was reported by Furnary and coworkers [9]. The study involved 3,554 patients undergoing CABG surgery from 1987 to 2001. Patients were divided into three groups based on the year of surgery, the method of glycemic control, and the targeted glucose levels. From 1987 to 1991,

Key Points: Intraoperative Glycemic Control Using Intravenous Insulin Infusions is Not Necessary in Cardiac Surgery Patients Without Diabetes Provided That Glucose Values Remain < 180 mg/dL

Is tight glycemic control necessary for all patients undergoing cardiac surgery? Butterworth and co-workers studied the effects of tight glycemic control in 381 patients without diabetes undergoing isolated CABG surgery [16]. In this prospective, randomized trial, one group received an insulin infusion when intraoperative glucose levels exceeded 100 mg/dL. The other group received no insulin coverage. The primary outcome was the incidence of new neurologic, neuro-ophthalmologic, or

Management of Hyperglycemia Using Insulin Protocols in the Perioperative Period Recommendations: Class I

  • Glycemic control is best achieved with continuous insulin infusions rather than intermittent subcutaneous insulin injections or intermittent IV insulin boluses (level of evidence = A).

  • All patients with diabetes undergoing cardiac surgical procedures should receive an insulin infusion in the operating room, and for at least 24 hours postoperatively to maintain serum glucose levels ≤ 180 mg/dL (level of evidence = B).

Intravenous insulin therapy is the preferred method of insulin delivery during

Preoperative Management and Assessment for Patients With Diabetes Recommendations: Class I

  • Patients taking insulin should hold their nutritional insulin (lispro, aspart, glulisine, or regular) after dinner the evening prior to surgery (level of evidence = B).

  • Scheduled insulin therapy, using a combination of long-acting and short-acting subcutaneous insulin, or an insulin infusion protocol, should be initiated to achieve glycemic control for in-hospital patients awaiting surgery (level of evidence = C).

  • All oral hypoglycemic agents and noninsulin diabetes medications should be held for

Class IIA

  • Prior to surgery, it is reasonable to maintain blood glucose concentration ≤ 180 mg/dL (level of evidence = B).

Efforts should be made to optimize glucose control prior to surgery, because poor preoperative glycemic control has been associated with increased morbidity, including a higher incidence of deep sternal wound infections and prolonged postoperative length of stay [10, 11]. In general, all oral diabetes medications should be withheld within the 24 hours prior to surgery, especially

Intraoperative Control Recommendations: Class I

  • Glucose levels > 180 mg/dL that occur in patients without diabetes only during cardiopulmonary bypass may be treated initially with a single or intermittent dose of IV insulin as long as levels remain ≤ 180 mg/dL. However, in those patients with persistently elevated serum glucose (> 180 mg/dL) after cardiopulmonary bypass, a continuous insulin drip should be instituted, and an endocrinology consult should be obtained (level of evidence = B).

  • If an intravenous insulin infusion is initiated in

Glycemic Control in the ICU Recommendation: Class I

  • Patients with and without diabetes with persistently elevated serum glucose (> 180 mg/dL) should receive IV insulin infusions to maintain serum glucose < 180 mg/dL for the duration of their ICU care (level of evidence = A).

  • All patients who require ≥ 3 days in the ICU because of ventilatory dependency or requiring the need for inotropes, intra-aortic balloon pump, or left ventricular assist device support, anti-arrhythmics, dialysis, or continuous veno-venous hemofiltration should have a

Glycemic Control in the Stepdown Units and on the Floor Recommendations: Class I

  • A target blood glucose level < 180 mg/dL should be achieved in the peak postprandial state (level of evidence = B).

  • A target blood glucose level ≤ 110 mg/dL should be achieved in the fasting and pre-meal states after transfer to the floor (level of evidence = C).

  • Oral hypoglycemic medications should be restarted in patients who have achieved target blood glucose levels if there are no contraindications. Insulin dosages should be reduced accordingly (level of evidence = C).

  • According to the

Preparation for Hospital Discharge Recommendations: Class I

  • Prior to discharge, all patients with diabetes and those who have started a new glycemic control regimen, should receive in-patient education regarding glucose monitoring, medication administration (including subcutaneous insulin injection if necessary), nutrition, and lifestyle modification (level of evidence = C).

  • Upon discharge, changes in therapy for glycemic control should be communicated to primary care physicians, and follow-up appointments should be arranged with an endocrinologist when

Future Areas of Study

Important issues in the management of hyperglycemia during cardiac surgery remain to be elucidated. Future studies will determine: (1) the optimal level of glycemic control and which, if any, specific time in the perioperative period is most crucial for maintaining glycemic control; (2) whether the level of glucose achieved is as important as the amount of insulin delivered; and (3) the importance of preoperative HbA1c levels and whether surgery should be delayed in patients with higher values.

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    This article was written by members of The Society of Thoracic Surgeons Blood Glucose Guideline Task Force whose names appear in the author line.

    For the full text of The Society of Thoracic Surgeons (STS) Guideline on Blood Glucose Management During Adult Cardiac Surgery, as well as other titles in STS Practice Guideline Series, visit http://www.sts.org/sections/aboutthesociety/practiceguidelines at the official website of STS at www.sts.org.

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