АСЕ/ADA Inpatient Diabetes and Glycemie Control Consensus Conference
Clinical Effects of Hyperglycemia in the Cardiac Surgery Population: The Portland Diabetic Project

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ABSTRACT

Objective

To determine the outcome effects of hyperglycemia, and its pharmacologic reduction with continuous intravenous insulin infusions (CII) in the cardiac surgery patient population.

Methods:

The Portland Diabetic Project is a prospective, non-randomized, observational study of 5,510 consecutive diabetic cardiac surgery patients treated between January 1987 and November 2005

Results

This study was the first to reveal that hyperglycemia in the first 3 postoperative days is independently predictive of mortality (P < 0.0001), deep sternal wound infection (P = 0.0001), and increased length of stay (P < 0.002) in diabetic cardiac surgery patients. Conversely, CII, designed to achieve predetermined target glucose levels, was shown to independently reduce the risks of death and deep sternal wound infection by 60% and 77%, respectively (P < 0.001 for both). Target glucose levels < 150mg/dL and a 3-day postoperative duration of CII therapy are both important variables that determine the impact of the CII therapy on improved outcomes.

Conclusions:

Perioperative hyperglycemia in cardiac surgery patients adversely alters mortality, length of stay, and infection rates. Three days of CII eliminates the incrementally increased risks of these complications previously seen in diabetic patients. (Endocr Pract. 2006; 12[Suppl 3]:22-26)

Section snippets

INTRODUCTION

At the time of this writing (in early 2006), the fact that acute hyperglycemia in hospitalized diabetic patients leads to poor in-hospital outcomes has been fairly well established (1., 2., 3., 4.). Our early work on this subject, which began in 1987, and continues today is known as the Portland Diabetic Project. This ongoing study is a prospective nonrandomized study of the effects of hyperglycemia, and its pharmacologic reduction with intensive intravenous insulin regimens, on outcomes in the

METHODS AND DEMOGRAPHICS

All cardiac surgery patients who were operated on at St. Vincent Medical Center between 1987 and 2005, and those who were either admitted or discharged with the diagnosis of “diabetes,” were enrolled in the Portland Diabetic Project. Of the 23,619 patients operated on during this period, 5,510 (23% of the overall open heart surgery population at this center) met these inclusion criteria and were entered into the study. The average age was 65 ± 10 years; 70% of the population was male, and 12%

Glycemic Control

The average 3-BG over time for all 5,510 patients in the study is shown in scattergram form (Fig. 1). As can be seen from this figure, glycemic control improved gradually and steadily over time. Interestingly, it continues to do so as both floor and ICU nurses have become used to the concept of total glycemic control, driving patients into the lower reaches of the specified target ranges. The average 3-BG for all 299 diabetic cardiac surgery patients in calendar year 2005 was 121 mg/dL.

Mortality

In the

DURATION OF 3-BG EFFECT AND CII THERAPY ON OUTCOMES

Detailed multivariable analyses of the interrelationship between the various components of 3-BG and LOS, mortality, and DSWI were performed to determine the time-related impact of hyperglycemia on these outcomes. A summary of these findings is shown in Table 1. Results showed that hyperglycemia on the day of surgery, and the first and second postoperative days, significantly affects mortality. Hyperglycemia also has a significant affect on DSWI outcomes throughout the perioperative period

CONCLUSION

Our data suggest that diabetes itself is not a risk factor for adverse outcomes following cardiac surgery. Rather, hyperglycemia, as defined by 3-BG, is the true risk factor for increases in mortality, DSWI, LOS, and other complications. Importantly, both the “3” and the “BG” are essential components of that risk. Because of these findings, CII should become the accepted gold standard of care and should be utilized to maintain euglycemia for 3 full days in all hyperglycemic cardiac surgery

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