Automated versus conventional perioperative glycemic control in adult diabetic patients undergoing open heart surgery

Roland Kaddoum, Amro Khalili, Fadia M Shebbo, Nathalie Ghanem, Layal Abou Daher, Arwa Bou Ali, Nour El Hage Chehade, Patrick Maroun, Marie T Aouad, Roland Kaddoum, Amro Khalili, Fadia M Shebbo, Nathalie Ghanem, Layal Abou Daher, Arwa Bou Ali, Nour El Hage Chehade, Patrick Maroun, Marie T Aouad

Abstract

Background: Intraoperative glycemic variability is associated with increased risks of mortality and morbidity and an increased incidence of hyperglycemia after cardiac surgery. Accordingly, clinicians tend to use a tight glucose control to maintain perioperative blood glucose levels and therefore the need to develop a less laborious automated glucose control system is important especially in diabetic patients at a higher risk of developing complications.

Methods: Patients, aged between 40 and 75 years old, undergoing open heart surgery were randomized to either an automated protocol (experimental) or to the conventional technique at our institution (control).

Results: We showed that the percentage of patients maintained between 7.8-10 mmol.l-1 was not statistically different between the two groups, however, through an additional analysis, we showed that the proportion of patients whose glucose levels maintained between a safety level of 6.7-10 mmol.l-1 was significantly higher in the experimental group compared to control group, 14 (26.7%) vs 5 (17.2%) P = 0.025. In addition, the percentage of patients who had at least one intraoperative hyperglycemic event was significantly higher in the control group compared to the experimental group, 17 (58.6%) vs 5 (16.7%), P < 0.001 with no hypoglycemic events in the experimental group compared to two events in the control group. We also showed that longer surgeries can benefit more from using the automated glucose control system, particularly surgeries lasting more than 210 min.

Conclusion: We concluded that the automated glucose control pump in diabetic patients undergoing open heart surgeries maintained most of the patients within a predefined glucose range with a very low incidence of hyperglycemic events and no incidence of hypoglycemic events.

Trial registration: Registered with clinicaltrials.gov (NCT # NCT03314272 , Principal investigator Roland Kaddoum, date of registration: 19/10/2017).

Keywords: Cardiac surgical procedures; Glycemic control; Hypoglycemia; Insulins.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Consort flow diagram of patient recruitment
Fig. 2
Fig. 2
Average glucose concentration in the two groups over time

References

    1. van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in critically ill patients. N Engl J Med. 2001;345(19):1359–1367. doi: 10.1056/NEJMoa011300.
    1. Higgs M, Fernandez R. The effect of insulin therapy algorithms on blood glucose levels in patients following cardiac surgery: a systematic review. JBI Evid Synth. 2015;13(5):205–243.
    1. Funk SD, Yurdagul A, Jr, Orr AW. Hyperglycemia and endothelial dysfunction in atherosclerosis: lessons from type 1 diabetes. Int J Vasc Med. 2012;2012:569654.
    1. Howangyin KY, Silvestre JS. Diabetes mellitus and ischemic diseases: molecular mechanisms of vascular repair dysfunction. Arterioscler Thromb Vasc Biol. 2014;34(6):1126–1135. doi: 10.1161/ATVBAHA.114.303090.
    1. Berbudi A, Rahmadika N, Tjahjadi AI, Ruslami R. Type 2 Diabetes and its impact on the immune system. Curr Diabetes Rev. 2020;16(5):442–449. doi: 10.2174/1573399815666191024085838.
    1. Preiser JC, Devos P, Ruiz-Santana S, Melot C, Annane D, Groeneveld J, et al. A prospective randomised multi-centre controlled trial on tight glucose control by intensive insulin therapy in adult intensive care units: the Glucontrol study. Intensive Care Med. 2009;35(10):1738–1748. doi: 10.1007/s00134-009-1585-2.
    1. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med. 2008;358(2):125–139. doi: 10.1056/NEJMoa070716.
    1. Yendamuri S, Fulda GJ, Tinkoff GH. Admission hyperglycemia as a prognostic indicator in trauma. J Trauma. 2003;55(1):33–38. doi: 10.1097/01.TA.0000074434.39928.72.
    1. Plank J, Blaha J, Cordingley J, Wilinska ME, Chassin LJ, Morgan C, et al. Multicentric, randomized, controlled trial to evaluate blood glucose control by the model predictive control algorithm versus routine glucose management protocols in intensive care unit patients. Diabetes Care. 2006;29(2):271–276. doi: 10.2337/diacare.29.02.06.dc05-1689.
    1. Cryer PE, Axelrod L, Grossman AB, Heller SR, Montori VM, Seaquist ER, et al. Evaluation and management of adult hypoglycemic disorders: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(3):709–728. doi: 10.1210/jc.2008-1410.
    1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2010:S62–9. .
    1. Krinsley JS. Association between hyperglycemia and increased hospital mortality in a heterogeneous population of critically ill patients. Mayo Clin Proc. 2003;78(12):1471–1478. doi: 10.4065/78.12.1471.
    1. Krinsley JS. Effect of an intensive glucose management protocol on the mortality of critically Ill adult patients. 2004.
    1. Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, O’Brien PC, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery: a randomized trial. Ann Intern Med. 2007;146(4):233–243. doi: 10.7326/0003-4819-146-4-200702200-00002.
    1. Reed CC, Stewart RM, Sherman M, Myers JG, Corneille MG, Larson N, et al. Intensive insulin protocol improves glucose control and is associated with a reduction in intensive care unit mortality. J Am Coll Surg. 2007;204(5):1048–54. doi: 10.1016/j.jamcollsurg.2006.12.047.
    1. Akiboye F, Rayman G. Management of hyperglycemia and diabetes in orthopedic surgery. Curr Diab Rep. 2017;17(2):13. doi: 10.1007/s11892-017-0839-6.
    1. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, et al. The society of thoracic surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg. 2009;87(2):663–669. doi: 10.1016/j.athoracsur.2008.11.011.
    1. Joshi GP, Chung F, Vann MA, Ahmad S, Gan TJ, Goulson DT, et al. Society for ambulatory anesthesia consensus statement on perioperative blood glucose management in diabetic patients undergoing ambulatory surgery. Anesth Analg. 2010;111(6):1378–1387. doi: 10.1213/ANE.0b013e3181f9c288.
    1. Turina M, Fry DE, Polk HC., Jr Acute hyperglycemia and the innate immune system: clinical, cellular, and molecular aspects. Crit Care Med. 2005;33(7):1624–1633. doi: 10.1097/01.CCM.0000170106.61978.D8.
    1. Cryer PE. Hypoglycemia, functional brain failure, and brain death. J Clin Invest. 2007;117(4):868–870. doi: 10.1172/JCI31669.

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