Recommended Manuscripts Library

As part of the Society’s increasing focus on quality, the Task Force on Quality Initiatives has created the Recommended Manuscripts Library— a resource for STS membership that provides summaries of pertinent articles relevant to cardiothoracic surgery. These articles will initially focus on quality webinar topics, as well as other quality-related areas.

Glycemic Control

The following manuscripts describe the role and rationale of glycemic control in cardiac surgery. Recent clinical studies suggest that normoglycemia is not desirable during surgery, but that blood glucose should always be less than 180 – 200 mg/dL. Studies also suggest that normoglycemia in the ICU is the optimal target and has the greatest influence on mortality and overall morbidity.

Some issues not addressed by these articles include:

1. Basic science elucidation of the biochemical basis for BG < 200 mg/dL during surgery and normoglycemia in the ICU.
2. Whether or not hyperglycemia is a cause or symptom among non-survivors.
3. Whether an optimal duration for normoglycemia should be defined or if simple average blood glucose levels are sufficient to improve outcomes.

STS Guideline: Blood Glucose Management During Adult Cardiac Surgery

Lazar HL, McDonnell M, Chipkin SR, et al. The Society of Thoracic Surgeons practice guideline series: blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009;87:663-9.

Provides an executive summary of the guideline for the management of hyperglycemia in patients with and without diabetes who are undergoing cardiac surgery.
Includes standard evidence-based medicine designations, clearly delineating Class I-III recommendations and corresponding levels of evidence A-C.

Superiority of Moderate Control of Hyperglycemia to Tight Control

Bhamidipati CM, LaPar DJ, Stukenborg GJ, et al. Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2011;141:543-51.

Retrospective review of postoperative glycemic control among 4,658 patients who underwent isolated CABG at the University of Virginia from 1995 to 2008.
Tight glycemic control (BG ≤ 126 mg/dL) was associated with higher observed operative mortality (2.9%) and higher incidence of renal failure requiring hemodialysis (7.5%).
Moderate glycemic control was associated with 30% reduction in occurrence of major complications.
This paper has good discussion of key references on postoperative glycemic control.

Role of Blood Glucose Concentrations in Predicting Outcomes

Duncan AE, Abd-Elsayed A, Maheshwari A, et al. Role of intraoperative and postoperative blood glucose concentrations in predicting outcomes after cardiac surgery. Anesthesiology. 2010;112:860-71.

A study of 4,302 cardiac surgery patients who had their operations at the Cleveland Clinic during a 20-month period from 2005 to 2007.
The Primary objective was to compare the influence of intraoperative vs. postoperative glycemic control on the incidence of death and major complications.
Glucose > 200 mg/dL had greatest influence; intraoperative hyperglycemia increased operative mortality by 90% and overall morbidity by 30%. Postoperative glucose >200 mg/dL had the greatest influence on outcomes resulting in 17.6% operative mortality and 36% overall morbidity.
Intraoperative and postoperative glucose < 140 mg/dL resulted in significant increases in morbidity and mortality despite a few cases of significant hypoglycemia (BG ≤ 40 mg/dL).
The best overall outcomes were achieved with both intraoperative and postoperative glucose values in the range of 140 – 170 mg/dL.
This paper has a good discussion of the potential pathophysiological mechanisms of hyperglycemia in the intraoperative and postoperative phases.

Eliminating the Diabetic Disadvantage: The Portland Diabetic Project

Furnary AP, Wu Y. Eliminating the diabetic disadvantage: the Portland Diabetic Project. Semin Thorac Cardiovasc Surg. 2006;18:302-8.

A review paper describing the evolution of Dr. Furnary’s protocol (i.e., Portland Diabetic Project) for achieving tight glycemic control in diabetic patients from 1987 to 2005.
The results of 5,534 patients who underwent isolated CABG demonstrated that operative mortality correlates best with the “3BG” level, i.e., the average blood glucose level of the first 3 days of heart surgery (including the day of surgery).
The trend of lower complication rates among patients whose 3BG approached normoglycemia is the basis of the recommended glucose target range of 70 – 120 mg/dL.
The physiologic rationale for normoglycemia during the first three days of surgery is described.
This paper is a description of the landmark clinical basis for tight glycemic control in heart surgery patients.

Achieving Tight Glycemic Control in the Operating Room: Lessons Learned

Furnary AP, Cheek DB, Holmes SC, Howell WL, Kelly SP. Achieving tight glycemic control in the operating room: lessons learned from 12 years in the trenches of a paradigm shift in anesthetic care. Semin Thorac Cardiovasc Surg. 2006;18:339-45.

This article clearly delineates four distinct but equally effective methods of intraoperative glucose management by anesthesia during cardiac surgery.
Determination of the degree of preoperative insulin resistance is the basis for the initial insulin dose and choice of bolus + insulin drip or graded insulin drip in controlling BG during surgery.
The modes of BG control during surgery are (a) incrementally greater insulin boluses with graded insulin infusions, (b) bolus IV insulin only, (c) stepped insulin drips with stepped boluses, and (d) aggressively titrated insulin drips with aggressive blousing.
The goal of intensive glucose control during surgery is a normoglycemic state upon arrival in the ICU.
This article is a good reference for anesthesiologists and heart surgery programs that are just starting or refining their glucose control program.

Intensive Intraop Insulin Therapy vs. Conventional Glucose Management

Gandhi GY, Nuttall GA, Abel MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery. Ann Intern Med. 2007;146:233-43.

This article from the Mayo Clinic attempted to look at whether patients who were already receiving "strict glucose control" post-operatively would receive additional benefit from "intensive" intraoperative glucose control.
The blood glucose target for the intensive control group was 80-100 mg/dL while the conventional group treated glucose for blood glucose > 200 mg/dL.
As seen in other studies, the intensive control group had greater morbidity and mortality rates than the conventional control group.

The STS Task Force on Quality Initiatives hopes STS membership finds the library useful. Please use this form to provide comments and suggestions.

Recommended Manuscripts Library

Glycemic Control

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