Blood glucose level on postoperative day 1 is predictive of adverse outcomes after cardiovascular surgery
Hyperglycaemia is now a recognized predictive factor of morbidity and mortality after coronary artery bypass grafting (CABG). For this reason, we aimed to evaluate the postoperative management of glucose control in patients undergoing cardiovascular surgery, and to assess the impact of glucose levels on in-hospital mortality and morbidity. This was a retrospective study investigating the association between postoperative blood glucose and outcomes, including death, post-surgical complications, and length of stay in the intensive care unit (ICU) and in hospital. A total of 642 consecutive patients were enrolled into the study after cardiovascular surgery (CABG, carotid endarterectomy and bypass in the lower limbs). Patients' mean age was 68+/-10 years, and 74% were male. In-hospital mortality was 5% in diabetic patients vs 2% in non-diabetic patients (OR: 1.66, P=0.076). Having blood glucose levels in the upper quartile range (> or =8.8 mmol/L) on postoperative day 1 was independently associated with death (OR: 10.16, P=0.0002), infectious complications (OR: 1.76, P=0.04) and prolonged ICU stay (OR: 3.10, P<0.0001). Patients presenting with three or more hypoglycaemic episodes (<4.1 mmol/L) had increased rates of mortality (OR: 9.08, P<0.0001) and complications (OR: 8.57, P<0.0001). Glucose levels greater than 8.8 mmol/L on postoperative day 1 and having three or more hypoglycaemic episodes in the postoperative period were predictive of mortality and morbidity among patients undergoing cardiovascular surgery. This suggests that a multidisciplinary approach may be able to achieve better postoperative blood glucose control.
- [Show abstract] [Hide abstract] ABSTRACT: To review the domains in which computerized information systems have proven beneficial in facilitating the metabolic and nutritional management In glucose control, computerized insulin algorithms have proven safer and more efficient than manual systems, reducing workload, time to target glycemia and numbers of hypoglycemic and hyperglycemic events. By rendering the nutritional variables visible through specific customization, computers do improve daily monitoring of energy balance and adherence to guidelines, particularly for substrate delivery. Nurse-centered systems have shown to be the most successful to enable routine workflow based on protocol-based care. Computers are needed to analyze the increasing amount of data collected from critically ill patients from monitoring systems, laboratories and other sources. Studies have shown that computerized information systems do facilitate glucose control, helping reducing hypoglycemic events. They also improve nutritional monitoring (energy delivery and balance, protein and fat delivery), and quality of nutrition. They reduce nurse workload associated with the multiple balance calculations and ease visualization of events out of planned targets. Though integrated systems are expensive, they improve work efficiency.0Comments 15Citations
- [Show abstract] [Hide abstract] ABSTRACT: Critically ill patients with diabetes are at increased risk for the development of complications, but the impact of diabetes on mortality is unclear. We conducted a systematic review and meta-analysis to determine the effect of diabetes on mortality in critically ill patients, making a distinction between different ICU types. We performed an electronic search of MEDLINE and Embase for studies published from May 2005 to May 2010 that reported the mortality of adult ICU patients. Two reviewers independently screened the resultant 3,220 publications for information regarding ICU, in-hospital or 30-day mortality of patients with or without diabetes. The number of deaths among patients with or without diabetes and/or mortality risk associated with diabetes was extracted. When only crude survival data were provided, odds ratios (ORs) and standard errors were calculated. Data were synthesized using inverse variance with ORs as the effect measure. A random effects model was used because of anticipated heterogeneity. We included 141 studies comprising 12,489,574 patients, including 2,705,624 deaths (21.7%). Of these patients, at least 2,327,178 (18.6%) had diabetes. Overall, no association between the presence of diabetes and mortality risk was found. Analysis by ICU type revealed a significant disadvantage for patients with diabetes for all mortality definitions when admitted to the surgical ICU (ICU mortality: OR [95% confidence interval] 1.48 [1.04 to 2.11]; in-hospital mortality: 1.59 [1.28 to 1.97]; 30-day mortality: 1.62 [1.13 to 2.34]). In medical and mixed ICUs, no effect of diabetes on all outcomes was found. Sensitivity analysis showed that the disadvantage in the diabetic surgical population was attributable to cardiac surgery patients (1.77 [1.45 to 2.16], P < 0.00001) and not to general surgery patients (1.21 [0.96 to 1.53], P = 0.11). Our meta-analysis shows that diabetes is not associated with increased mortality risk in any ICU population except cardiac surgery patients.0Comments 23Citations
- [Show abstract] [Hide abstract] ABSTRACT: Despite acute myocardial infarction and cardiac surgery accounting for 2 of the most common reasons patients are admitted to the intensive care unit, little attention and investigation have been directed specifically for these patients. This patient population therefore deserves special attention as they are often malnourished but require emergent interventions, making nutrition intervention challenging. This article reviews current medical interventions implemented in critically ill cardiothoracic patients and discusses evidence-based nutrition therapy, including enteral and parenteral feeding, glycemic control, and antioxidant provision.0Comments 6Citations