Perioperative control of blood glucose level in cardiac surgery
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CURRENT TOPICS REVIEW ARTICLE
Perioperative control of blood glucose level in cardiac surgery Kenji Minakata • Ryuzo Sakata
Received: 9 August 2012 / Published online: 5 January 2013 Ó The Japanese Association for Thoracic Surgery 2012
Abstract It is well recognized that poor perioperative blood glucose (BG) control can increase the risk of infection, cardiovascular accidents, and even death in patients undergoing cardiac surgery. Since it has been reported that tight BG control (80–110 mg/dL) yields better outcomes in critically ill patients, it became a standard of care to control BG using intravenous insulin infusion in ICU. However, it has been debated in terms of the optimal target range whether a strict control with intensive insulin therapy is better than liberal control. Because strict BG control can often cause hypoglycemia, which in turn increases the hospital mortality. In fact, a meta-analysis of randomized clinical trials concluded that tight BG control was not associated with significantly reduced hospital mortality but was associated with an increased risk of hypoglycemia. According to the current published guidelines, it seems to be optimal to control BG level of 140–180 mg/dL in ICU. In terms of more strict BG control (110–140 mg/dL), it may be appropriate in selected patients as long as this can be achieved without significant hypoglycemia. Keywords Blood glucose level Cardiac surgery Diabetes mellitus Infection Mortality
Introduction Physical stress induces a number of neuro-hormonal responses to maintain or increase blood glucose (BG) level (part of the ‘‘fight or flight’’ response). This is especially true in cardiac surgery, which often involves one of the most invasive and stressful procedures in modern medicine: cardiopulmonary bypass. However, in diabetic patients or others with glucose intolerance, the BG level may increase beyond the optimal range, causing hyperglycemia. During or immediately after surgery, hyperglycemia can cause numerous complications: abnormal immune response, vascular malfunction, metabolic acidosis and even coma. Perhaps one of the most noteworthy complications is the increased rate of infection, including deep sternal wound infection (DSWI). It is well known that poor BG control perioperatively can increase the incidence of DSWI, which can easily lead to sepsis, multi-organ failure and even death. In this review, the dangers of perioperative hyperglycemia are discussed, and the most recent strategies for perioperative BG control are summarized based on the findings of large clinical trials. The diabetic disadvantage
The review was submitted at the invitation of the editorial committee. K. Minakata (&) R. Sakata Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine, 54 Kawahara-cho, Shogoin, Sakyo-ku, Kyoto 606-8507, Japan e-mail: [email protected]
The prevalence of diabetes mellitus (DM) has increased dramatically in Western countries over the last several decades, leading in turn to increased mortality due to car
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