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Ann Thorac Surg 2009;88:1384-1385. doi:10.1016/j.athoracsur.2009.04.115
© 2009 The Society of Thoracic Surgeons
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Correspondence

Risks of Tight Glycemic Control During Adult Cardiac Surgery

Ann M. Sheehy, MD, MSa, Douglas B. Coursin, MDb, Mark T. Keegan, MDc

a Department of Medicine, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, H6/169, Madison, WI 53792
b Department of Medicine and Anesthesiology, University of Wisconsin School of Medicine and Public Health, 600 Highland Ave, H6/169, Madison, WI 53792
c Department of Anesthesiology, Mayo Clinic, 200 First St SW, Rochester, MN 55905

(Email: asr{at}medicine.wisc.edu; dcoursin{at}wisc.edu; keegan.mark{at}mayo.edu).

To the Editor:

The recent guidelines of The Society of Thoracic Surgeons Practice Guideline Series on glucose control deserve cautionary comment [1]. Consideration of the adverse events reported by Gandhi and colleagues [2] (STS guideline reference 17), when tight glucose control (TGC) was maintained in cardiac surgical patients intraoperatively seems merited. The incidence and risks of hypoglycemia in TGC protocols in other critically ill adult patients should also be highlighted.

Gandhi and colleagues [2] prospectively randomized 400 diabetic and nondiabetic patients undergoing cardiac surgery to either an intravenous insulin protocol to achieve intraoperative glucose between 80 to 100 mg/dL, or intravenous insulin only, to attain blood glucose < 200 mg/dL (control). All were postoperatively maintained at 80 to 100 mg/dL. There was a significantly increased risk of stroke (p = 0.02) and trend in death rate (p = 0.06) in the TGC group.

That stroke risk was greater in the TGC arm even without evidence of frank hypoglycemia should not be ignored, as this suggests that patients may be at risk of adverse events as blood glucose levels fall into the low normal range, far above values typically defined as hypoglycemic. Recommending a lower limit of intraoperative glycemic targets based on these data (such as not < 100 mg/d), instead of citing this study to support a < 180 mg/dL target makes sense for now. Gandhi's study [2] raises the possibility that a "one-size-fits-all" intervention is harmful. In addition, large amounts of insulin administered intraoperatively may induce post-cardiopulmonary bypass hypoglycemia and protocols attempting to achieve TGC need to address this issue.

The risk of hypoglycemia merits further emphasis and caution than "... the risk of hypoglycemia, which is fortunately rare and has resulted in minimal morbidity" implies [1]. Although some report no adverse effects attributable to hypoglycemia, others detail increasing concern over hypoglycemia during TGC. In a mixed medical-surgical intensive care unit, a retrospective study identified that even a single episode of blood glucose < 40 mg/dL increased mortality [3]. A prospective multicenter intensive care unit trial was stopped early because of events attributed to hypoglycemia [4], whereas another prospective multicenter intensive care unit study that included cardiac surgical patients reported increased mortality with hypoglycemia [5]. In 2009, the American Diabetes Association identified the risk of hypoglycemia as the limiting factor for in-hospital glucose control and advocated higher targets to avoid hypoglycemia.

The guidelines also do not mention the importance of the methodology for glucose measurement. Point-of-care glucometer measurements may differ significantly from laboratory analyses particularly in anemia, which occurs commonly during cardiac surgery. Overestimates of actual glucose concentration and potentially inappropriate insulin administration or masking of true hypoglycemia are worrisome.

Glycemic control is important, but emphasis of possible adverse consequences of TGC strengthens this guideline.


   References
Top
 References
 

  1. 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;87:663-669.[Free Full Text]
  2. Gandhi GY, Nuttall GA, Abel, MD, et al. Intensive intraoperative insulin therapy versus conventional glucose management during cardiac surgery Ann Intern Med 2007;146:233-243.[Abstract/Free Full Text]
  3. Krinsley JS, Grover A. Severe hypoglycemia in critically ill patients: risk factors and outcomes Crit Care Med 2007;35:2262-2267.[Medline]
  4. Brunkhorst FM, Engel C, Bloos F, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis N Engl J Med 2008;358:125-139.[Medline]
  5. Bagshaw SM, Egi M, George C, Bellomo R. Early blood glucose control and mortality in critically ill patients in Australia Crit Care Med 2009;37:463-470.[Medline]

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Harold L. Lazar and Marie McDonnell
Ann. Thorac. Surg. 2009 88: 1385-1386. [Extract] [Full Text] [PDF]



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H. L. Lazar and M. McDonnell
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Ann. Thorac. Surg., October 1, 2009; 88(4): 1385 - 1386.
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