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Department of Surgery, Duke University Medical Center, Hospital North, Box 3474, Durham, NC 27710
(Email: jagge003{at}mc.duke.edu).
This article is a descriptive observation study that attempted to determine if glucose level was associated with adverse outcome in a population of 144 pediatric cardiac surgical patients [1]. In the final version and analysis of this study, glucose was treated as a continuous variable, and in fact, no level of glucose predicted an increased risk for the primary composite mortality and infection end point (MORTINF). Only prebypass glucose, risk adjustment for congenital heart surgery (RACHS-1) level, and being a neonate predicted increased length of stay. The authors conclude that hyperglycemia occurs commonly after infant cardiac surgery and that hyperglycemia was not associated with adverse outcome.
Interestingly, in no patient did serum glucose level rise above 200 mg/dL in the study period, which contrasts with other reports in which perioperative glucose often rises above 200 mg/dL. Glucose levels were somewhat arbitrarily selected throughout the postoperative period as the "last glucose day 1 and 2." In fact, the significance of the "postbypass glucose level" is questionable because continuous ultrafiltration was used throughout the bypass period and the ultrafiltration process removes glucose.
The study was not appropriately powered for mortality as a primary end point, so the authors chose to combine mortality and infections as a composite end point. This choice appears to be based on the assumption that hyperglycemia may be associated with increased risk of perioperative infection. Although this association seems reasonably sound in the adult cardiac surgical population, there is no definitive support for this in the pediatric cardiac surgical population. This association has not been clearly determined in existing literature, and the MORTINF composite outcome has not been validated in previous studies.
It has recently been shown that occurrence of hyperglycemia in adult cardiac surgical patients is not benign. Several studies have shown that tight glycemic control in the perioperative period decreases mortality after cardiac procedures and reduces the incidence of postoperative adverse events, including infectious complications (pneumonia and mediastinitis), myocardial complications (low cardiac output, atrial fibrillation, recurrent ischemia), and prolonged mechanical ventilation and intensive care unit length of stay.
The evidence for benefit of tight glycemic control in the pediatric cardiac surgical population is both insufficient and conflicting. A recent article by Ballweg and colleagues [2] suggests that hyperglycemia after cardiopulmonary bypass did not result in increased risk of neurologic injury. In another study [3], the greater the duration of hyperglycemia (glucose > 126 mg/dL) was associated with longer duration of hospitalization.
More recently, a randomized prospective trial of aggressive glycemic control with insulin was done in a pediatric intensive care population that included 75% pediatric cardiac surgical patients. In this study of 700 patients, intensive glucose control resulted in decreased intensive care unit lengths of stay, lower lactate, decreased risk of infection, decreased inflammatory response as measured by C-reactive protein, and increased hypoglycemia. Importantly, this trial did not demonstrate an increased risk of neurologic injury with hypoglycemia or tighter glucose control [4].
This study by DeCampli and colleagues [1] adds to the debate regarding the benefit of glucose control in the pediatric cardiac surgical patient. But this question will best be resolved with well-designed randomized trials that have enough power to determine the potential risks or benefits of glycemic control.
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