Effects of peri-operative glucose levels on adverse outcomes in infants receiving open-heart surgery for congenital heart disease with cardiopulmonary bypass

Abstract

Objective: Studies designed to evaluate the association of hyperglycemia and adverse events in pediatric patients receiving open cardiac surgery have yielded inconsistent results. The aim of this retrospective, observational study was to evaluate the effects of peri-operative glucose levels on adverse events in infants receiving open-heart surgery with CPB. Methods: From Nov 2009 through Dec 2009, 100 infants undergoing open-heart surgery were enrolled. All glucose values during the operation and intensive care unit stay were documented. Metrics of glucose control, including mean, peak and minimum glucose levels were calculated. Hyperglycemia was defined as a mean glucose above 150mg/dl. Hypoglycemia was defined as minimum glucose below 65mg/dl. Multivariable regression analyses were used to determine relationships between these metrics of glucose control and a composite morbidity-mortality outcome after controlling for multiple variables known to influence early outcomes after congenital heart surgery.

Results: According to our definition, 43 patients (43%) developed hyperglycemia and 9 patients (9%) developed at least one episode of hypoglycemia. A total of 58 patients reached the overall composite morbidity-mortality end point at some point during the study period. After adjusting the effects of age, cross-clamp time and pre-operative percutaneous oxygen saturation by multivariable analysis, euglycemia, defined as mean glucose ≤150mg/dl, was found to be a significant predictor for morbidity, with an odds ratio of 5.1(95% confidence interval 1.5-17.5).

Conclusion: In contrast to adult critically ill patients, data from the present study did not prove that hyperglycemia was detrimental to infants receiving open-heart surgery with CPB. The existing literature and findings of our present study warranted future clinical studies of strict glycemic control in critically ill children, considering a more permissive glycemic range as a desirable target.

Keywords

hyperglycemia infants cardiac surgery cardiopulmonary bypass adverse outcome

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References

van den Berghe G. , Wouters P. , Weekers F. , et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001: 345: 1359-1367.

Wiener RS , Wiener DC , Larson RJ Benefits and risks of tight glucose control in critically ill adults: a meta-analysis . JAMA 2008: 300: 933-944.

Polito A. , Thiagarajan RR , Laussen PC , et al. Association between intraoperative and early postoperative glucose levels and adverse outcomes after complex congenital heart surgery. Circulation 2008: 118: 2235-2242.

Rossano JW , Taylor MD , Smith EO , et al. Glycemic profile in infants who have undergone the arterial switch operation: hyperglycemia is not associated with adverse events. J Thorac Cardiovasc Surg 2008: 135: 739-745.

Falcao G. , Ulate K. , Kouzekanani K. , Bielefeld MR , Morales JM , Rotta AT Impact of postoperative hyperglycemia following surgical repair of congenital cardiac defects. Pediatr Cardiol 2008: 29: 628-636.

Vlasselaers D. , Milants I. , Desmet L. , et al. Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomized controlled study. Lancet 2009: 373: 547-556.

de Ferranti S. , Gauvreau K. , Hickey PR , et al. Intraoperative hyperglycemia during infant cardiac surgery is not associated with adverse neurodevelopmental outcomes at 1, 4 and 8 years. Anesthesiology 2004: 100: 1345-1352.

Yates AR , Dyke PC 2nd , Taeed R. , et al. Hyperglycemia is a marker for poor outcome in the postoperative pediatric cardiac patient. Pediatr Crit Care Med 2006: 7: 351-355.

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.

10.

NICE-SUGAR Study Investigators , Finfer S. , Chittock DR , et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009: 360: 1283-1297.

11.

Hirshberg E. , Lacroix J. , Sward K. , Willson D. , Morris AH Blood glucose control in critically ill adults and children: a survey on stated practice. Chest 2008: 133: 1328-1335.

12.

Fanelli C. , Pampanelli S. , Epifano L. , et al. Relative roles of insulin and hypoglycaemia on induction of neuroendocrine responses to, symptoms of, and deterioration of cognitive function in hypoglycaemia in male and female humans. Diabetologia 1994: 37: 797-807.

13.

Wintergerst KA , Buckingham B. , Gandrud L. , Wong BJ , Kache S. , Wilson DM Association of hypoglycemia, hyperglycemia, and glucose variability with morbidity and death in the pediatric intensive care unit. Pediatrics 2006: 118: 173-179.

14.

Anand KJ , Hansen DD , Hickey PR Hormonal-metabolic stress responses in neonates undergoing cardiac surgery . Anesthesiology 1990: 73: 661-670.

15.

Jenkins KJ , Gauvreau K. , Newburger JW , Spray TL , Moller JH , Iezzoni LI Consensus-based method for risk adjustment for surgery for congenital heart disease. J Thorac Cardiovasc Surg 2002: 123: 110-118.

16.

Grisaru-Soen G. , Paret G. , Yahav D. , Boyko V. , Lerner-Geva L. Nosocomial infections in pediatric cardiovascular surgery patients: a 4-year survey. Pediatr Crit Care Med 2009: 10: 20202-6.

17.

Careaga G. , Salazar D. , Téllez S. , Sánchez O. , Borrayo G. , Argüero R. Clinical impact of histidine-ketoglutaratetryptophan (HTK) cardioplegic solution on the perioperative period in open heart surgery patients. Arch Med Res 2001: 32: 296-299.

18.

Cappabianca G. , Rotunno C. , de Luca Tupputi Schinosa L. , Ranieri VM , Paparella D. Protective effects of steroids in cardiac surgery: a meta-analysis of randomized double-blind trials. J Cardiothorac Vasc Anesth 2010 May 25. [Epub ahead of print]