1. Blood Glucose Control post-CABG
Is that your final answer??
Angela Hodges, PharmD, RPh
Clinical Pharmacist Diabetes Specialist
Texas Health Huguley
September 2013

2. What is the optimal
BG range?
Intensive Insulin Therapy: 80 – 110 mg/dL
AACE/ADA & STS*: 140 – 180 mg/dL
2000 B.C. <250mg/dL
Angela Hodges, PharmD, RPh 2013
*Society of Thoracic Surgeons.

3. W h o c a r e s
w h a t w e u s e ! !
What does blood sugar have
to do with heart surgery
anyway?
Angela Hodges, PharmD, RPh 2013

4. Hyperglycemia
 Post-op BG >250mg/dL
 10 x greater risk of complications
 Intraoperative hyperglycemia, an independent risk
factor for complications
 Abnormal glucose levels studied as a predictor for
survival post-CABG
 Sternal wounds
Angela Hodges, PharmD, RPh 2013
Ann Thorac Surg 2009;87:633-9

5. Effect of Perioperative
Hyperglycemia in CABG Patients
 Increases free fatty acids
 Decreases myocardial glucose uptake
 Endothelial dysfunction
 Caused by increased oxidative stress
 Caused by an inflammatory response
 Leading to less nitrous oxide and more superoxides
 Abnormal platelet function
 Increased plasminogen activator inhibitor-1 (PAI-1)
 Increased adhesion molecules
 Increased risk of arterial thrombosis and loss of graft patency.
Angela Hodges, PharmD, RPh 2013

6. Effect of Insulin
 Improves myocardial metabolism
 Reduces the inflammatory response
 Preserves endothelial integrity
 Maintains platelet function during myocardial ischemia
 Decreases free fatty acids levels
 Decreases C-reactive protein levels
 Limits injury to vein grafts through endothelial function
preservation
Angela Hodges, PharmD, RPh 2013

7. Van Den Berhe et al. AND
Intensive Insulin Therapy
 1st Intensive insulin therapy trial showing major benefit
 1500 critically ill patients
 DM and non-DM
 Cardiac Surgery Patients
 BG range: 80-110 mg/dL vs. 180-200mg/dL
 BG ave: 143 vs. 173 mg/dL
 Outcome: Decrease in mortality by 3%
 Less: Septicemia, blood transfusions, LOS, renal failure, bacteremia
 This trial was not reproducible.
Angela Hodges, PharmD, RPh 2013

8. NICE-SUGAR
Normoglycemia in Intensive Care Evaluation-Survival Using
Glucose Algorithm Regulation
 Intensive Control vs. Conventional Therapy
 81- 108mg/dL vs. 144 -180mg/dL
 >6000 patients
 Not a cardiac surgery exclusive population
 ICU
 DM and Non-DM
 90 day assessment of mortality
 Greater mortality with intensive arm by 2.6%
 Only ~37% operative patients therefore <37% CABG
 HYPOGLYCEMIA
Angela Hodges, PharmD, RPh 2013

9. Society of Thoracic Surgeons:
Recommendations
 All patients with diabetes undergoing cardiac surgical procedures
should receive an insulin infusion in the operating room, and for at
least 24 hours postoperatively to maintain serum glucose levels
<180mg/dL (level of evidence = B).
 Patients with or without diabetes with persistently elevated serum
glucose (>180mg/dL )should receive IV insulin infusions to maintain
serum glucose <180mg/dL for the duration of their ICU care (level of
evidence = A).
Angela Hodges, PharmD, RPh 2013

10. The Lesson
 BG =180mg/dL absolute max in the ICU setting
 Insulin infusion is the best method
 Use protocols that prevent hypoglycemia
 Use protocols that re-evaluate the glucose level q1h until stable.
 Treat both Diabetic and Non-Diabetic patients with perioperative
hyperglycemia.
We know that blood glucose control is needed, but we are undecided
about which specific range is best for each patient type.
Angela Hodges, PharmD, RPh 2013

11. References:
 Haga et al. J Cardiothorac Surg 2011,6:3.
 Breithaupt, T. Proc(Bayl Univ Med Cent.)2010
January;23(1):79-82.
 Weiner RS et al. JAMA 2008,300 (8):933-944
 Lazar HL et al. Ann Thorac Surg 2009;87:633-9
Angela Hodges, PharmD, RPh 2013