|Year : 2016 | Volume
| Issue : 6 | Page : 742-746
A retrospective analysis of blood gases with two different insulin infusion protocols in patients undergoing cardiovascular surgery
SM Kuskonmaz1, Ö Kurtipek2, ME Aydın2, ME Erbatur2, M Alkan2, Y Ünal2, M Arslan2
1 Department of Endocrinology and Metabolism, Medical Faculty, Gazi University, Ankara, Turkey
2 Department of Anaesthesiology and Reanimation, Medical Faculty, Gazi University, Ankara, Turkey
|Date of Acceptance||20-Dec-2015|
|Date of Web Publication||4-Nov-2016|
Dr. M Arslan
Department of Anesthesiology and Reanimation, Medical Faculty, Gazi University, 06510 Ankara
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: Intraoperative blood glucose concentration is known to be an independent risk factor for morbidity and mortality in patients undergoing cardiovascular surgery. Arterial blood gas analysis is an important investigation to monitor the acid-base balance and gas exchange in these patients. Hyperglycemia leads to a series of metabolic changes which affect acid-base balance and serum electrolytes. In this study, we aimed to look into the effect of glycemic control on arterial blood gas parameters, serum electrolytes, and hemoglobin (Hb).
Materials and Methods: We collected data from diabetic patients who underwent cardiovascular surgery between 2010 and 2014. The patients were divided into two groups according to the insulin infusion protocols applied such as with conventional (180–250 mg/dl) (n = 17) (Group 1) and tighter glycemic targets (121–180 mg/dl) (n = 51) (Group 2). We retrospectively analyzed arterial blood gas results taken at different perioperative time points from these patients.
Results: We found that pH HCO3and base excess, serum sodium, potassium, calcium, and Hb were similar in both groups.
Conclusion: Our study showed that a tighter intraoperative glycemic control does not affect arterial blood gas parameters, serum electrolytes, or Hb when compared to the conventional glycemic control.
Keywords: Base excess, cardiovascular surgery, diabetes mellitus, electrolytes, perioperative insulin infusion
|How to cite this article:|
Kuskonmaz S M, Kurtipek &, Aydın M E, Erbatur M E, Alkan M, Ünal Y, Arslan M. A retrospective analysis of blood gases with two different insulin infusion protocols in patients undergoing cardiovascular surgery. Niger J Clin Pract 2016;19:742-6
|How to cite this URL:|
Kuskonmaz S M, Kurtipek &, Aydın M E, Erbatur M E, Alkan M, Ünal Y, Arslan M. A retrospective analysis of blood gases with two different insulin infusion protocols in patients undergoing cardiovascular surgery. Niger J Clin Pract [serial online] 2016 [cited 2020 Jul 11];19:742-6. Available from: http://www.njcponline.com/text.asp?2016/19/6/742/178943
ŞM Kuşkonmaz, M Alkan
These authors contributed equally to this work
| Introduction|| |
Diabetes mellitus (DM) is a significant risk factor for coronary artery disease.,, Intraoperative blood glucose concentration is known to be an independent risk factor for morbidity and mortality in surgical patients.,, Several studies demonstrated the benefit of continuous insulin infusion regarding perioperative morbidity and mortality.,, A significant mortality benefit was shown in surgical Intensive Care Unit with tight glycemic control (target blood glucose: 80–110 mg/dl) in a prospective study. However, results of some other studies showed increased mortality with tight glycemic control, probably due to increased incidence of hypoglycemia.,, Due to these conflicting data, guidelines about perioperative management of diabetes state different target blood glucose values, ranging from 108–180 to 140–200 mg/dl.
DM is implied as a risk factor for intraoperative bleeding or blood transfusion after cardiovascular surgery.,,, There are only a few studies looking into the effect of tight glycemic control on these outcomes. A recent prospective study reported no difference in the incidence of bleeding in patients undergoing cardiovascular surgery, whether they received intraoperative insulin infusion, thus achieved a tight glycemic control, or not. The study included both diabetic and nondiabetic patients.
Arterial blood gas analysis is an important investigation to monitor the acid-base balance and gas exchange in a patient who undergoes cardiovascular surgery. Hyperglycemia leads to a series of metabolic changes which affect acid-base balance and serum electrolytes. In this study, we aimed to compare arterial blood gas parameters, serum electrolytes, and hemoglobin (Hb) values in diabetic patients who had undergone cardiovascular surgery with two different intraoperative insulin infusion protocols.
| Materials and Methods|| |
This study was approved by the Ethics Committee of Gazi University Hospital (Gazi University Ethics Committee for Clinical Research. Decision Number: 22). The study is carried out in a university hospital setting, in which 100–130 major cardiovascular surgeries are performed per year. We analyzed the blood glucose levels and blood gas parameters derived from diabetic patients who underwent major cardiovascular surgery (coronary artery bypass grafting, valve replacement, and aortic aneurysm) between 2010 and 2014. Patients with Type 1 diabetes, chronic renal failure, chronic liver disease, New York Heart Association Class II–IV heart failure, and active malignant disease are not included in the study. Between 2010 and 2012, we had preferred to initiate insulin infusion only when blood glucose level exceeds 200 mg/dl and we had targeted a target blood glucose value of 180–250 mg/dl. After 2012, we began to initiate insulin infusion directly preoperatively and used a more intensive approach to keep blood glucose between 121 and 180 mg/dl. The details of these two protocols are given in [Table 1]. Patients in the conventional insulin infusion protocol are named as Group 1 (n = 17) and patients in the intensive glucose control group as Group 2 (n = 51). The perioperative Hb, serum electrolytes (calcium [Ca], sodium [Na], and potassium [K]) blood glucose, arterial blood gas parameters (pO2, pCO2, HCO3, base excess [BE], and pH) obtained in 11 different time points (T0: Initial blood glucose, T1–T10: Blood glucose measurements 60 min apart intraoperatively, and T11: Blood glucose measurement at the end of surgery) perioperatively were retrospectively analyzed. All parameters were measured by an arterial blood gas analyzer (Radiometer. Blood gas analyzer, ABL835 Flex, I902-754R0288N0008, Copenhagen, Denmark).
|Table 1: Insulin infusion protocols for conventional and intensive perioperative glucose control|
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The statistical analyses were performed using (IBM Corp. Released 2011. IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.), and P < 0.05 was considered statistically significant. Variations in blood glucose levels and blood gas parameters between study groups were assessed using the Student's t-test. The results were expressed as mean ± standard deviation and minimum–maximum.
| Results|| |
A total of 420 major cardiovascular surgeries -all on pump- were performed within the study period. Sixty-eight of them were eligible for our study (regarding the inclusion criteria explained above). Of those, 52 were cardiovascular bypass surgeries and 16 were valvular operations. The demographic properties of the patients were similar in two groups [Table 2].
|Table 2: Demographic properties of the patients (mean±SD (minimum-maximum))|
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Perioperative blood glucose measurements are shown in [Table 3]. Initial blood glucose measurements (T0) were similar in both groups. Blood glucose measurements in Group 1 were significantly lower than that of Group 2 in all other time points (T1–T11).
|Table 3: Perioperative blood glucose measurements of the patients (mean±SD (minimum-maximum))|
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For practical purposes, we preferred to compare T1, T11, and a mean of intraoperative measurements (T2–T10). We did not find a statistically significant difference between pH, HCO3, and BE levels in different perioperative time points between two groups [Table 4]. We did not find a statistically significant difference between two groups when hemoglobin, Na, K, or Ca levels are compared in different perioperative time points between two groups [Table 5] except a significantly higher calcium in Group 2 in T11 measurements.
|Table 4: Arterial blood gas parameters at different perioperative time points in two groups (mean±SD (minimum-maximum))|
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|Table 5: Hemoglobin and electrolytes at different perioperative time points in two groups (mean±SD (minimum-maximum))|
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| Discussion|| |
Arterial blood gas analysis provides important data about the metabolic status of a patient who is under surgical stress. Although the adverse effects of hyperglycemia on various surgical outcomes are well established, there are a few studies that looked into the association between glycemic management and perioperative arterial blood gas parameters.,
Rucka et al. hypothesized that insulin may influence the genes associated with surfactant and, in turn, have an effect on pulmonary gas exchange. They investigated the effect of insulin infusion on oxygenation in patients undergoing lung resection. The study was conducted in a cohort of 64 patients (15 had diabetes). The authors did not find a difference in pO2 or pCO2 in patients who received intraoperative insulin infusion. Masoumi et al. investigated the effect of intraoperative insulin infusion on arterial blood gas parameters in patients undergoing cardiovascular surgery. In this prospective study, 61 patients (17 had diabetes) were divided into two groups such as one group received insulin infusion with tight glycemic control (target blood glucose value between 90 and 150 mg/dl) and the other group was followed without insulin infusion. The authors reported that pO2, PCO2, and pH values obtained at different time points preoperatively were similar in both groups. Our results were consistent with the results of these two studies. We thought that gas exchange is more dependent on patient-related factors such as respiratory function and surgical technique used (on-pump or off-pump) in cardiovascular surgery.
In our study, we also evaluated serum Na, K, and Ca. Hyperglycemia itself and insulin infusion are both known to affect serum electrolyte levels. We found that a tighter intraoperative glycemic control does not influence serum electrolytes. We should remind that potassium infusion is given with insulin at appropriate doses in our protocols.
Intraoperative blood loss is an important cause of morbidity in cardiovascular surgery. Several studies implied DM as a risk factor for intraoperative bleeding or blood transfusion after cardiovascular surgery.,,, In a large multicenter study, in patients undergoing coronary artery bypass grafting surgery, no significant difference was found between postoperative Hb values of diabetic patients on oral anti-diabetic medications or insulin and nondiabetic patients. In the study mentioned above, Masoumi et al. failed to find a difference in the risk of bleeding from surgical site between patients who were given insulin infusion and patients followed without insulin infusion. In our preliminary study, we showed that a tighter glycemic control does not affect postoperative Hb values in cardiovascular surgery. Although diabetes increases the risk of intraoperative bleeding, the way and degree of glycemic control do not seem to be related to bleeding. To our opinion, bleeding may be more related to the baseline health status of the diabetic patient. Further studies are needed to clarify the effect of glucose control on intraoperative bleeding.
Our study has some limitations. First, we were unable to evaluate important parameters such as the incidence of hypoglycemic episodes in this retrospective design. Second, data about short-term and long-term morbidity and mortality of these patients are not analyzed in this study. The absence of a prestudy power analysis is also a potential limitation of our study. Finally, the small study group precludes a more powerful statistical analysis to be done.
| Conclusion|| |
This preliminary study on diabetic patients undergoing cardiovascular surgery showed that a tighter intraoperative glycemic control does not affect arterial blood gas parameters, serum electrolytes, BE, or Hb when compared to the conventional glycemic control. Intraoperative tight glycemic control does not seem to be superior to conventional insulin regimens in diabetic patients as far as the electrolyte and acid-base balance are concerned. Tight glycemic control does not influence gas exchange and the risk of intraoperative bleeding either. Further studies are warranted to detect the impact of intraoperative tight glycemic control on short-term and long-term morbidity and mortality in diabetic patients undergoing cardiovascular surgery.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Aronow WS, Ahn C. Incidence of heart failure in 2,737 older persons with and without diabetes mellitus. Chest 1999;115:867-8.
Shindler DM, Kostis JB, Yusuf S, Quinones MA, Pitt B, Stewart D, et al.
Diabetes mellitus, a predictor of morbidity and mortality in the studies of left ventricular dysfunction (SOLVD) trials and registry. Am J Cardiol 1996;77:1017-20.
Airaksinen KE. Silent coronary artery disease in diabetes – A feature of autonomic neuropathy or accelerated atherosclerosis? Diabetologia 2001;44:259-66.
Ouattara A, Lecomte P, Le Manach Y, Landi M, Jacqueminet S, Platonov I, et al.
Poor intraoperative blood glucose control is associated with a worsened hospital outcome after cardiac surgery in diabetic patients. Anesthesiology 2005;103:687-94.
Finney SJ, Zekveld C, Elia A, Evans TW. Glucose control and mortality in critically ill patients. JAMA 2003;290:2041-7.
Gandhi GY, Nuttall GA, Abel MD, Mullany CJ, Schaff HV, Williams BA, et al.
Intraoperative hyperglycemia and perioperative outcomes in cardiac surgery patients. Mayo Clin Proc 2005;80:862-6.
Furnary AP, Gao G, Grunkemeier GL, Wu Y, Zerr KJ, Bookin SO, et al.
Continuous insulin infusion reduces mortality in patients with diabetes undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2003;125:1007-21.
Kersten JR, Warltier DC, Pagel PS. Aggressive control of intraoperative blood glucose concentration: A shifting paradigm? Anesthesiology 2005;103:677-8.
Lell WA, Nielsen VG, McGiffin DC, Schmidt FE Jr., Kirklin JK, Stanley AW Jr. Glucose-insulin-potassium infusion for myocardial protection during off-pump coronary artery surgery. Ann Thorac Surg 2002;73:1246-51.
van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al.
Intensive insulin therapy in critically ill patients. N Engl J Med 2001;345:1359-67.
Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al.
Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449-61.
NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY, Blair D, Foster D, et al.
Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.
Hua J, Chen G, Li H, Fu S, Zhang LM, Scott M, et al.
Intensive intraoperative insulin therapy versus conventional insulin therapy during cardiac surgery: A meta-analysis. J Cardiothorac Vasc Anesth 2012;26:829-34.
Dhatariya K, Levy N, Kilvert A, Watson B, Cousins D, Flanagan D, et al.
NHS diabetes guideline for the perioperative management of the adult patient with diabetes. Diabet Med 2012;29:420-33.
Qaseem A, Humphrey LL, Chou R, Snow V, Shekelle P; Clinical Guidelines Committee of the American College of Physicians. Use of intensive insulin therapy for the management of glycemic control in hospitalized patients: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2011;154:260-7.
Magovern JA, Sakert T, Benckart DH, Burkholder JA, Liebler GA, Magovern GJ Sr., et al.
A model for predicting transfusion after coronary artery bypass grafting. Ann Thorac Surg 1996;61:27-32.
Moskowitz DM, Klein JJ, Shander A, Cousineau KM, Goldweit RS, Bodian C, et al.
Predictors of transfusion requirements for cardiac surgical procedures at a blood conservation center. Ann Thorac Surg 2004;77:626-34.
Ferraris VA, Ferraris SP. Risk factors for postoperative morbidity. J Thorac Cardiovasc Surg 1996;111:731-38.
Sellman M, Intonti MA, Ivert T. Reoperations for bleeding after coronary artery bypass procedures during 25 years. Eur J Cardiothorac Surg 1997;11:521-7.
Masoumi G, Frasatkhish R, Jalali A, Ziyaeifard M, Sadeghpour-Tabae A, Mansouri M. Effects of moderate glycemic control in type II diabetes with insulin on arterial blood gas parameters following coronary artery bypass graft surgery. Res Cardiovasc Med 2014;3:e17857.
Verma AK, Paul R. The interpretation of arterial blood gases. Aust Prescr 2010;33:124-9.
Preiser JC, Ichai C, Orban JC, Groeneveld AB. Metabolic response to the stress of critical illness. Br J Anaesth 2014;113:945-54.
Rucka Z, Vanhara P, Koutna I, Tesarova L, Potesilova M, Stejskal S, et al.
Differential effects of insulin and dexamethasone on pulmonary surfactant-associated genes and proteins in A549 and H441 cells and lung tissue. Int J Mol Med 2013;32:211-8.
Rucka Z, Koutná I, Tesarová L, Potešilová M, Stejskal S, Simara P, et al.
Intravenous insulin therapy during lung resection does not affect lung function or surfactant proteins. BMC Pulm Med 2014;14:155.
Maletkovic J, Drexler A. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Endocrinol Metab Clin North Am 2013;42:677-95.
Székely A, Levin J, Miao Y, Tudor IC, Vuylsteke A, Ofner P, et al.
Impact of hyperglycemia on perioperative mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg 2011;142:430-7.e1.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]