Monitoring/OutcomesHyperglycemia, hypoglycemia, and glycemic complexity are associated with worse outcomes after surgery☆,☆☆
Introduction
Hyperglycemia is common in critically ill patients and is associated with increased morbidity and mortality, longer lengths of stay, and higher costs [1], [2]. High glucose levels interfere with protein function, impair endothelial cell function, inhibit nitric oxide production, and suppress normal immune function [3], [4]. Conversely, hypoglycemia is associated with impaired cell energetics, neuronal death, and mortality in critically ill patients [5], [6]. However, the level of glycemic control is controversial [1], [6], [7], and other studies have suggested that the variability or complexity of the glucose time series is more important than the actual glucose levels [8], [9], [10], [11]. The Society of Thoracic Surgeons guideline states that glucose should be kept less than 180 mg/dL but that studies to determine the optimal glucose levels are needed [12]. The purpose of this study is to determine the associations between glucose levels and control and complications.
Section snippets
Methods
This retrospective cohort study of prospectively collected data in cardiac surgery patients who were treated in the era of tight control was approved by the institutional review board, which waived consent. The primary outcome was composite complications of arrest, atrial fibrillation, bleeding, coagulopathy, gastrointestinal, heart block, infections, multisystem organ dysfunction, myocardial infarction, prolonged mechanical ventilation, renal failure, reoperation, stroke, and tamponade (//www.sts.org/sites/default/files/documents/pdf/trainingmanuals/adult2.61/Section_P_COMPLICATIONS.pdf
Results
A total of 970 patients underwent cardiac surgery between February 1, 2008, and July 30, 2010. Of the 431 patients with diabetes, 220 (51%) were controlled on oral medications; 137 (32%), on insulin; 32 (7%), by diet; and 42 (10%) had no treatment. Average glycemic control was poor (mean hemoglobin A1c, 7.7% ± 2.0%; only 45% had hemoglobin A1c <7.0%). Of the 11 235 glucose measurements, only 4194 (37%) were in the goal range (80-110 mg/dL), 1489 (13%) were below goal (<80 mg/dL), with 667 (5.9%)
Discussion
We found that after correcting for presurgical comorbidities, type of surgery, and intraoperative processes, both hyperglycemia and hypoglycemia were independently associated with increased risks of complications (Table 3). Importantly, we also found that hypoglycemia was associated with longer times (114 ± 124 vs 90 ± 91 minutes; P < .001) between glucose measurements, which suggests that avoiding delays or more frequent measurements in checking glucose levels, particularly when glucose levels
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Expert consensus on the glycemic management of critically ill patients
2022, Journal of Intensive MedicineCitation Excerpt :Hyperglycemia also correlates closely with mortality, disability, and length of hospital stay. An observational study of critically ill patients undergoing surgery showed significantly higher fatality (OR=4.8, 95% CI: 1.4–20; P=0.02) among those with a blood glucose level >7.8 mmol/L than those with a blood glucose level of 4.4–7.8 mmol/L.[98] Another observational study found that patients with postoperative glucose >10.0 mmol/L had a higher incidence of postoperative complications, including acute kidney injury (OR=2.58), arrhythmias (OR=2.40), and sepsis (OR=3.86) than those with glucose <10.0 mmol/L.[99] However, postoperative hypoglycemia is also strongly associated with increased postoperative infection rates, poor wound healing, and fatality.[97,100] An observational study of patients undergoing cardiac surgery found that postoperative hypoglycemia (blood glucose <3.9 mmol/L) significantly increased postoperative fatality (OR=5.47, 95% CI: 3.14–9.5%) and disability (OR=4.66, 95% CI: 3.55–6.1%) rates.[101]
Classification of glucose records from patients at diabetes risk using a combined permutation entropy algorithm
2018, Computer Methods and Programs in BiomedicineCitation Excerpt :Among all these more advanced mathematical methods, those based on signal complexity, regularity, or predictability estimation are gaining momentum due to their ability of capturing the subtle differences among subjects. Approximate Entropy (ApEn) [8], Sample Entropy (SampEn) [9], Fuzzy Entropy (FuzzEn) [10], Dispersion Entropy [11], State–Space Correlation Entropy [12], Bubble Entropy [13], Lempel Ziv Complexity (LZC) [14], Detrended Fluctuation Analysis (DFA) [15], Distribution Entropy (DistEn) [16], and Permutation Entropy (PE) [17], are just a few of these methods that have been applied successfully in the context of biomedical records, including glucose time series in some cases [18–23]. Specifically, Permutation Entropy (PE) [17] is a complexity measure that is receiving a lot of attention in the last years.
Effect of Hypoglycemia on the Incidence of Revision in Total Knee Arthroplasty
2017, Journal of ArthroplastyIntranasal administration of 40 and 80 units of insulin does not cause hypoglycemia during cardiac surgery: a randomized controlled trial
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This study was conducted at Mercy St Vincent Medical Center, Toledo, OH, and the University of Michigan, Ann Arbor, MI.
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This study was supported by departmental and institutional support.