Diabetes and the association of postoperative hyperglycemia with clinical and economic outcomes in cardiac surgery

Giampaolo Greco, Bart S. Ferket, David A. D'Alessandro, Wei Shi, Keith A. Horvath, Alexander Rosen, Stacey Welsh, Emilia Bagiella, Alexis E. Neill, Deborah L. Williams, Ann Greenberg, Jeffrey N. Browndyke, A. Marc Gillinov, Mary Lou Mayer, Jessica Keim-Malpass, Lopa S. Gupta, Samuel F. Hohmann, Annetine C. Gelijns, Patrick T. O'Gara, Alan J. Moskowitz

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Abstract

Objective The management of postoperative hyperglycemia is controversial and generally does not take into account pre-existing diabetes. We analyzed clinical and economic outcomes associated with postoperative hyperglycemia in cardiac surgery patients, stratifying by diabetes status. Research Design and Methods Multicenter cohort study in 4,316 cardiac surgery patients operated on in 2010. Glucose was measured at 6-h intervals for 48 h postoperatively. Outcomes included cost, hospital length of stay (LOS), cardiac and respiratory complications, major infections, and death. Associations between maximum glucose levels and outcomes were assessed with multivariable regression and recycled prediction analyses. Results In patients without diabetes, increasing glucose levels were associated with a gradual worsening of outcomes. In these patients, hyperglycemia (≥180 mg/dL) was associated with an additional cost of $3,192 (95% CI 1,972 to 4,456), an additional hospital LOS of 0.8 days (0.4 to 1.3), an increase in infections of 1.6% (0.5 to 2.8), and an increase in respiratory complications of 2.6% (0.0 to 5.3). However, among patients with insulin-treated diabetes, optimal outcomes were associated with glucose levels considered to be hyperglycemic (180 to 240 mg/dL). This level of hyperglycemia was associated with cost reductions of $6,225 (212,886 to 2222), hospital LOS reductions of 1.6 days (23.7 to 0.4), infection reductions of 4.1% (29.1 to 0.0), and reductions in respiratory complication of 12.5% (222.4 to 23.0). In patients with non-insulin-treated diabetes, outcomes did not differ significantly when hyperglycemia was present. Conclusions Glucose levels <180 mg/dL are associated with better outcomes in most patients, but worse outcomes in patients with diabetes with a history of prior insulin use. These findings support further investigation of a stratified approach to the management of patients with stress-induced postoperative hyperglycemia based on prior diabetes status.

Original languageEnglish (US)
Pages (from-to)408-417
Number of pages10
JournalDiabetes care
Volume39
Issue number3
DOIs
StatePublished - Mar 2016

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ASJC Scopus subject areas

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Advanced and Specialized Nursing

Cite this

Greco, G., Ferket, B. S., D'Alessandro, D. A., Shi, W., Horvath, K. A., Rosen, A., Welsh, S., Bagiella, E., Neill, A. E., Williams, D. L., Greenberg, A., Browndyke, J. N., Gillinov, A. M., Mayer, M. L., Keim-Malpass, J., Gupta, L. S., Hohmann, S. F., Gelijns, A. C., O'Gara, P. T., & Moskowitz, A. J. (2016). Diabetes and the association of postoperative hyperglycemia with clinical and economic outcomes in cardiac surgery. Diabetes care, 39(3), 408-417. https://doi.org/10.2337/dc15-1817