Previous retrospective studies have established a relationship between postoperative hypoglycemia and adverse outcomes after cardiac surgery, but none have accounted for the cause of hypoglycemia.

A retrospective review was performed of patients who underwent cardiac surgery at a single institution between 2016 and 2021. Patients were categorized as hypoglycemic if they had 1 or more postoperative blood glucose measurement less than 70 mg/dL and normoglycemic otherwise. Hypoglycemia was subcategorized as noniatrogenic (underlying liver failure, adrenal insufficiency, sepsis, or shock) or iatrogenic (insulin infusion continued while nil per os or infusion protocol violated) via manual chart review. Baseline characteristics were compared between groups using Pearson χ2, analysis of variance, and Kruskal-Wallis testing, and outcomes were compared using multivariable logistic regression.

In total, 5373 patients and 183,346 glucose measurements were included. Hypoglycemia occurred in 5% (267) of patients, of whom 63% (169) were iatrogenic and 37% (98) were noniatrogenic. In a multivariate analysis adjusting for age, sex, case urgency, pre-existing diabetes, and bypass time, both iatrogenic and noniatrogenic hypoglycemia were associated with greater odds of renal failure, prolonged ventilation, and prolonged intensive care unit length of stay relative to normoglycemia, but the magnitude was substantially lower in iatrogenic hypoglycemia. Patients with noniatrogenic hypoglycemia had 68.6 times greater odds of mortality relative to patients who were normoglycemic (odds ratio, 68.6; confidence interval, 39.5-119), but patients with iatrogenic hypoglycemia had no increased odds of mortality (odds ratio, 1.45; confidence interval, 0.77-2.73).

When excluding patients with conditions known to cause hypoglycemia from the analysis, the morbidity and mortality of iatrogenic hypoglycemia from tight postoperative glycemic control is dramatically attenuated.

Hypoglycemia is a known risk of intensive postoperative glucose control in neurosurgical patients. However, the impact of postoperative hypoglycemia after craniotomy remains unexplored. This study aimed to determine the association between postoperative hypoglycemia and mortality in patients undergoing elective craniotomy.

This study involved adult patients who underwent elective craniotomy at the West China Hospital, Sichuan University, between January 2011 and March 2021. We defined moderate hypoglycemia as blood glucose levels below 3.9 mmol/L (70 mg/dL) and severe hypoglycemia as blood glucose levels below 2.2 mmol/L (40 mg/dL). The primary outcome was postoperative 90-day mortality.

This study involved 15 040 patients undergoing an elective craniotomy. Overall, 504 (3.4%) patients experienced moderate hypoglycemia, whereas 125 (0.8%) patients experienced severe hypoglycemia. Multivariable analysis revealed that both moderate hypoglycemia (adjusted odds ratio [aOR] 1.86, 95% CI 1.24-2.78) and severe (aOR 2.94, 95% CI 1.46-5.92) hypoglycemia were associated with increased 90-day mortality compared with patients without hypoglycemia. Moreover, patients with moderate (aOR 2.78, 95% CI 2.28-3.39) or severe (aOR 16.70, 95% CI 10.63-26.23) hypoglycemia demonstrated a significantly higher OR for major morbidity after adjustment, compared with those without hypoglycemia. Patients experiencing moderate (aOR 3.20, 95% CI 2.65-3.88) or severe (aOR 14.03, 95% CI 8.78-22.43) hypoglycemia had significantly longer hospital stays than those without hypoglycemia. The risk of mortality and morbidity showed a tendency to increase with the number of hypoglycemia episodes in patients undergoing elective craniotomy (P for trend = .01, <.001).

Among patients undergoing an elective craniotomy, moderate hypoglycemia and severe hypoglycemia are associated with increased mortality, major morbidity, and prolonged hospital stays. In addition, the risk of mortality and major morbidity increases with the number of hypoglycemia episodes.

Blood glucose level variability has been associated with increased risk of complication in the postoperative setting of cardiovascular surgery. Although interesting for optimization of blood glucose management in this context, continuous blood glucose (CBG) devices can have a limited reliability in this context, in particular because of the use of paracetamol. The aim of this study was to evaluate the reliability of Dexcom G6®, a recently developed continuous glucose monitoring device.

We performed a prospective, observational, non-randomized, single-centre study comparing Dexcom G6® CBG level monitoring with the standard methods routinely used in this context. The standard blood glucose values were paired to the time corresponding values measured with Dexcom G6®. Agreement between the two methods and potential correlation in case of paracetamol use were calculated.

From May 2020 to August 2021, 36 out of 206 patients operated for isolated coronary artery bypass grafting were enrolled; 673 paired blood glucose level were analyzed. Global agreement (ρc) was 0.85 (95% C.I.: 0.84-0.86), intensive care unit agreement was 0.78 (95%C.I.: 0.74-0.82) and ward agreement was 0.91 (95%C.I.: 0.89-0.93). In the diabetic population, it was 0.87 (95%C.I.: 0.85-0.90). When paracetamol was used, the difference was 0.02 mmol/l (95%C.I.: 0.29-0.33).

Dexcom G6® provides good blood glucose level accuracy in the postoperative context of cardiac surgery compared to the standard methods of measurements. The results are particularly reliable in the ward where the need for repeated capillary glucose measurements implies patient discomfort and time-consuming manipulations for the nursing staff.

We evaluated the feasibility of real-time continuous glucose monitoring (CGM) for titrating continuous intravenous insulin infusion (CII) to manage hyperglycemia in postoperative individuals in the cardiovascular intensive care unit and assessed their accuracy, nursing acceptance, and postoperative individual satisfaction.

Dexcom G6 CGM devices were applied to 59 postsurgical patients with hyperglycemia receiving CII. A hybrid approach combining CGM with periodic point-of-care blood glucose (POC-BG) tests with two phases (initial-ongoing) of validation was used to determine CGM accuracy. Mean and median absolute relative differences and Clarke Error Grid were plotted to evaluate the CGM accuracy. Surveys of nurses and patients on the use of CGMs experience were conducted and results were analyzed.

In this cohort (mean age 64, 32% female, 32% with diabetes) with 864 paired POC-BG and CGM values analyzed, mean and median absolute relative difference between POC-BG and CGM values were 13.2% and 9.8%, respectively. 99.7% of paired CGM and POC-BG were in Zones A and B of the Clarke Error Grid. Responses from nurses reported CGMs being very or quite convenient (n = 28; 93%) and it was favored over POC-BG testing (n = 28; 93%). Majority of patients (n = 42; 93%) reported their care process using CGM as being good or very good.

This pilot study demonstrates the feasibility, accuracy, and nursing convenience of adopting CGM via a hybrid approach for insulin titration in postoperative settings. These findings provide robust rationale for larger confirmatory studies to evaluate the benefit of CGM in postoperative care to improve workflow, enhance health outcomes, and cost-effectiveness.

Diabetes and hyperglycemic events in cardiac surgical patients are associated with postoperative morbidity and mortality. The causes of dysglycemia, the abnormal fluctuations in blood glucose concentrations, in the perioperative period include surgical stress, surgical techniques, medications administered perioperatively, and patient factors. Both hyperglycemia and hypoglycemia lead to poor outcomes after cardiac surgery. While trying to control blood glucose concentration tightly for better postoperative outcomes, hypoglycemia is the main adverse event. Currently, there is no definite consensus on the optimum perioperative blood glucose concentration to be maintained in cardiac surgical patients. This review provides an overview of perioperative glucose homeostasis, the pathophysiology of dysglycemia, factors that affect glycemic control in cardiac surgery, and current practices for glycemic control in cardiac surgery.

Burn survivors undergoing complex glycemic derangements in the acute period after burn are at significantly increased risk of worse outcomes. Although most critical care investigations recommend intensive glycemic control to prevent morbidity and mortality, conflicting recommendations exist. To date, no literature review has studied outcomes associated with intensive glucose control in the burn intensive care unit (ICU) population. This review addresses this gap to improve practice guidelines and support further research regarding glycemic control. This is a narrative review of literature utilizing PubMed for articles published at any time. Inclusion criteria were English studies describing glucose management in ICU adult burn patients. Studies involving pediatric patients, non-human subjects, care non-ICU care, case reports, editorials, and position pieces were excluded. Our literature search identified 2154 articles. Full text review of 61 articles identified eight meeting inclusion criteria. Two studies reported mortality benefit of intensive glucose control ( mg/dL) compared to controls ( mg/dL), while two studies showed no mortality differences. Three studies reported reduced infectious complications such as pneumonia, urinary tract infection, sepsis, and bacteremia. A majority of the studies (6/8) reported higher risk for hypoglycemia with tight glucose control, but few reported instances of adverse sequela associated with hypoglycemia. Intensive glucose control may provide benefit to burn patients, but complications associated with hypoglycemia must be considered. This review recommends an individualized patient-centered approach factoring comorbidities, burn injury characteristics, and risk factors when determining whether to employ intensive glucose control.

Acute kidney injury (AKI) is a common comorbidity, affecting approximately one in five hospitalized adults. The kidney is the site for the production, metabolism or excretion of most hormones, including the production of erythropoietin (EPO), the active form of vitamin D, renin, thrombopoietin, and the excretion of insulin, catecholamines, gastrin and many other hormones. Therefore, it is reasonable to say that AKI can have a considerable impact on the endocrine system. Although the effects of AKI on various parameters, including cardiovascular parameters, serum electrolytes and acid-base disorders, neuro-humoral mechanisms and neurological outcomes have been extensively studied, the endocrinological consequences of AKI are understudied. Thyroid dysfunction, mainly euthyroid sick syndrome, hypo/hyperglycemia, bone mineral disorders, changes in EPO and atrial natriuretic peptide (ANP) levels are commonly found in AKI. EPO, thyroxine and ANP administration have been evaluated as potential tools to prevent or treat AKI with varying success, while the effects of AKI on some key hormones, including cortisol and insulin, have never been studied. Aim of this narrative review is to illustrate what is known and what is not known about the endocrinological outcomes of AKI. Few clinical trials are ongoing: however, there is a clear need for large-scale randomized controlled trials investigating the endocrinological consequences of AKI.

To investigate the effect of early postoperative hypoglycaemia on hospitalization outcomes including major cardiovascular complications and in-hospital mortality among patients undergoing coronary artery bypass grafting (CABG).

Data from an observational study of 9583 patients in the intensive care unit (ICU) who underwent CABG were analyzed. Hypoglycaemia was defined as a nadir blood glucose level <70 mg/dL (3.9 mmol/L). One-to-one propensity score matching (PSM) was used to identify 251-balanced pairs of patients to compare outcomes.

A total of 306 (3.2%) patients experienced hypoglycaemia, of whom, 133 had diabetes, 173 hadn't diabetes. Patients who were hypoglycaemia had higher incidences of compositeoutcomes than those without hypoglycaemia (12.1% versus 6.0%, P < 0.0001). Postoperative length of ICU stay was longer in patients with hypoglycaemia [2.8 (0.8-21.0) versus 2.0 (0.25-36.0) days, P < 0.0001]. After PSM, the compositeoutcomes and length of ICU stay remained significantly increased for the patients with hypoglycaemia [compositeoutcomes: odd ratio (OR) 2.78, 95% CI, 1.30-5.88, P = 0.01; length of ICU stay: OR 1.60, 95% CI, 1.14-2.26, P = 0.007].

Postoperative hypoglycaemia was an independent associated factor of adverse composite outcomes and a lengthened ICU stay after CABG. Hypoglycaemia should be avoided for both postoperative patients with and without diabetes.

Perioperative poor glycemic control in diabetic patients undergoing Coronary Artery Bypass Graft (CABG) surgery has been associated with infectious complications, particularly surgical site infections that are linked with adverse health surgical outcomes. The purpose of this study was to investigate the effect of two different intraoperative glycemic control protocol, tight and conventional, on thirty-day postoperative surgical site infection (SSI) rates among diabetic patients undergoing CABG surgery.

A randomized controlled trial (RCT) design was employed in the study, with a convenience sample of 144 adult patients who were scheduled to undergo coronary artery bypass grafting surgery.

A main referral heart institute in Amman, Jordan.

Subjects were randomly assigned to either the tight glycemic control group (n = 72), which maintained an intraoperative blood glucose level of 110-149 mg/dl via continuous intravenous insulin infusion, or the conventional glycemic control group (n = 72), which maintained an intraoperative blood glucose level of 150-180 mg/dl via continuous intravenous insulin infusion. The postoperative SSIs among both groups were evaluated and compared by independent blinded physicians.

The primary findings of this study indicated no statistically significant difference between the two treatment groups in terms of SSI rates and their potential adverse surgical outcomes (p = 0.512).

Nurses should consider the glycemic stability and glycemic control approach to minimize adverse surgical outcomes post CABG surgery. Healthcare providers should also carefully consider diabetic patients who have undergone CABG surgery and are at risk of developing postoperative SSIs.

NCT04451655 was retrospectively registered in 30/06/2020.

Perioperative hyperglycemia is associated with poor postoperative recovery, including compromised immune function and increased risk of infection. A closed-loop glycemic control system (artificial pancreas) has demonstrated strict safe perioperative glycemic control without hypoglycemia risk. The authors hypothesized that the artificial pancreas would reduce surgical site infections (SSIs) and postoperative inflammatory reactions. This study aimed to assess the effect of the artificial pancreas on SSIs and C-reactive protein (CRP) levels after cardiac surgery.

A single-center retrospective, propensity score-matched analysis.

A university hospital.

In total, 295 patients who underwent cardiovascular surgery with cardiopulmonary bypass were included.

Patients were divided into two groups: artificial pancreas (target blood glucose: 120-150 mg/dL) and intravenous insulin infusion (conventional insulin therapy, target blood glucose: <200 mg/dL).

The differences in the incidence of SSIs and CRP levels between the two groups were assessed. After 1:1 propensity score matching based on their covariates, 101 matched patients were selected from each group. The incidence of SSIs was reduced by 3%, 5% (conventional insulin therapy), and 2% (artificial pancreas), but the reduction was not statistically significant (p = 0.45). The postoperative maximum CRP level was significantly lower in the artificial pancreas group than in the conventional insulin therapy group, mean (standard deviation)14.53 (5.64) mg/dL v 16.57 (5.58) mg/dL; p = 0.01.

The artificial pancreas did not demonstrate a significant reduction in the incidence of SSIs. However, the artificial pancreas was safe and suppressed postoperative inflammation compared with conventional insulin therapy.

Diabetes is not uncommon in patients requiring cardiac surgery. These patients have a higher incidence of morbidity and mortality. Subsequently, diabetes represents a major medico-economic problem in both developed and developing countries. This study was designed to observe the association between glycemic control and outcome of patients after open heart surgery in adult population.

Data was collected retrospectively in all patients who underwent open cardiac surgery (coronary artery bypass grafting, valve, or bypass grafting with valve surgery) and survived 72 hours postoperatively and had diabetes. The study was conducted from January 2015 to December 2016.

Of the 129 patients included in the study, male dominated 101 (78.3%). Most frequent surgery was coronary artery bypass grafting (CABG) 123 (95.3%), CABG plus aortic valve replacement 4 (3.1%), and CABG plus mitral valve replacement 2 (1.6%). Considering diabetes, only 3 (2.3%) were on diet control, 112 (86.8%) on oral hypoglycemic agents (OHA), whereas 9 (7%) had control on both insulin and OHA. Only 5 (3.9%) had type I diabetes. The mean fasting blood sugar (FBS) was 154.58 g/dl, and the mean duration of diabetic mellitus was observed 12.32 years. Microvascular and macrovascular complications were 26/129 (20.16%) and 17/129 (13.17%), respectively. Total 75 (58.1%) patients did not require insulin and 54 (41.9%) were treated with insulin intraoperatively to keep the blood glucose level less than 200 g/dl. Cardiac arrhythmias were frequent in the insulin group (P < 0.05), which was also associated with increased stay in the cardiac intensive care unit.

Inadequate glycemic control during open cardiac surgery can possibly lead to increased perioperative morbidity and mortality and with decreased long-term survival and recurrent ischemic events. Therefore, aiming for blood glucose levels around 140 mg/dl appears reasonable. Further studies are required to define specific glucose ranges for a clearer definition of recommended blood glucose goals in postoperative cardiac patients for the best outcomes in patients with diabetes mellitus.

To determine if treatment with sitagliptin, a dipeptidyl peptidase-4 inhibitor, can prevent stress hyperglycemia in patients without diabetes undergoing coronary artery bypass graft (CABG) surgery.

We conducted a pilot, double-blinded, placebo-controlled randomized trial in adults (18-80 years) without history of diabetes. Participants received sitagliptin or placebo once daily, starting the day prior to surgery and continued for up to 10 days. Primary outcome was differences in the frequency of stress hyperglycemia (blood glucose (BG) >180 mg/dL) after surgery among groups.

We randomized 32 participants to receive sitagliptin and 28 to placebo (mean age 64±10 years and HbA1c: 5.6%±0.5%). Treatment with sitagliptin resulted in lower BG levels prior to surgery (101±mg/dL vs 107±13 mg/dL, p=0.01); however, there were no differences in the mean BG concentration, proportion of patients who developed stress hyperglycemia (21% vs 22%, p>0.99), length of hospital stay, rate of perioperative complications and need for insulin therapy in the intensive care unit or during the hospital stay.

The use of sitagliptin during the perioperative period did not prevent the development of stress hyperglycemia or need for insulin therapy in patients without diabetes undergoing CABG surgery.

We reviewed the strategies associated with hypoglycemia risk reduction among critically ill non-pregnant adult patients.

Hypoglycemia in the ICU has been associated with increased mortality in a number of studies. Insulin dosing and glucose monitoring rules, response to impending hypoglycemia, use of computerization, and attention to modifiable factors extrinsic to insulin algorithms may affect the risk for hypoglycemia. Recurring use of intravenous (IV) bolus doses of insulin in insulin-resistant cases may reduce reliance upon higher IV infusion rates. In order to reduce the risk for hypoglycemia in the ICU, caregivers should define responses to interruption of continuous carbohydrate exposure, incorporate transitioning strategies upon initiation and interruption of IV insulin, define modifications of antihyperglycemic therapy in the presence of worsening renal function or chronic kidney disease, and anticipate the effects traceable to other medications and substances. Institutional and system-wide quality improvement efforts should assign priority to hypoglycemia prevention.

High-value CCC is rapidly evolving to meet the demands of increased patient acuity and to incorporate advances in technology. The high-performing CCC system and culture should aim to learn quickly and continuously improve. CCC demands a proactive, interactive, precise, an expert team, and continuity.

This purpose of this prospective study was to use a continuous glucose monitoring (CGM) system to evaluate the suitability of our institution's glucose management protocol after cardiovascular surgery and to clarify the impact of glycemic variability on postoperative complications.

In all, 76 patients who underwent elective cardiovascular surgery and were monitored perioperatively using a CGM system were evaluated. Postoperative glucose management consisted of continuous intravenous insulin infusion (CIII) in the intensive care unit, and subcutaneous insulin injections (SQII) after oral food intake started. CIII and subcutaneous injections were initiated when blood glucose level exceeded 150 mg/dL. CGM data were used to analyze perioperative glycemic variability and association with postoperative complications.

Target glucose levels (71-180 mg/dL) were achieved during 97.1 ± 5.5% and 86.4 ± 19.0% of the continuous insulin infusion and subcutaneous injection periods, respectively. Major postoperative complications were surgical site infections, found in 6.6% of total patients, and atrial fibrillation, found in 44% of patients with off-pump coronary artery bypass grafting. High glycemic variability during SQII was associated with increased risk for both complications.

Data analysis revealed that our glucose management protocol during CIII was adequate. However, the management protocol during SQII required improvement.

Hypoglycemia is a known risk of intensive postoperative glucose control in patients undergoing cardiac operations. However, neither the consequences of hypoglycemia relative to hyperglycemia, nor the possible interaction effects, have been well described. We examined the effects of postoperative hypoglycemia, hyperglycemia, and their interaction on short-term morbidity and mortality.

Single-institution Society of Thoracic Surgeons (STS) database patient records from 2010 to 2014 were merged with clinical data, including blood glucose values measured in the intensive care unit (ICU). Exclusion criteria included fewer than three glucose measurements and absence of an STS predicted risk of morbidity or mortality score. Primary outcomes were operative mortality and composite major morbidity (permanent stroke, renal failure, prolonged ventilation, pneumonia, or myocardial infarction). Secondary outcomes included ICU and postoperative length of stay. Hypoglycemia was defined as below 70 mg/dL, and hyperglycemia as above 180 mg/dL. Simple and multivariable regression models were used to evaluate the outcomes.

A total of 2,285 patient records met the selection criteria for analysis. The mean postoperative glucose level was 140.8 ± 18.8 mg/dL. Overall, 21.4% of patients experienced a hypoglycemic episode (n = 488), and 1.05% (n = 24) had a severe hypoglycemic episode (<40 mg/dL). The unadjusted odds ratio (UOR) for operative mortality for patients with any hypoglycemic episode compared with those without was 5.47 (95% confidence interval [CI] 3.14 to 9.54), and the UOR for major morbidity was 4.66 (95% CI 3.55 to 6.11). After adjustment for predicted risk of morbidity or mortality and other significant covariates, the adjusted odds (AOR) of operative mortality were significant for patients with any hypoglycemia (AOR 4.88, 95% CI 2.67 to 8.92) and patients with both events (AOR 8.29, 95% CI 1.83 to 37.5) but not hyperglycemia alone (AOR 1.62, 95% CI 0.56 to 4.69). The AOR of major morbidity for patients with both hypoglycemic and hyperglycemic events was 14.3 (95% CI 6.50 to 31.4).

Postoperative hypoglycemia is associated with both mortality and major morbidity after cardiac operations. The combination of both hyperglycemia and hypoglycemia represents a substantial increase in risk. Although it remains unclear whether hypoglycemia is a cause, an early warning sign, or a result of adverse events, this study suggests that hypoglycemia may be an important event in the postoperative period after cardiac operations.

Recipients of liver transplantation (LT) may experience disturbance of blood glucose balance, which is aggravated by various exogenous factors. The Model for End-stage Liver Disease (MELD) score is an indicator of the severity of pretransplantation liver disease. In this study, we investigated the role of the MELD score in intraoperative changes in blood glucose in patients undergoing living donor LT (LDLT).

Perioperative data from 280 patients undergoing LDLT were reviewed, including glucose-related data. Intraoperatively, blood glucose levels were checked every hour, and the mean values at each phase of LDLT were calculated. Patients were divided into high and low MELD groups. An unpaired t-test and repeated measures analysis of variance (RMANOVA) were used in intergroup and intragroup comparisons of perioperative blood glucose.

The high MELD group consisted of 79 patients. Both the time sequential change during LDLT and the interaction between perioperative blood glucose and MELD score were significant (RMANOVA with multivariate adjustment; P < .05). Pretransplant blood glucose levels did not differ between the 2 groups, but the mean levels of blood glucose were lower and the incidence of hypoglycemia was higher in the high compared with the low MELD group during all phases of LDLT (P < .05).

Blood glucose levels progressively increased during LDLT with an interaction with the MELD score. Patients with a high MELD score had low blood glucose levels and a greater incidence of intraoperative hypoglycemia. MELD score is a useful determinant of intraoperative blood glucose levels in LDLT patients.

Basal insulin and DPP4 inhibitors are both possible options in patients with type 2 diabetes failing to oral drugs. The identification of clinical predictors of success with either one of the two approaches could be of help in personalizing therapy.

The retrospective study was performed on a consecutive series of patients with type 2 diabetes (n = 1,002) failing to at least one oral agent, who had been prescribed either basal insulin or DPP4 inhibitors in the previous 2 years, with a duration of follow-up of at least 6 months. Clinical predictors of success after 6 months from the beginning of second-line treatment were identified in the cohort.

Among patients receiving a prescription of basal insulin, the proportion of therapeutic success at 6 months was 26.5 %. At multivariate analysis, a higher age and BMI, and a lower duration of diabetes were associated with success, as well as treatment with acarbose; conversely, a history of ischemic heart disease was associated with failure. Prescription of DPP4 inhibitors produced a therapeutic success in 24.8 % of cases. At multivariate analysis, success was associated with a lower baseline HbA1c and duration of diabetes, and a higher BMI and comorbidity; in addition, a lower success rate was found in women after adjusting for other confounders.

The present data support the view that insulin treatment is preferable in patients with severe hyperglycemia, failing to one or more drugs, whereas DPP4 inhibitors appear to be more useful in those with comorbid conditions.

Abnormalities of blood glucose (BG) concentration (hyper- and hypoglycemia), now referred to with the cumulative term of dysglycemia, are frequently observed in critically ill patients, and significantly affect their clinical outcome. Acute kidney injury (AKI) may further complicate glycemic control in the same clinical setting. This narrative review was aimed at describing the pathogenesis of hyper- and hypoglycemia in the intensive care unit (ICU), with special regard to patients with AKI. Moreover, the complex relationship between AKI, glycemic control, hypoglycemic risk, and outcomes was analyzed.

An extensive literature search was performed, in order to identify the relevant studies describing the epidemiology, pathogenesis, treatment and outcome of hypo- and hyperglycemia in critically ill patients with AKI.

Patients with AKI are at increased risk of both hyper-and hypoglycemia. The available evidence does not support a protective effect on the kidney by glycemic control protocols employing Intensive Insulin Treatment (IIT), i.e. those aimed at maintaining normal BG concentrations (80-110 mg/dl). Recent guidelines taking into account the high risk for hypoglycemia associated with IIT protocols in critically ill patients, now suggest higher BG concentration targets (<180 mg/dl or 140-180 mg/dl) than those previously recommended (80-110 mg/dl). Notwithstanding the limited evidence available, it seems reasonable to extend these indications also to ICU patients with AKI.

Hyperglycemia is common in the post-cardiac surgery population and has been associated with increased mortality rates, surgical length of stay, and infection rates. Although hospitalized patients with diabetes are known to have more complications, recent studies in various hospital settings have reported worse outcomes in patients with stress hyperglycemia than in those with diabetes.

The primary objective of this study was to analyze 30- and 90-day mortality rates in post-cardiac surgery patients with stress hyperglycemia and diabetes who were managed to achieve similar moderate blood glucose goals using the University of Michigan Hospital (Ann Arbor, MI) insulin protocol between 2005 and 2008. The secondary outcomes were rates of postoperative complications, including hypoglycemia.

A standardized glucose management program was followed to treat all patients in the cardiac intensive care unit, with a blood glucose goal of 100 to 140 mg/dL. Data from 1973 patients with either diabetes or stress hyperglycemia were analyzed to identify associations between mean postoperative blood glucose levels and mortality, incidence of hypoglycemia, and complication rates.

Mortality rates did not differ between patients with diabetes and stress hyperglycemia (3.4 and 2.3%; P = 0.2). Rates of severe hypoglycemia were low (1%) for both groups and were not associated with an increase in mortality (P = 0.95). Other complication rates were similar between patients with diabetes and stress hyperglycemia.

Maintaining a blood glucose range between 100 to 140 mg/dL in post-cardiac surgery patients was associated with a low mortality rate, low risk of hypoglycemia, and with complications rates that were similar in patients with diabetes and stress hyperglycemia.

Glycemic control in the perioperative period decreases mortality and morbidity, but data are scarce with regard to the effects of glucose control approaches on survival. We assessed long-term survival in patients treated with 2 strategies of glucose control after first-time isolated coronary artery bypass graft.

In a previously published trial, patients were prospectively randomized to strict (90-120 mg/dL) or liberal (121-180 mg/dL) glucose control protocols. The aim of this study was to assess long-term data on survival and health-related quality of life based on the original prospective randomized study population.

No differences were found in cumulative survival between the strict (95.5%) and liberal (93.5%) target range groups (log-rank = 0.32, p = 0.57) over a mean follow-up of 40.0 ± 4.4 months. Physical health-related quality of life significantly improved in all patients from baseline to 6 months after surgery (F = 17.73, p < 0.001), and there were no differences in improvement of health-related quality of life between the 2 target range groups (F = 0.15, p = 0.70).

These results support our previous findings and indicate that a liberal glycemic control strategy after coronary artery bypass leads to survival rates and improvements in health-related quality of life that are similar to those achieved with a strict target range. In addition, the liberal strategy is superior in glucose control and target range management.

This study aimed to determine the safety and efficacy of intraoperative intensive glycaemic treatment with modified glucose-insulin-potassium solution by hyperinsulinemic normoglycaemic clamp in cardiopulmonary bypass surgery patients. We hypothesised that the treatment would reduce infection rates in this group of patients.

A prospective, randomised, double-blind trial was conducted in cardiopulmonary bypass surgery patients. A total of 199 adult patients (out of a planned 400) were randomly allocated to intensive or conventional treatment with target glucose levels of 4.4-8.3 mmol/l and < 13.8 mmol/l, respectively. The primary outcomes were clinical infection and cytokine levels, including interleukin (IL)-6 and IL-10. The secondary outcomes were morbidity and mortality.

The study was terminated early because of safety concerns (hypoglycaemia). The clinical post-operative infection rate was 17% in the intensive group and 13% in the conventional group (P = 0.53). The proportion of patients with hypoglycaemia was significantly higher in the intensive group (23%) compared with the conventional group (3%) (P < 0.001). Morbidity and mortality rates were similar for both groups. Anaesthetic duration > 2 h (vs. ≤ 2 h), pre-operative IL-6 level > 15 pg/ml (vs. ≤ 15 pg/ml) and post-operative IL-6 level 56-110 pg/ml (vs. ≤ 55 pg/ml) were independent predictors for post-operative infection.

Intraoperative intensive glycaemic treatment significantly increased the risk of hypoglycaemia, but its effect on post-operative infection by clinical assessment could not be determined. Anaesthetic duration, pre-operative and post-operative IL-6 levels can independently predict post-operative infection.

To describe the use of an adverse event detection system to identify, characterize, and categorize preventable versus nonpreventable hypoglycemia AEs in PICUs and cardiac ICUs.

Retrospective observational study.

PICU and cardiac ICU of a tertiary pediatric hospital.

All hypoglycemia triggers generated over a 3-year period.

All hypoglycemia triggers generated via an electronic health record-driven surveillance system were investigated to determine if they represented a true adverse event and if that event was preventable or nonpreventable. Clinical and demographic variables were analyzed to identify characteristics of patients who developed a preventable or nonpreventable hypoglycemia adverse event.

There were 197 hypoglycemia adverse events in 90 patients. Thirty percent of the adverse events in the PICU and 36% of the adverse events in the cardiac ICU were characterized as preventable. Of the adverse events, 118 (59.9%) necessitated an intravenous dextrose bolus. No adverse events were associated with reporting of symptoms of hypoglycemia including apnea, altered mental status, or seizures. Events were more likely to be preventable (p < 0.001) if the patient was receiving only parenteral sources of nutrition (intravenous fluids or total parenteral nutrition). Controlling for weekends and holidays, adverse events associated with sole parenteral nutrition source had an increased odds ratio of 9.5 (95% confidence interval: 2.8-31.9) of being preventable. Stratifying by ICU, cardiac ICU events occurring on a weekend or holiday were more likely to be preventable (p = 0.001). Stratifying by unit and controlling for parenteral nutrition source, adverse events in the cardiac ICU occurring on weekends or holidays had an increased odds ratio of 11.6 (95% confidence interval: 2.7-50.2) of being preventable.

Preventable hypoglycemia adverse events are associated with patients receiving sole parenteral sources of nutrition in both the PICU and cardiac ICU. In the cardiac ICU, there is an association between weekend and holiday time periods and the development of preventable hypoglycemia adverse events.

Continuous glucose monitoring could be helpful for glucose regulation in critically ill patients; however, its accuracy is uncertain and might be influenced by microcirculation. We investigated the microcirculation and its relation to the accuracy of 2 continuous glucose monitoring devices in patients after cardiac surgery.

The present prospective, observational study included 60 patients admitted for cardiac surgery. Two continuous glucose monitoring devices (Guardian Real-Time and FreeStyle Navigator) were placed before surgery. The relative absolute deviation between continuous glucose monitoring and the arterial reference glucose was calculated to assess the accuracy. Microcirculation was measured using the microvascular flow index, perfused vessel density, and proportion of perfused vessels using sublingual sidestream dark-field imaging, and tissue oxygenation using near-infrared spectroscopy. The associations were assessed using a linear mixed-effects model for repeated measures.

The median relative absolute deviation of the Navigator was 11% (interquartile range, 8%-16%) and of the Guardian was 14% (interquartile range, 11%-18%; P = .05). Tissue oxygenation significantly increased during the intensive care unit admission (maximum 91.2% [3.9] after 6 hours) and decreased thereafter, stabilizing after 20 hours. A decrease in perfused vessel density accompanied the increase in tissue oxygenation. Microcirculatory variables were not associated with sensor accuracy. A lower peripheral temperature (Navigator, b = -0.008, P = .003; Guardian, b = -0.006, P = .048), and for the Navigator, also a higher Acute Physiology and Chronic Health Evaluation IV predicted mortality (b = 0.017, P < .001) and age (b = 0.002, P = .037) were associated with decreased sensor accuracy.

The results of the present study have shown acceptable accuracy for both sensors in patients after cardiac surgery. The microcirculation was impaired to a limited extent compared with that in patients with sepsis and healthy controls. This impairment was not related to sensor accuracy but the peripheral temperature for both sensors and patient age and Acute Physiology and Chronic Health Evaluation IV predicted mortality for the Navigator were.

Hyperglycemia is a frequent occurrence in adult hospitalized patients who receive nutrition support. Both hyperglycemia and hypoglycemia (resulting from attempts to correct hyperglycemia) are associated with adverse outcomes in diabetic as well as nondiabetic patients. This American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Clinical Guideline summarizes the most current evidence and provides guidelines for the desired blood glucose goal range in hospitalized patients receiving nutrition support, the definition of hypoglycemia, and the rationale for use of diabetes-specific enteral formulas in hospitalized patients.

A systematic review of the best available evidence to answer a series of questions regarding glucose control in adults receiving parenteral or enteral nutrition was undertaken and evaluated using concepts adopted from the Grading of Recommendations, Assessment, Development and Evaluation working group. A consensus process was used to develop the clinical guideline recommendations prior to external and internal review and approval by the A.S.P.E.N. Board of Directors.

1. What is the desired blood glucose goal range in adult hospitalized patients receiving nutrition support? We recommend a target blood glucose goal range of 140-180 mg/dL (7.8-10 mmol/L). (Strong) 2. How is hypoglycemia defined in adult hospitalized patients receiving nutrition support? We recommend that hypoglycemia be defined as a blood glucose concentration of <70 mg/dL (<3.9 mmol/L). (Strong) 3. Should diabetes-specific enteral formulas be used for adult hospitalized patients with hyperglycemia? We cannot make a recommendation at this time.