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Navaratnarajah M, Al-Zubaidi FI, Kattach H, Barlow C, Tsang G, Ohri S. Effect of glycaemic control on coronary artery bypass grafting outcomes - a United Kingdom centre experience. JRSM Cardiovasc Dis 2025; 14:20480040251325918. [PMID: 40110177 PMCID: PMC11921007 DOI: 10.1177/20480040251325918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2024] [Revised: 01/01/2025] [Accepted: 01/18/2025] [Indexed: 03/22/2025] Open
Abstract
Objectives Assess whether pre-operative HbA1c demonstrates positive predictive value relating to outcomes following coronary artery bypass grafting (CABG) in diabetes patients. Methods Retrospective analysis of outcomes and mortality following CABG; examining the effects of diabetes and HbA1c. Results Post-operative length of stay (LOS) was prolonged in elective and urgent diabetes patients;7.3 ± 2.1 versus 6.4 ± 1.6 days and 9.0 ± 1.9 versus 7.6 ± 1.8 days, respectively; (p < 0.001). Sternal and leg wound infection rate was higher in elective diabetes group compared to no-diabetes group; 7% versus 3% (p < 0.01) and 3% versus 1% (p < 0.05), respectively. Pneumonia rate increased in elective and urgent diabetes patients; 19% versus 8% (p < 0.001) and 21% versus 15% (p < 0.05), respectively. Diabetes increased new-onset atrial fibrillation; 26% versus 14% (p < 0.001), and doubled blood transfusion rate; 28% versus 14% (p < 0.001) in elective patients; with similar findings in urgent patients. Long-term mortality was higher with diabetes compared to no-diabetes in elective patients; 15% versus 5%, (p < 0.001), and urgent patients; 10% versus 2%, (p < 0.001). Elevated HbA1c showed significant positive predictive value relating to long-term mortality, and rates of pneumonia, blood transfusion, wound infection in elective and urgent diabetes patients; (p < 0.001). Elevated HbA1c was an independent predictor of long-term mortality (hazard ratio:5.27, 95% CI:2.53-10.99; p < 0.001), superficial wound infection (odds ratio (OR):18.23, p < 0.001) and delayed discharge (OR:8.15, p < 0.001). Conclusions Diabetes patients have prolonged LOS and increased morbidity following CABG. HbA1c is predictive of morbidity and long-term mortality in diabetes patients, and pre-operative HbA1c screening is justified in all surgical patients.
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Affiliation(s)
| | | | - Hassan Kattach
- Department of Cardiac Surgery, Southampton University Hospital, Southampton, UK
| | - Clifford Barlow
- Department of Cardiac Surgery, Southampton University Hospital, Southampton, UK
| | - Geoff Tsang
- Department of Cardiac Surgery, Southampton University Hospital, Southampton, UK
| | - Sunil Ohri
- Department of Cardiac Surgery, Southampton University Hospital, Southampton, UK
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Authors/Task Force Members:, Jeppsson A, (Co-Chairperson) (Sweden), Rocca B, (Co-Chairperson) (Italy), Hansson EC, (Sweden), Gudbjartsson T, (Iceland), James S, (Sweden), Kaski JC, (United Kingdom), Landmesser U, (Germany), Landoni G, (Italy), Magro P, (Portugal), Pan E, (Finland), Ravn HB, (Denmark), Sandner S, (Austria), Sandoval E, (Spain), Uva MS, (Portugal), Milojevic M, (Serbia), EACTS Scientific Document Group
. 2024 EACTS Guidelines on perioperative medication in adult cardiac surgery. Eur J Cardiothorac Surg 2024; 67:ezae355. [PMID: 39385505 DOI: 10.1093/ejcts/ezae355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Collaborators] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 08/14/2024] [Accepted: 09/26/2024] [Indexed: 10/12/2024] Open
Affiliation(s)
| | - Anders Jeppsson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Bianca Rocca
- Department of Medicine and Surgery, LUM University, Casamassima, Bari, Italy
- Department of Safety and Bioethics, Catholic University School of Medicine, Rome, Italy
| | | | - Emma C Hansson
- Department of Cardiothoracic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Landspitali University Hospital, Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | | | - Stefan James
- Department of Medical Sciences, Uppsala University Uppsala Sweden
| | | | - Juan Carlos Kaski
- Molecular and Clinical Sciences Research Institute, St. George's University of London, UK
| | | | - Ulf Landmesser
- Department of Cardiology, Angiology and Intensive Care Medicine; Deutsches Herzzentrum Charité, Campus Benjamin Franklin, Berlin, Germany
- Charité-University Medicine Berlin, Corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité Berlin, Universitätsmedizin Berlin, Germany
| | | | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | | | - Pedro Magro
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
| | | | - Emily Pan
- Department of Surgery, Central Finland Central Hospital, Jyväskylä, Finland
| | | | - Hanne Berg Ravn
- Department of Anaesthesia, Odense University Hospital, Institute of Clinical Medicine, University of Southern, Denmark
| | | | - Sigrid Sandner
- Department of Cardiac Surgery, Medical University Vienna, Vienna, Austria
| | | | - Elena Sandoval
- Department of Cardiovascular Surgery, Hospital Clinic, Barcelona, Spain
| | | | - Miguel Sousa Uva
- Department of Cardiac Surgery, Hospital Santa Cruz, Carnaxide, Portugal
- Cardiovascular Research Centre, Department of Surgery and Physiology, Faculty of Medicine-University of Porto, Porto, Portugal
| | | | - Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia
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Collaborators
Matthias Siepe, Vesa Anttila, Lauren Barron, Dobromir Dobrev, Fabio Guarracino, Ziad Hijazi, Andreas Koster, Tomislav Kostic, Vladimir Lomivorotov, Vojislava Neskovic, Bjorn Redfors, Lars Peter Riber, Andrea Székely, Juan Tamargo, Theis Tönnessen, Alicja Zientara,
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Luthra S, Viola L, Navaratnarajah M, Thirukumaran D, Velissaris T. Glycated Haemoglobin (HbA 1C) in Cardiac Surgery: A Narrative Review. J Clin Med 2024; 14:23. [PMID: 39797106 PMCID: PMC11721050 DOI: 10.3390/jcm14010023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Revised: 12/21/2024] [Accepted: 12/23/2024] [Indexed: 01/13/2025] Open
Abstract
Background: Perioperative dysglycaemia in cardiac surgery is associated with poor outcomes. Glycaemic variability rather than glucose levels is a predictor of the length of an ICU stay, a rise in creatinine and acute kidney injury after cardiac surgery. Glycated haemoglobin (HbA1C) values correspond closely to average blood glucose levels and cut-off values can be used to define a diabetic and pre-diabetic status. These have been correlated with perioperative events. Methods: In this narrative review, MEDLINE (via PubMed) and the Cochrane Library were used to search for the effects of different preoperative HbA1C levels on the postoperative outcomes after cardiac surgery. HbA1C values correspond closely with average blood glucose levels and cut-off values can be used to define a diabetic and pre-diabetic status; these have been correlated with perioperative events. This narrative review discusses the role of HbA1C in cardiac surgery. Discussion: The scientific data show controversial results: some systematic reviews and randomised control trials demonstrated that a high level of HbA1C seems to be an indicator for postoperative complications in cardiac surgery; other studies dissented and reported that mortality and morbidity cannot be directly attributed to HbA1c levels. Conclusions: The scientific community seems to be in general agreement that high levels of HbA1C are prognostic markers of adverse outcomes post cardiac surgery, but it has also been proved that there could be multiple underlying factors contributing to them.
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Affiliation(s)
- Suvitesh Luthra
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
- Academic Unit of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton SO17 1BJ, UK
| | - Laura Viola
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Manoraj Navaratnarajah
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - David Thirukumaran
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
| | - Theodore Velissaris
- Wessex Cardiothoracic Centre, Division of Cardiac Surgery, University Hospital Southampton NHS Foundation Trust, Southampton SO16 6YD, UK
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Quero G, Laterza V, Di Giuseppe G, Lucinato C, Massimiani G, Nista EC, Sionne F, Biffoni B, Brunetti M, Rosa F, De Sio D, Ciccarelli G, Fiorillo C, Menghi R, Langellotti L, Soldovieri L, Gasbarrini A, Pontecorvi A, Giaccari A, Alfieri S, Tondolo V, Mezza T. A single-center prospective analysis of the impact of glucose metabolism on pancreatic fistula onset after pancreaticoduodenectomy for periampullary tumors. Am J Surg 2024; 238:115987. [PMID: 39342881 DOI: 10.1016/j.amjsurg.2024.115987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2024] [Revised: 09/05/2024] [Accepted: 09/23/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Glucose impairment notably affects the postoperative course of gastrointestinal surgeries. However, evidence on its impact on clinically relevant pancreatic fistulas(CR-POPFs) after pancreaticoduodenectomy(PD) is lacking. This study evaluates if and how preoperative glucose metabolism affects the development of CR-POPF after PD. METHODS One hundred and ten consecutive PDs were included. Patients underwent preoperative metabolic profiling using the Oral Glucose Tolerance Test(OGTT) and the hyperinsulinemic euglycemic clamp procedure. Accordingly, patients were categorized as normal glucose tolerant (NGT), impaired glucose tolerant (IGT), diabetic (DM), and longstanding-DM. Receiver operating characteristics(ROC) analyses were performed to determine the values of metabolic features in prediction of CR-POPF. RESULTS The CR-POPF rate was 36.3 %(40 patients). NGT patients had a higher CR-POPF rate (51.7 %) compared to IGT(45.2 %), DM (15.8 %), and longstanding-DM (25.8 %) (p = 0.03). CR-POPF patients had lower median fasting glucose levels (p = 0.01) and higher c-peptide values at all OGTT time points (p < 0.05). Fasting glucose and c-peptide levels had high diagnostic accuracy for CR-POPF (AUC>0.8) and were independent risk factors for CR-POPF (OR: 24.7[95%CI: 3.7-165.3] for fasting glucose; OR: 19.9[95%CI: 3.2-125.3] for c-peptide). CONCLUSION Normoglycemia and normal beta cell function may be risk factors for CR-POPF after PD. Fasting glucose and c-peptide levels effectively predicted CR-POPF development following PD. CLINICALTRIALS GOV IDENTIFIER NCT02175459.
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Affiliation(s)
- Giuseppe Quero
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vito Laterza
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Gianfranco Di Giuseppe
- Endocrinologia e Diabetologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Chiara Lucinato
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Giuseppe Massimiani
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Enrico Celestino Nista
- Pancreas Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Roma, Italy
| | - Francesco Sionne
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Beatrice Biffoni
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Michela Brunetti
- Endocrinologia e Diabetologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Fausto Rosa
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Davide De Sio
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Gea Ciccarelli
- Endocrinologia e Diabetologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Claudio Fiorillo
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Roberta Menghi
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Lodovica Langellotti
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Laura Soldovieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy
| | - Antonio Gasbarrini
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy; Pancreas Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Roma, Italy
| | - Alfredo Pontecorvi
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy; Endocrinologia e Diabetologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Andrea Giaccari
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy; Endocrinologia e Diabetologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Sergio Alfieri
- Gemelli Pancreatic Center, CRMPG (Advanced Pancreatic Research Center) Fondazione Policlinico Universitario "Agostino Gemelli" IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy; Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy
| | - Vincenzo Tondolo
- General Surgery Unit, Fatebenefratelli Isola Tiberina - Gemelli Isola, Via di Ponte Quattro Capi, 39, 00186, Roma, Italy
| | - Teresa Mezza
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Roma, Italy; Pancreas Unit, CEMAD Centro Malattie dell'Apparato Digerente, Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario Gemelli IRCCS, Roma, Italy.
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Câmara de Souza AB, Toyoshima MTK, Cukier P, Lottenberg SA, Bolta PMP, Lima EG, Serrano Júnior CV, Nery M. Electronic Glycemic Management System Improved Glycemic Control and Reduced Complications in Patients With Diabetes Undergoing Coronary Artery Bypass Surgery: A Randomized Controlled Trial. J Diabetes Sci Technol 2024:19322968241268352. [PMID: 39096188 PMCID: PMC11571349 DOI: 10.1177/19322968241268352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/05/2024]
Abstract
BACKGROUND In-hospital hyperglycemia poses significant risks for patients with diabetes mellitus undergoing coronary artery bypass graft (CABG) surgery. Electronic glycemic management systems (eGMSs) like InsulinAPP offer promise in standardizing and improving glycemic control (GC) in these settings. This study evaluated the efficacy of the InsulinAPP protocol in optimizing GC and reducing adverse outcomes post-CABG. METHODS This prospective, randomized, open-label study was conducted with 100 adult type 2 diabetes mellitus (T2DM) patients post-CABG surgery, who were randomized into two groups: conventional care (gCONV) and eGMS protocol (gAPP). The gAPP used InsulinAPP for insulin therapy management, whereas the gCONV received standard clinical care. The primary outcome was a composite of hospital-acquired infections, renal function deterioration, and symptomatic atrial arrhythmia. Secondary outcomes included GC, hypoglycemia incidence, hospital stay length, and costs. RESULTS The gAPP achieved lower mean glucose levels (167.2 ± 42.5 mg/dL vs 188.7 ± 54.4 mg/dL; P = .040) and fewer patients-day with BG above 180 mg/dL (51.3% vs 74.8%, P = .011). The gAPP received an insulin regimen that included more prandial bolus and correction insulin (either bolus-correction or basal-bolus regimens) than the gCONV (90.3% vs 16.7%). The primary composite outcome occurred in 16% of gAPP patients compared with 58% in gCONV (P < .010). Hypoglycemia incidence was lower in the gAPP (4% vs 16%, P = .046). The gAPP protocol also resulted in shorter hospital stays and reduced costs. CONCLUSIONS The InsulinAPP protocol effectively optimizes GC and reduces adverse outcomes in T2DM patients' post-CABG surgery, offering a cost-effective solution for inpatient diabetes management.
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Affiliation(s)
- Alexandre Barbosa Câmara de Souza
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcos Tadashi Kakitani Toyoshima
- Oncoendocrinology Service, Instituto do Câncer do Estado de São Paulo Octávio Frias de Oliveira, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Priscilla Cukier
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Simão Augusto Lottenberg
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Paula Mathias Paulino Bolta
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Eduardo Gomes Lima
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carlos Vicente Serrano Júnior
- Instituto do Coração, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcia Nery
- Department of Endocrinology and Metabolism, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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Deer TR, Russo MA, Sayed D, Pope JE, Grider JS, Hagedorn JM, Falowski SM, Al-Kaisy A, Slavin KV, Li S, Poree LR, Eldabe S, Meier K, Lamer TJ, Pilitsis JG, De Andrés J, Perruchoud C, Carayannopoulos AG, Moeschler SM, Hadanny A, Lee E, Varshney VP, Desai MJ, Pahapill P, Osborn J, Bojanic S, Antony A, Piedimonte F, Hayek SM, Levy RM. The Neurostimulation Appropriateness Consensus Committee (NACC)®: Recommendations for the Mitigation of Complications of Neurostimulation. Neuromodulation 2024; 27:977-1007. [PMID: 38878054 DOI: 10.1016/j.neurom.2024.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 03/27/2024] [Accepted: 04/08/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION The International Neuromodulation Society convened a multispecialty group of physicians based on expertise and international representation to establish evidence-based guidance on the mitigation of neuromodulation complications. This Neurostimulation Appropriateness Consensus Committee (NACC)® project intends to update evidence-based guidance and offer expert opinion that will improve efficacy and safety. MATERIALS AND METHODS Authors were chosen on the basis of their clinical expertise, familiarity with the peer-reviewed literature, research productivity, and contributions to the neuromodulation literature. Section leaders supervised literature searches of MEDLINE, BioMed Central, Current Contents Connect, Embase, International Pharmaceutical Abstracts, Web of Science, Google Scholar, and PubMed from 2017 (when NACC last published guidelines) to October 2023. Identified studies were graded using the United States Preventive Services Task Force criteria for evidence and certainty of net benefit. Recommendations are based on the strength of evidence or consensus when evidence was scant. RESULTS The NACC examined the published literature and established evidence- and consensus-based recommendations to guide best practices. Additional guidance will occur as new evidence is developed in future iterations of this process. CONCLUSIONS The NACC recommends best practices regarding the mitigation of complications associated with neurostimulation to improve safety and efficacy. The evidence- and consensus-based recommendations should be used as a guide to assist decision-making when clinically appropriate.
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Affiliation(s)
- Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA.
| | | | - Dawood Sayed
- The University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Jay S Grider
- UKHealthCare Pain Services, Department of Anesthesiology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Jonathan M Hagedorn
- Department of Anesthesiology and Perioperative Medicine, Division of Pain Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Adnan Al-Kaisy
- Guy's and St. Thomas National Health Service (NHS) Foundation Trust, The Walton Centre for Neurology and Neurosurgery, Liverpool, UK
| | - Konstantin V Slavin
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA; Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Sean Li
- National Spine & Pain Centers, Shrewsbury, NJ, USA
| | - Lawrence R Poree
- Department of Anesthesia and Perioperative Care, University of California at San Francisco, San Francisco, CA, USA
| | - Sam Eldabe
- The James Cook University Hospital, Middlesbrough, UK
| | - Kaare Meier
- Department of Anesthesiology (OPINord), Aarhus University Hospital, Aarhus, Arhus, Denmark; Department of Neurosurgery (Afd. NK), Aarhus University Hospital, Aarhus, Arhus, Denmark
| | | | | | - Jose De Andrés
- Valencia School of Medicine, Anesthesia Critical Care and Pain Management Department, General University Hospital, Valencia, Spain
| | | | - Alexios G Carayannopoulos
- Department of Physical Medicine and Rehabilitation and Comprehensive Spine Center, Rhode Island Hospital, Providence, RI, USA; Brown University Warren Alpert Medical School (Neurosurgery), Providence, RI, USA
| | - Susan M Moeschler
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN, USA
| | - Amir Hadanny
- Department of Neurosurgery, Albany Medical College, Albany, NY, USA
| | - Eric Lee
- Mililani Pain Center, Mililani, HI, USA
| | - Vishal P Varshney
- Anesthesiology and Pain Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Mehul J Desai
- International Spine, Pain & Performance Center, Virginia Hospital Center, Monument Research Institute, George Washington University School of Medicine, Arlington, VA, USA
| | - Peter Pahapill
- Functional Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - J Osborn
- St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Stana Bojanic
- Department of Neurosurgery, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Ajay Antony
- The Orthopaedic Institute, Gainesville, FL, USA
| | - Fabian Piedimonte
- School of Medicine, University of Buenos Aires, Buenos Aires, Argentina
| | - Salim M Hayek
- Case Western Reserve University, University Hospitals of Cleveland, Cleveland, OH, USA
| | - Robert M Levy
- Neurosurgical Services, Clinical Research, Anesthesia Pain Care Consultants, Tamarac, FL, USA
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7
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Alshair FM, Baghaffar AH, Fatani MA, Alqahtani AK, Al Assiri AK, Alsulymani BM, Sanedi AM, Bamousa SM. Glycosylated Hemoglobin (HbA1C) as a Predictor of Early Postoperative Outcomes After Coronary Artery Bypass Grafting: A Single-Center Observational Study. Cureus 2024; 16:e65567. [PMID: 39192939 PMCID: PMC11348824 DOI: 10.7759/cureus.65567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2024] [Indexed: 08/29/2024] Open
Abstract
Background Diabetic patients present a majority of patients undergoing surgical revascularization. Hyperglycemia is associated with increased adverse events. Glycosylated hemoglobin (HbA1c) is an effective biological marker for long-term glycemic control. As a result, there is an increased trend in its use as a predictor of adverse outcomes. This study aims to assess the impact of elevated HbA1c on the occurrence of postoperative complications after coronary artery bypass grafting (CABG). Methods We conducted a retrospective review of medical records from January 2015 to December 2022 for adult patients who underwent isolated CABG. We assessed patient demographics, medication, laboratory results, HbA1c results, and clinical data. The separate statistical models were designed to assess the predictors for the development of postoperative complications. Results This retrospective single-center study was conducted on 289 consecutive adult patients who underwent on-pump CABG. Patient demographics showed that uncontrolled HbA1c was more in females (p=0.022), and hemodialysis patients (p=0.018). Across different levels of HbA1C, there were no significant differences in terms of the incidence of postoperative complications (p=0.788 for infection, p=0.372 for the need for blood transfusion, p=0.721 for heart failure, p=0.692 for arrhythmia, and p=0.712 for death). HbA1c had no predictive value for postoperative complications as indicated by multivariate and stepwise analysis in a separate model for each complication with receiver operator characteristics curves of each model showing similar strength of both multivariate and stepwise models. Conclusions In our data, elevated preoperative HbA1c had no predictive value for early complications and intermediate postoperative outcomes. We recommend that surgery should proceed without delay, even if patients have elevated HbA1C levels. As for elective patients with low-risk features and anatomy, optimizing preoperative glycemic control can be considered.
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Affiliation(s)
- Fahad M Alshair
- Cardiac Surgery, King Abdulaziz University Hospital, Jeddah, SAU
| | - Abdullah H Baghaffar
- Medicine, King Abdulaziz University, Jeddah, SAU
- Cardiac Surgery, King Abdulaziz University Hospital, Jeddah, SAU
| | - Mazin A Fatani
- Medicine, King Abdulaziz University, Jeddah, SAU
- Cardiac Surgery, King Abdulaziz University Hospital, Jeddah, SAU
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Rodriguez-Quintero JH, Skendelas JP, Phan DK, Fisher MC, DeRose JJ, Slipczuk L, Forest SJ. Elevated glycosylated hemoglobin levels are associated with severe acute kidney injury following coronary artery bypass surgery. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2024; 62:50-57. [PMID: 38030457 DOI: 10.1016/j.carrev.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/15/2023] [Accepted: 11/20/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND Diabetic patients are at increased risk of acute kidney injury (AKI) following surgery. The significance of uncontrolled diabetes on kidney function after coronary artery bypass grafting (CABG) remains controversial. Our aim was to study the association between pre-operative hemoglobin A1c (HbA1c) and severe cardiac surgery-associated AKI (CSA-AKI) following CABG. METHODS A single-center, retrospective cohort study including patients who underwent isolated CABG from 2010 to 2018 was performed. Patients were grouped into pre-operative HbA1c of <6.5 %, 6.5-8.5 %, and ≥8.5 %. Postoperative serum creatinine levels were queried for up to 30 days, and the 30-day risk of severe AKI was compared among groups. Multivariable logistic regression was used to study factors associated with severe CSA-AKI and the association of severe CSA-AKI with postoperative outcomes. Cox regression was used to study the association between severe CSA-AKI and all-cause mortality from the time of surgery to the last follow-up or death. RESULTS A total of 2424 patients met the inclusion criteria. Patients were primarily male (70.5 %), with a median age of 64 years (IQR 57-71). Median bypass and cross-clamp times were 95 (IQR 78-116) and 78 min (IQR 63-95). Severe CSA-AKI occurred within 30 days in 5.7 %, 6.7 %, and 9.1 % of patients with pre-op HbA1c of <6.5 %, 6.5-8.5 %, and ≥8.5 %, respectively. After adjusting for covariates, HbA1c >8.5 %, was independently associated with severe CSA-AKI 30 days after CABG (aOR 1.59, 95%CI 1.06-2.40). In addition, severe CSA-AKI was associated with increased 30- (aOR 15.83,95%CI 7.94-31.56) and 90- day mortality (aOR 9.54, 95%CI 5.46-16.67), prolonged length of stay (aOR 3.46,95%CI 2.41-4.96) and unplanned 30-day readmission (aOR 2.64, 95%CI 1.77-3.94). Lastly, severe CSA-AKI was associated with increased all-cause mortality (aHR 3.19, 95%CI 2.43-4.17). CONCLUSION Elevated preoperative HbA1c (≥8.5 %) was independently associated with an increased 30-day risk of severe CSA-AKI, which is a consistent predictor of adverse outcomes after CABG. Delaying surgery to achieve optimal glycemic control in an elective setting may be reasonable.
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Affiliation(s)
- Jorge Humberto Rodriguez-Quintero
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Cardiovascular and Thoracic Surgery, 3400 Bainbridge, Bronx, NY 10467, United States of America
| | - John P Skendelas
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Cardiovascular and Thoracic Surgery, 3400 Bainbridge, Bronx, NY 10467, United States of America
| | - Donna K Phan
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Cardiovascular and Thoracic Surgery, 3400 Bainbridge, Bronx, NY 10467, United States of America
| | - Molly C Fisher
- Montefiore Medical Center/Albert Einstein College of Medicine, Division of Nephrology, 3400 Bainbridge, Bronx, NY 10467, United States of America
| | - Joseph J DeRose
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Cardiovascular and Thoracic Surgery, 3400 Bainbridge, Bronx, NY 10467, United States of America
| | - Leandro Slipczuk
- Montefiore Medical Center/Albert Einstein College of Medicine, Division of Cardiology, 3400 Bainbridge, Bronx, NY 10467, United States of America
| | - Stephen J Forest
- Montefiore Medical Center/Albert Einstein College of Medicine, Department of Cardiovascular and Thoracic Surgery, 3400 Bainbridge, Bronx, NY 10467, United States of America.
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9
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Zhao W, Xie J, Zheng Z, Zhou H, Ooi OC, Luo H. Association between HbA1c and deep sternal wound infection after coronary artery bypass: a systematic review and meta-analysis. J Cardiothorac Surg 2024; 19:51. [PMID: 38311780 PMCID: PMC10840199 DOI: 10.1186/s13019-024-02549-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 01/28/2024] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Deep sternal wound infection (DSWI) constitutes a serious complication after coronary artery bypass grafting (CABG) surgery. The aim of this study is to evaluate the dose-response relationship between glycated hemoglobin (HbA1c) level and the risk of DSWI after CABG. METHODS PubMed, Scopus, and Cochrane Library databases were searched to identify potentially relevant articles. According to rigorous inclusion and exclusion criteria, fourteen studies including 15,570 patients were enrolled in our meta-analysis. Odds ratio (OR) with 95% confidence intervals (CIs) was used as the summary statistic. The robust-error meta-regression model was used to synthesize the dose-response relationship. RESULTS Our meta-analysis shows that among patients undergoing CABG, preoperative elevated HbA1c was associated with the risk of developing DSWI (OR = 2.67, 95% CI 2.00-3.58) but with low prognostic accuracy (diagnostic OR = 2.70, 95% CI 1.96-3.73; area under the curve = 0.66, 95% CI 0.62-0.70) for predicting postoperative DSWI. Subgroup analyses showed the relationship became nonsignificant in patients without diabetes and studies adopting lower HbA1c thresholds. Dose-response analysis showed a significant nonlinear (p = 0.03) relationship between HbA1c and DSWI, with a significantly increased risk of DSWI when HbA1c was > 5.7%. CONCLUSIONS An elevated HbA1c level of > 5.7% was related to a higher risk of developing DSWI after CABG, and the risk increased as the HbA1c level grew. The association between HbA1c and DSWI was nonsignificant among nondiabetic patients while significant among diabetic patients.
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Affiliation(s)
- Wenyu Zhao
- School of Management, University of Science and Technology of China, Hefei, China
| | - Jingui Xie
- School of Management, Technical University of Munich, Heilbronn, Germany
- Munich Data Science Institute, Technical University of Munich, Munich, Germany
| | - Zhichao Zheng
- Lee Kong Chian School of Business, Singapore Management University, Singapore, Singapore
| | - Han Zhou
- School of Management, Technical University of Munich, Heilbronn, Germany.
| | - Oon Cheong Ooi
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, Singapore, Singapore
| | - Haidong Luo
- Department of Cardiac, Thoracic & Vascular Surgery, National University Hospital, Singapore, Singapore
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El-Andari R, Fialka NM, Kang J, Bozso SJ, Nagendran J, Nagendran J. The Use of Sodium-Glucose Cotransporter-2 Inhibitors in Coronary Revascularization: Where Are We Now? A Systematic Review. Am J Cardiovasc Drugs 2024; 24:55-69. [PMID: 37975979 DOI: 10.1007/s40256-023-00618-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Diabetes and coronary artery disease are two common conditions that often co-exist. In recent years, sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been demonstrated to provide significant cardioprotective benefits, especially among patients with heart failure. OBJECTIVE In this systematic review, we look to identify the outcomes SGLT2i use in patients undergoing coronary revascularization. METHODS Pubmed and Embase were systematically searched for articles describing the outcomes of patients taking SGLT2i and undergoing coronary revascularization. 834 titles and abstracts were screened, 42 full texts were reviewed, and 18 studies were found to meet the inclusion criteria and were included in this review. RESULTS For patients undergoing coronary artery bypass grafting and percutaneous coronary intervention, the use of SGLT2i resulted in reductions in mortality, hospitalization for heart failure, and improved blood glucose; however, these benefits were not consistently reported in the literature. Reduced inflammatory markers and positive cardiac remodeling were identified among patients taking SGLT2i. CONCLUSIONS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been demonstrated to provide benefits for patients with heart failure along with a host of positive modulatory effects on the cardiovascular system, including reductions in inflammatory properties, hypertension, and left ventricular volume load. Given the clear benefit provided by SGLT2i to patients with cardiovascular disease and a host of positive properties that are expected to be protective for patients with ischemic heart disease, future investigation into the relationship between SGLT2i and outcomes for patients undergoing revascularization is imperative.
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Affiliation(s)
- Ryaan El-Andari
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, 8602-112 Street, Edmonton, AB, T6G 2E1, Canada
| | - Nicholas M Fialka
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, 8602-112 Street, Edmonton, AB, T6G 2E1, Canada
| | - Jimmy Kang
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, 8602-112 Street, Edmonton, AB, T6G 2E1, Canada
| | - Sabin J Bozso
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, 8602-112 Street, Edmonton, AB, T6G 2E1, Canada
| | - Jayan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, 8602-112 Street, Edmonton, AB, T6G 2E1, Canada
| | - Jeevan Nagendran
- Division of Cardiac Surgery, Department of Surgery, University of Alberta, Mazankowski Alberta Heart Institute, 4-108A Li Ka Shing Health Research Centre, 8602-112 Street, Edmonton, AB, T6G 2E1, Canada.
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Kourek C, Georgopoulou M, Kolovou K, Rouvali N, Panoutsopoulou M, Kinti C, Soulele T, Doubou D, Karanikas S, Elaiopoulos D, Karabinis A, Dimopoulos S. Intensive Care Unit Hyperglycemia After Cardiac Surgery: Risk Factors and Clinical Outcomes. J Cardiothorac Vasc Anesth 2024; 38:162-169. [PMID: 37880037 DOI: 10.1053/j.jvca.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 09/01/2023] [Accepted: 09/16/2023] [Indexed: 10/27/2023]
Abstract
OBJECTIVES Patients with hyperglycemia after cardiac surgery face increased morbidity and mortality due to postoperative complications. The main purpose of this study was to evaluate the incidence of postoperative hyperglycemia, the hyperglycemia risk factors, and its association with clinical outcomes in patients admitted to the cardiac surgery intensive care unit after cardiac surgery. DESIGN Prospective, observational study. SETTING Single-center hospital. PARTICIPANTS Two hundred ten consecutive postoperative cardiac surgery patients admitted to the cardiac surgery intensive care unit. INTERVENTIONS Patients' blood glucose levels were evaluated immediately after cardiac surgery and every 3 hours daily for 7 days or earlier upon discharge. Intravenous insulin was administered as per the institution's protocol. Perioperative predisposing risk factors for hyperglycemia and clinical outcomes were assessed. MEASUREMENTS AND MAIN RESULTS Postoperative hyperglycemia, defined as glucose level ≥180 mg/dL, occurred in 30% of cardiac surgery patients. Diabetes mellitus (odds ratio [OR] 6.73; 95% CI [3.2-14.3]; p < 0.001), white blood cell count (OR 1.28; 95% CI [1.1-1.4]; p < 0.001), and EuroSCORE II (OR 1.20; 95% CI [1.1-1.4]; p = 0.004) emerged as independent prognostic factors for hyperglycemia. Moreover, patients with glucose ≥180 mg/dL had higher rates of acute kidney injury (34.9% v 18.9%, p = 0.013), longer duration of mechanical ventilation (959 v 720 min, p = 0.019), and sedation (711 v 574 min, p = 0.034), and higher levels of intensive care unit (ICU)-acquired weakness (14% v 5.5%, p = 0.027) and rate of multiorgan failure (6.3% v 0.7%, p = 0.02) compared with patients with glucose levels <180 mg/dL. CONCLUSIONS In the intensive care unit, hyperglycemia occurs frequently in patients immediately after cardiac surgery. Diabetes, high EuroSCORE II, and preoperative leukocytosis are independent risk factors for postoperative hyperglycemia. Hyperglycemia is associated with worse clinical outcomes, including a higher rate of acute kidney injury and ICU-acquired weakness, greater duration of mechanical ventilation, and a higher rate of multiorgan failure.
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Affiliation(s)
- Christos Kourek
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Magda Georgopoulou
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Kyriaki Kolovou
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Niki Rouvali
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Maria Panoutsopoulou
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Charalampia Kinti
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Theodora Soulele
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Dimitra Doubou
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Karanikas
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Dimitris Elaiopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Andreas Karabinis
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stavros Dimopoulos
- Cardiac Surgery Intensive Care Unit, Onassis Cardiac Surgery Center, Athens, Greece.
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12
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Rayman G, Page E, Hodgson S, Henley W, Wr Briggs T, Gray WK. Improving the outcomes for people with diabetes undergoing surgery: An observational study of the Improving the Peri-operative Pathway of People with Diabetes (IP3D) intervention. Diabetes Res Clin Pract 2024; 207:111062. [PMID: 38110122 DOI: 10.1016/j.diabres.2023.111062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 12/01/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
AIMS We evaluated the effectiveness of an intervention to improve the care of people with diabetes undergoing surgery when implemented across multiple organisations. METHODS This was an observational study using routinely collected data. Eight hospitals in England implemented the Improving the Peri-operative Pathway of People with Diabetes (IP3D) intervention, with pre-implementation data collected from 1st February to 31st July 2019 and post-implementation data collection within the period 1st February to 31st October 2021. Key elements were the use of a patient empowering peri-operative passport and the employment of a peri-operative diabetes specialist nurse. The primary outcome was the change in length of stay. RESULTS In total 1837 patients at pre-implementation and 1164 patients at post-implementation undergoing elective surgery were included. Pre- and post-implementation 23.8 % and 33.4 % of patients had day-case surgery respectively. For in-patients median length of stay decreased from 3.2 days (inter-quartile range 1.5-6.1) pre-implementation to 2.5 days (inter-quartile range 1.4-5.4) post-implementation. There were also significant improvements in patient experience, hypo- and hyper-glycaemic events, wound complications and diabetes related complications. CONCLUSIONS The IP3D intervention has the potential to increase efficiency and reduce waiting lists for elective surgery on a nationwide basis.
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Affiliation(s)
- Gerry Rayman
- Getting It Right First Time Programme, NHS England, London, UK; The Ipswich Diabetes and Endocrine Centre, Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK; The Medical School, University of East Anglia, Norwich, UK
| | - Emma Page
- Getting It Right First Time Programme, NHS England, London, UK; The Ipswich Diabetes and Endocrine Centre, Ipswich Hospital, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | | | - William Henley
- Department of Health and Community Sciences, University of Exeter Medical School, Exeter, UK
| | - Tim Wr Briggs
- Getting It Right First Time Programme, NHS England, London, UK; Department of Surgery, Royal National Orthopaedic Hospital NHS Trust, Stanmore, London, UK
| | - William K Gray
- Getting It Right First Time Programme, NHS England, London, UK.
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13
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Bachar A, Wang X, Herzog K, Sahil S, Cheng AL, Ohene-Agyei JA, Shepherd JP, Sutkin G. Hemoglobin A1c and Reoperation After Surgery for Stress Incontinence or Prolapse. UROGYNECOLOGY (PHILADELPHIA, PA.) 2023:02273501-990000000-00158. [PMID: 38113124 DOI: 10.1097/spv.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
IMPORTANCE Few studies compare the link between hemogobin A1c (HbA1c) and urogynecologic surgical complications. OBJECTIVE The objective of this study was to determine the association between HbA1c and reoperation in women undergoing surgery for stress urinary incontinence (SUI) or pelvic organ prolapse (POP). STUDY DESIGN We performed 2 separate retrospective cohort analyses using Cerner's HealthFacts Database (750 hospitals; 519,000,000 patient encounters from January 1, 2010, to November 30, 2018). We included women undergoing surgery for (1) SUI or (2) apical POP by International Classification of Diseases coding who had HbA1c at the initial procedure. Each analysis compared those undergoing reoperation for complications or recurrence and those who did not. Multivariable logistic regression assessed the association between reoperation and HbA1c both as a continuous variable and comparing the commonly accepted cutoff ≥8. RESULTS Of 30,180 SUI surgical procedures and 26,389 POP surgical procedures, 1,625 (5.4%) and 805 (3.1%) had HbA1c. Median (interquartile range) HbA1c in grams per deciliter was similar by reoperation status (SUI: 6.0 [5.6-6.8] vs 6.1 [5.6-6.9], P = 0.35; POP: 6.2 [5.6-6.6] vs 6.1 [5.7-6.8], P = 0.60). Reoperation was also similar using the HbA1c ≥8% cutoff (SUI: 6.9% vs 7.4%, P = 0.79; POP: 6.3% vs 5.4%, P = 0.77). On multivariate analysis, HbA1c value was not a significant predictor of reoperation either as a continuous (SUI: odds ratio [OR] = 0.966, 95% CI = 0.833-1.119; POP: OR = 1.040, 95% CI = 0.801-1.350) or dichotomous variable ≥8 (SUI: OR = 0.767, 95% CI = 0.407-1.446; POP: OR = 0.988, 95% CI = 0.331-2.951). Mean follow-up was 4.28-5.13 years. CONCLUSION Although other studies have shown a link between diabetes and complications, we were unable to show an association between HbA1c values and rates of reoperation.
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Affiliation(s)
- Austin Bachar
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Xi Wang
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Kiersten Herzog
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Suman Sahil
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - An-Lin Cheng
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
| | - Jada A Ohene-Agyei
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
| | | | - Gary Sutkin
- From the University of Missouri Kansas City School of Medicine, Kansas City, MO
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14
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Thanh NV, Hien NS, Son PN, Pho DC, Son PT. Heart Rate Variability and Its Role in Predicting Atrial Fibrillation in Patients Undergoing Coronary Artery Bypass Graft. Int J Gen Med 2023; 16:4919-4930. [PMID: 37928958 PMCID: PMC10625374 DOI: 10.2147/ijgm.s435901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023] Open
Abstract
Background An association between heart rate variability (HRV) and cardiac events in certain diseases has been demonstrated. However, the association with new-onset atrial fibrillation (AF) after coronary artery bypass grafting (CABG) is still controversial. This study aimed to investigate the association between HRV and new-onset AF in patients undergoing CABG during a 6-month follow-up. Methods This prospective study included 119 consecutive patients who underwent off-pump CABG. All patients were assessed using 24-hour Holter recordings 2 days before CABG and 1 week, 3 months, and 6 months postoperatively. HRV was analyzed, and AF was detected from its recordings. Main results In patients undergoing CABG, NYHA III increased the AF rate 7 days postoperatively, and advanced age and diabetes were associated with AF 6 months postoperatively. A reduction in time-domain measurements before surgery was significantly associated with a higher risk of developing AF seven days postoperatively; no association between preoperative HRV and AF was found at six months. Reduced preoperative HRV (SDNN (standard deviation of all normal-to-normal intervals [) < 50 ms) was an independent predictor of AF at 3 (AUC = 0.65) and 6 months (AUC = 0.62) following surgery. Conclusion A reduction in the time domain measurements before CABG was associated with a higher risk of new-onset AF at 7 days postoperatively but not at 6 months. An SDNN <50 ms was a weak independent predictor of a higher incidence of AF at 3 and 6 months post-surgery.
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Affiliation(s)
| | | | | | - Dinh Cong Pho
- Department of Cardiology, Heart Institute, 108 Military Central Hospital, Hanoi, Vietnam
| | - Pham Truong Son
- Department of Cardiology, Heart Institute, 108 Military Central Hospital, Hanoi, Vietnam
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15
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Bloomgarden Z. Should glucagon-like peptide-1 receptor agonist treatment be withheld in preoperative management? J Diabetes 2023; 15:712-713. [PMID: 37727016 PMCID: PMC10509509 DOI: 10.1111/1753-0407.13469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/21/2023] Open
Affiliation(s)
- Zachary Bloomgarden
- Department of Medicine, Division of Endocrinology, Diabetes, and Bone DiseaseIcahn School of Medicine at Mount SinaiNew YorkNYUSA
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16
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Mihaljevic MZ, Petricevic M, Konosic S, Svetina L, Urlic M, Starcevic Z, Krzelj K, Milosevic M, Kalamar V, Gasparovic H, Biocina B. The Association between Glycosylated Hemoglobin Level and Platelets Reactivity in Patients with Diabetes Mellitus Undergoing Elective Coronary Artery Bypass Grafting. Thorac Cardiovasc Surg 2023; 71:469-482. [PMID: 35752164 DOI: 10.1055/s-0042-1748768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Diabetic patients tend to have increased platelet reactivity after coronary artery bypass grafting (CABG). The aim of this study was to determine the association between hemoglobin A1c (HbA1c) values and platelet reactivity and to evaluate the consequent impact on clinical outcomes in patients undergoing CABG. METHODS This prospective observational trial consecutively enrolled 225 diabetic patients undergoing CABG, between February 2014 and October 2018. HbA1c levels and platelet function (multiple electrode aggregometry [MEA]) were analyzed the day before surgery and on postoperative day 4 (POD 4). Patients were divided into two groups according to the HbA1c value: HBA1c < 7% and HbA1c ≥ 7%. RESULTS Significantly higher postoperative ASPI (platelet function test based on arachidonic acid) and ADP (platelet function test based on adenosine diphosphate) test values were observed at POD 4 compared with preoperative values (ASPI test: p < 0.001; ADP test: p < 0.001). The prevalence of preoperative aspirin resistance (AR) was 46.4% relative to 57.2% after surgery showing consistent increase in postoperative AR by approximately 10%. In addition, the prevalence of AR in the HbA1c < 7% group was higher by 10% compared with the HbA1c ≥ 7% group, both before and after surgery. We did not demonstrate differences in clinical outcomes between the HbA1c groups. CONCLUSION Perioperative assessment of platelet reactivity in diabetic patients detects those with AR who may be at increased risk of adverse ischemic events. A personalized approach guided by MEA and administration of early and more potent antiaggregation therapy after CABG can be beneficial in this group of patients.
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Affiliation(s)
- Martina Zrno Mihaljevic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Mate Petricevic
- Department of Cardiac Surgery, University Department of Health Studies, University of Split, UHC Zagreb, Split, Croatia
| | - Sanja Konosic
- Department of Anesthesiology, University Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Lucija Svetina
- Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Marjan Urlic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Zrinka Starcevic
- Department of Cardiovascular Diseases, University Hospital Centre Zagreb, University of Zagreb, Zagreb, Croatia
| | - Kristina Krzelj
- Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Milan Milosevic
- Andrija Stampar Teaching Institute of Public Health, Zagreb, Croatia
| | - Viktor Kalamar
- Department of Thoracic Surgery, Sestre Milosrdnice University Hospital Center, Zagreb, Croatia
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
| | - Bojan Biocina
- Department of Cardiac Surgery, University Clinical Hospital Center Zagreb, University of Zagreb, Zagreb, Croatia
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Beaulieu RJ. Preoperative Assessment of Patients with Vascular Disease. Surg Clin North Am 2023; 103:577-594. [PMID: 37455026 DOI: 10.1016/j.suc.2023.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023]
Abstract
Patients with vascular disease represent a particularly high-risk surgical population. Many of the comorbidities that contribute to their vascular presentation impact a number of vascular beds or other organ systems. As a result, these patients have the highest rates of cardiac and pulmonary complications among patients with noncardiac surgery. The vascular surgeon is in a unique position to help evaluate and treat many of these conditions to not only reduce the perioperative risk but also to improve the patient's overall health. This article presents a comprehensive review of the common preoperative evaluations that have a high impact on patients with vascular disease.
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Affiliation(s)
- Robert J Beaulieu
- Department of Surgery, University of Michigan, 1500 E. Medical Center Drive, Ann Arbor, MI, USA.
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Abstract
Type 1 diabetes (T1D) is an increasingly common condition. Although often more effective, treatment regimens for patients with T1D have become more variable and complex with newer insulin analogues and increasing use of diabetes technology. Both surgery and anesthesia are known to trigger a stress response that causes dramatic metabolic changes in the patient that tend to increase glucose variability. Close monitoring of glucose levels and clear algorithms for insulin administration can ameliorate these characteristic responses. As T1D treatment technology becomes more effective at maintaining glucose in target range, there should be more consideration of using this technology during hospitalization and surgery.
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Affiliation(s)
- Grace B Nelson
- Pediatrics, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38105, USA.
| | - Kathryn M Sumpter
- Pediatrics, University of Tennessee Health Science Center, 49 North Dunlap Street, Memphis, TN 38105, USA
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Huang A, Tin AL, Vickers AJ, Shahrokni A, Flory J. Preoperative glucose in surgical oncology patient is not associated with postoperative outcomes after adjustment for frailty. J Surg Oncol 2023; 128:167-174. [PMID: 37006122 PMCID: PMC11373875 DOI: 10.1002/jso.27262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/09/2023] [Accepted: 03/11/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Observational studies have shown associations between even small elevations in preoperative glucose and poorer outcomes, including increased length of stay (LOS) and higher mortality. This has led to calls for aggressive glycemic control in the preoperative period, including delay of treatment until glucose is reduced. However, it is not known whether there is a direct causal effect of blood glucose or whether adverse outcomes result from overall poorer health in patients with higher glucose. METHODS Analysis was performed using a retrospective database of patients aged 65 and older who underwent cancer surgery. The last measured preoperative glucose was the exposure variable. The primary outcome was extended LOS (>4 days). Secondary outcomes included mortality, acute kidney injury (AKI), major postoperative complications during the admission period, and readmission within 30 days. The primary analysis was a logistic regression with prespecified covariates: age, sex, surgical service, and the Memorial Sloan Kettering-Frailty Index. In an exploratory analysis, lasso regression was used to select covariates from a list of 4160 candidate variables. RESULTS This study included 3796 patients with a median preoperative glucose of 104 mg/dL (interquartile range: 93-125). Higher preoperative glucose was univariately associated with increased odds of LOS > 4 days (odds ratio [OR]: 1.45, 95% confidence interval [CI]: 1.22-1.73), with similar results for AKI, readmission, and mortality. Adjustment for confounders eliminated these associations for LOS (OR: 0.97 [95% CI: 0.80-1.18]) and attenuated all other glucose-outcome associations. Lasso regression gave comparable results to the primary analysis. Using the upper bound of the respective 95% confidence interval, we estimated that, at best, successful reduction of elevated preoperative glucose would reduce the risk of LOS > 4 days, 30-day major complication, and 30-day mortality by 4%, 0.5%, and 1.3%, respectively. CONCLUSIONS Poor outcomes following cancer surgery in older adults with elevated glucose are most likely related to poorer overall health in these patients rather than a direct causal effect of glucose. Aggressive glycemic management in the preoperative period has very limited potential benefits and is therefore unwarranted.
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Affiliation(s)
- Alex Huang
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
- Icahn School of Medicine at Mount Sinai Hospital, New York, City, New York, USA
| | - Amy L Tin
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Andrew J Vickers
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Armin Shahrokni
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - James Flory
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
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20
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Madhu M, Patni A. Use of pre-operative hemoglobin a1c to predict early post-operative renal failure and infection risks in patients who are not diabetics and undergoing elective off pump coronary artery bypass graft surgery. Ann Card Anaesth 2023; 26:160-165. [PMID: 37706380 PMCID: PMC10284492 DOI: 10.4103/aca.aca_46_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/04/2022] [Accepted: 07/31/2022] [Indexed: 09/15/2023] Open
Abstract
Background Recent studies have indicated that patients, both with and without diabetes with an increased HbA1c, have a higher rate of adverse outcomes following cardiac surgeries. Our study is focused on to evaluate the prognostic impact of admission value of HbA1c in non-diabetic patients for postoperative renal failure and infections. Materials and Methods Plasma HbA1c levels were collected from 200 consecutive nondiabetic patients who got admitted for elective off pump coronary artery bypass graft (CABG) procedure over a 2-year period under two groups, Group A whose HbA1c was < 6% at admission and Group B whose HbA1c was ≥6% and ≤6.4% at admission. After surgery, patients were followed up to see if they have got infection or renal failure as postoperative complication. Student's unpaired t test was used to test the significance of difference between the quantitative variables, Yate's and Fisher's chi square tests were used for qualitative variables. Results We found early postoperative renal failure in 14 (3/96 in Group A and 11/104 in Group B) out of 200 patients (7%) and infection in 21 (8/96 in Group A and 13/104 in Group B) out of 200 patients (10.5%). After data analysis, it was noted that there is a positive correlation between HbA1c and postoperative renal failure (P = 0.0213) whereas no association was found between HbA1c and postoperative infections (P = 0.175) in patients undergoing off-pump CABG surgery. Conclusion In patients without diabetes, a plasma HbA1c ≥6% was a significant independent predictor for early postoperative renal failure.
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Affiliation(s)
- M Madhu
- Department of Pediatric Cardiac Anaesthesia and Critical Care, Sri Sathya Sai Sanjeevani Centre for Child Heart Care, Sector 37, Kharghar, Navi Mumbai, Maharashtra, India
| | - Ankita Patni
- Critical Care Registrar, Apollo Hospital, Bannerghatta Road, Bengaluru, Karnataka, India
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21
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Omiya K, Sato H, Sato T, Nooh A, Koo BW, Kandelman S, Schricker T. The Quality of Preoperative Glycemic Control Predicts Insulin Sensitivity During Major Upper Abdominal Surgery: A Case-Control Study. ANNALS OF SURGERY OPEN 2023; 4:e234. [PMID: 37600876 PMCID: PMC10431449 DOI: 10.1097/as9.0000000000000234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/19/2022] [Indexed: 02/05/2023] Open
Abstract
Objective To examine the association of the quality of preoperative glycemic control and insulin sensitivity during major upper abdominal surgery. Background In cardiac surgery, glycated hemoglobin A1c (HbA1c), an indicator of glycemic control during the preceding 3 months, correlated with intraoperative insulin sensitivity. Furthermore, insulin resistance showed a significant association with adverse clinical outcomes. Methods This study is a post hoc exploratory analysis of a randomized controlled trial in patients undergoing elective hepatectomy and receiving the hyperinsulinemic-normoglycemic clamp (HNC) as a potential intervention to reduce surgical site infections (ClinicalTrials.gov NCT01528189). Immediately before skin incision, the HNC was initiated by infusing insulin at the rate of 2 mU/kg/min. Dextrose was administered at rates titrated to maintain normoglycemia (4.0-6.0 mmol/L). The average of 3 consecutive dextrose infusion rates during steady state was used as a measure of insulin sensitivity. Primary outcome was the relationship between preoperative HbA1c and insulin sensitivity during surgery. Secondary outcomes were the associations of insulin sensitivity with the patient's body mass index (BMI) and postoperative morbidity. Results Thirty-four patients were studied. HbA1c (Y = -0.52X + 4.8, P < 0.001, R2 = 0.29), BMI (Y = -0.12X + 5.0, P < 0.001, R2 = 0.43) showed negative correlations with insulin sensitivity. The odds ratio of postoperative complications within 30 days of surgery for every increase in insulin sensitivity by 1 mg/kg/min was 0.22 (95% confidential interval, 0.06-0.59; P = 0.009). Conclusions We demonstrate significant associations of the quality of preoperative glycemic control and body mass index with insulin sensitivity during hepatectomy. The degree of insulin resistance correlated with postoperative morbidity.
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Affiliation(s)
- Keisuke Omiya
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Hiroaki Sato
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Tamaki Sato
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Abdulwahaab Nooh
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Bon-Wook Koo
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Stanislas Kandelman
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
| | - Thomas Schricker
- From the Department of Anesthesia, McGill University Health Centre Glen Site, Royal Victoria Hospital, Montreal, QC, Canada
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22
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Hung KC, Chang PC, Hsu CW, Lan KM, Liao SW, Lin YT, Huang PW, Sun CK. Usefulness of Analgesia Nociception Index for guiding intraoperative opioid administration: a systematic review and meta-analysis. Minerva Anestesiol 2023; 89:74-84. [PMID: 36282226 DOI: 10.23736/s0375-9393.22.16697-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION This study primarily aimed at investigating the efficacy of Analgesia Nociception Index (ANI) for guiding intraoperative opioid administration in patients receiving surgery under general anesthesia. EVIDENCE ACQUISITION The Medline, Embase, Google scholar, and the Cochrane Library databases were searched from inception to April 2022 for randomized controlled trials. The primary outcome was intraoperative opioid administration, while the secondary outcomes included postoperative opioid consumption, pain score, emergency time, risk of nausea/vomiting (PONV), and Postanesthesia Care Unit (PACU) stay. EVIDENCE SYNTHESIS Six studies including 399 participants (published from 2015 to 2022) focused on non-cardiac surgery, including spine surgery (two trials), breast surgery (two trials), gynecologic surgery (one trial), and laparoscopic cholecystectomy (one trial) were included. Meta-analysis revealed no difference in intraoperative opioid administration with the use of ANI-guided analgesia compared to the control group that used conventional clinical measurements (e.g., heart rate) to guide opioid use [standardized mean difference (SMD)=-0.17, 95% CI: -0.56 to 0.22, P=0.39, I2=72%, six trials, 399 participants]. Gender-based subgroup analysis showed effectiveness of ANI for reducing opioid administration in female patients (SMD=-0.53, P=0.02). There were no differences in postoperative recovery characteristics including pain score [Mean difference (MD): -0.03, P=0.79], opioid consumption (SMD: -0.34, P=0.08), emergence time (MD=1.12, P=0.47), length of stay in the PACU (MD: -0.56, P=0.83), and risk of PONV [risk ratio(RR): 0.75, P=0.46] between the two groups. CONCLUSIONS Analgesia nociception index-guided analgesia was unable to reduce intraoperative opioid administration compared to monitoring using conventional clinical parameters. Further studies are required to support our findings.
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Affiliation(s)
- Kuo-Chuan Hung
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Po-Chih Chang
- Division of Thoracic Surgery, Department of Surgery, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung, Taiwan.,Weight Management Center, Kaohsiung Medical University Hospital/Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Sports Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.,Program in Biomedical Engineering, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Chih-Wei Hsu
- Department of Psychiatry, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Kuo-Mao Lan
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Shu-Wei Liao
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Yao-Tsung Lin
- Department of Anesthesiology, Chi Mei Medical Center, Tainan, Taiwan
| | - Ping-Wen Huang
- Department of Emergency Medicine, Show Chwan Memorial Hospital, Changhua City, Taiwan
| | - Cheuk-Kwan Sun
- Department of Emergency Medicine, E-Da Hospital, Kaohsiung, Taiwan - .,College of Medicine, I-Shou University, Kaohsiung, Taiwan
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23
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Yavuz Ş, Özsin KK, Sanrı US, Toktaş F, Özsin M, Eriş C. Evaluation of the effect of preoperative HbA1c value on development of postoperative atrial fibrillation in diabetic patients with on-pump coronary artery bypass graft. J Card Surg 2022; 37:4371-4378. [PMID: 36229974 DOI: 10.1111/jocs.17028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/20/2022] [Accepted: 08/31/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND We aimed to determine the relationship between hemoglobin A1c (HbA1c) levels and the development of postoperative atrial fibrillation (PoAF). METHODS Two hundred and eighty-eight patients diagnosed with diabetes mellitus and undergoing on-pump coronary bypass were included in the study. Those with serum HbA1c levels between 5.5% and 7.0% were defined as Group 1, those with serum HbA1c levels between 7.1% and 8.9% were defined as Group 2, while those with serum HbA1c levels 9.0% and above formed Group 3. Data between groups were compared. The predictive values of the independent variables for the development of PoAF were measured. RESULTS We did not find a difference between groups in terms of development PoAF (p = .170). The presence of hypertension was determined as an independent predictor for the development of PoAF (p = .003), but not HbA1c levels (p = .134). There was 50.5% sensitivity and 61.1% specificity for HbA1c values of 9.06% and above to predict PoAF (area under curve: 0.571, p = .049). CONCLUSIONS HbA1c levels were not an independent predictor of PoAF development. However, we think that high HbA1c levels may be a risk factor for the development of PoAF.
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Affiliation(s)
- Şenol Yavuz
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Kadir Kaan Özsin
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Umut Serhat Sanrı
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Faruk Toktaş
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
| | - Meral Özsin
- Department of Medical Biochemistry, Faculty of Medicine, University of Kahramanmaraş Sütçü İmam, Kahramanmaraş, Turkey
| | - Cüneyt Eriş
- Department of Cardiovascular Surgery, Bursa Yuksek Ihtisas Training and Research Hospital, University of Health Sciences, Bursa, Turkey
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24
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Budak AB. Predictive power of elevated preoperative HbA1c levels for postoperative atrial fibrillation in patients undergoing isolated coronary artery bypass surgery-Many questions to be asked and many answers to be given. J Card Surg 2022; 37:4379-4381. [PMID: 36229987 DOI: 10.1111/jocs.17026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 09/26/2022] [Indexed: 01/06/2023]
Abstract
The authors performed a detailed retrospective analysis of diabetic patients undergoing isolated coronary artery bypass graft surgery aiming to investigate the association of the preoperative glycosylated hemoglobin with occurrence of postoperative atrial fibrillation. Although statistical analysis showed a weak relationship between HbA1c values of 9.06% or above and postoperative atrial fibrillation (PoAF), they concluded that serum level of HbA1c could not be used as a predictor for the development of PoAF. But there are many questions to be asked and answers to be found.
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Affiliation(s)
- Ali Baran Budak
- Department of Cardiovascular Surgery, Ulus Liv Hospital, Istanbul, Turkey
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25
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Liu S, Shi L, Wang B, Lou J, Sun M, Yang H, Zhang F, Liu M, Song Y, Mi W, Ma Y. Preoperative hyperglycemia is associated with elevated risk of perioperative ischemic stroke in type 2 diabetic patients undergoing non-cardiovascular surgery: A retrospective cohort study. Front Aging Neurosci 2022; 14:990567. [PMID: 36337712 PMCID: PMC9631439 DOI: 10.3389/fnagi.2022.990567] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 10/03/2022] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) has been reported to be associated with perioperative stroke, but the effects of preoperative hyperglycemia on the risk of perioperative stroke in diabetic patients undergoing non-cardiovascular surgery remain unclear. This study investigated the association between preoperative hyperglycemia and the risk of perioperative ischemic stroke in type 2 diabetic patients undergoing non-cardiovascular surgery. METHODS This retrospective cohort study screened 27,002 patients with type 2 DM undergoing non-cardiovascular surgery with general anesthesia between January 2008 and August 2019 at The First Medical Center of Chinese People's Liberation Army (PLA) General Hospital. The exposure of interest was preoperative hyperglycemia, defined as a fasting plasma glucose (FPG) ≥ 7 mmol/L. The outcome of interest was a new diagnosis of perioperative ischemic stroke within 30 days after surgery. Residual confounding was minimized by controlling for observable patient and intraoperative factors. Logistic regression was conducted in the total and propensity score matched cohorts. In addition, we stratified patients into six subgroups to investigate whether the association between preoperative hyperglycemia and perioperative ischemic stroke differs in these subgroups. RESULTS The overall incidence of perioperative ischemic stroke was 0.53% (n = 144) in the current cohort. The odds of perioperative ischemic stroke were significantly increased for patients with preoperative hyperglycemia after adjusting for patient- related variables (OR: 1.95; 95% CI: 1.39-2.75; p < 0.001), surgery-related variables (OR: 2.1; 95% CI: 1.51-2.94; p < 0.001), and all confounding variables (OR: 1.78; 95% CI: 1.26-2.53; p < 0.001). The risk of perioperative stroke was significantly increased in patients with preoperative hyperglycemia (OR: 2.51; 95% CI: 1.66-3.9; p < 0.001) in the propensity score matched cohort. Preoperative hyperglycemia was associated with the outcome for all the subgroups except for patients undergoing neurosurgery. CONCLUSION Preoperative hyperglycemia is associated with an elevated risk of perioperative stroke in patients with type 2 DM undergoing non-cardiovascular surgery. The effect could be eliminated for patients undergoing neurosurgery, during which specific risk factors should be considered.
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Affiliation(s)
- Siyuan Liu
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Likai Shi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Binbin Wang
- Department of Anesthesiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Jingsheng Lou
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Miao Sun
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Huikai Yang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Faqiang Zhang
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Min Liu
- Department of Anesthesiology, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Yuxiang Song
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Weidong Mi
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
| | - Yulong Ma
- Department of Anesthesiology, The First Medical Center of Chinese PLA General Hospital, Beijing, China
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26
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Knight JB, Subramanian H, Sultan I, Kaczorowski DJ, Subramaniam K. Prehabilitation of Cardiac Surgical Patients, Part 1: Anemia, Diabetes Mellitus, Obesity, Sleep Apnea, and Cardiac Rehabilitation. Semin Cardiothorac Vasc Anesth 2022; 26:282-294. [PMID: 36006868 DOI: 10.1177/10892532221121118] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The concept of "prehabilitation" consists of screening for and identification of pre-existing disorders followed by medical optimization. This is performed for many types of surgery, but may have profound impacts on outcomes particularly in cardiac surgery given the multiple comorbidities typically carried by these patients. Components of prehabilitation include direct medical intervention by preoperative specialists as well as significant care coordination and shared decision making. In this two-part review, the authors describe existing evidence to support the optimization of various preoperative problems and present a few institutional protocols utilized by our center for cardiac presurgical care. This first installment will focus on the management of anemia, obesity, sleep apnea, diabetes, and cardiac rehabilitation prior to surgery. The second will focus on frailty, malnutrition, respiratory disease, alcohol and smoking cessation, and depression.
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Affiliation(s)
- Joshua B Knight
- 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Ibrahim Sultan
- 6595University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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27
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Beckles DL, Tavilla G, Malhotra A, Williams NE, Jackson T, Koerner MM, Reddy RC. The use of simple ultrafiltration technology as a fluid management strategy for high-risk coronary artery bypass grafting surgery. J Card Surg 2022; 37:2951-2957. [PMID: 35998279 DOI: 10.1111/jocs.16867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/15/2022] [Accepted: 08/03/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Daniel L Beckles
- Department of Surgery, Division of Cardiothoracic Surgery, Baylor Scott & White Health, Temple, Texas, USA
| | - Giuseppe Tavilla
- Department of Surgery, Division of Cardiothoracic Surgery, Baylor Scott & White Health, Temple, Texas, USA
| | - Amber Malhotra
- Department of Surgery, Division of Cardiothoracic Surgery, Baylor Scott & White Health, Temple, Texas, USA
| | - Nikki E Williams
- Department of Surgery, Division of Cardiothoracic Surgery, Baylor Scott & White Health, Temple, Texas, USA
| | - Tamara Jackson
- Department of Surgery, Division of Cardiothoracic Surgery, Baylor Scott & White Health, Temple, Texas, USA
| | - Michael M Koerner
- Department of Medicine, Baylor Scott & White Health, Temple, Texas, USA
| | - Ramachandra C Reddy
- Department of Surgery, Division of Cardiothoracic Surgery, Baylor Scott & White Health, Temple, Texas, USA
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28
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Wu LP, Pang K, Li B, Le Y, Tang YZ. Predictive Value of Glycosylated Hemoglobin for Post-operative Acute Kidney Injury in Non-cardiac Surgery Patients. Front Med (Lausanne) 2022; 9:886210. [PMID: 35899215 PMCID: PMC9309303 DOI: 10.3389/fmed.2022.886210] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 06/22/2022] [Indexed: 11/18/2022] Open
Abstract
Objective Recent studies have indicated that patients (both with and without diabetes) with elevated hemoglobin A1c (HbA1c) have a higher rate of acute kidney injury (AKI) following cardiac surgery. However, whether HbA1c could help to predict post-operative AKI in patients after non-cardiac surgery is less clear. This study aims to explore the predictive value of pre-operative HbA1c for post-operative AKI in non-cardiac surgery. Methods We reviewed the medical records of patients (≥ 18 years old) who underwent non-cardiac surgery between 2011 and 2020. Patient-related variables, including demographic and laboratory and procedure-related information, were collected, and univariable and multivariable logistic regression analyses were performed to determine the association of HbA1c with AKI. The area under the receiver operating curve (AUC), net reclassification improvement index (NRI), and integrated discriminant improvement index (IDI) were used to evaluate the predictive ability of the model, and decision curve analysis was used to evaluate the clinical utility of the HbA1c-added predictive model. Results A total of 3.3% of patients (94 of 2,785) developed AKI within 1 week after surgery. Pre-operative HbA1c was an independent predictor of AKI after adjustment for some clinical variables (OR comparing top to bottom quintiles 5.02, 95% CI, 1.90 to 13.24, P < 0.001 for trend; OR per percentage point increment in HbA1c 1.20, 95% CI, 1.07 to 1.33). Compared to the model with only clinical variables, the incorporation of HbA1c increased the model fit, modestly improved the discrimination (change in area under the curve from 0.7387 to 0.7543) and reclassification (continuous net reclassification improvement 0.2767, 95% CI, 0.0715 to 0.4818, improved integrated discrimination 0.0048, 95% CI, -5e-04 to 0.0101) of AKI and non-AKI cases, NRI for non-AKI improvement 0.3222, 95% CI, 0.2864 to 0.3580 and achieved a higher net benefit in decision curve analysis. Conclusion Elevated pre-operative HbA1c was independently associated with post-operative AKI risk and provided predictive value in patients after non-cardiac surgery. HbA1c improved the predictive power of a logistic regression model based on traditional clinical risk factors for AKI. Further prospective studies are needed to demonstrate the results and clinical application.
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Affiliation(s)
- Lan-Ping Wu
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Ke Pang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Bo Li
- Surgery Center, The Third Xiangya Hospital, Central South University, Changsha, China
| | - Yuan Le
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
- *Correspondence: Yuan Le,
| | - Yong-Zhong Tang
- Department of Anesthesiology, The Third Xiangya Hospital, Central South University, Changsha, China
- Yong-Zhong Tang,
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Postoperative Glycemic Variability as a Predictor of Adverse Outcomes Following Lumbar Fusion. Spine (Phila Pa 1976) 2022; 47:E304-E311. [PMID: 34474452 DOI: 10.1097/brs.0000000000004214] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN A retrospective cross-sectional study. OBJECTIVE This study aims to evaluate the effect size of postoperative glycemic variability on surgical outcomes among patients who have undergone one- to three-level lumbar fusion. SUMMARY OF BACKGROUND DATA While numerous patient characteristics have been associated with surgical outcomes after lumbar fusion, recent studies have described the measuring of postoperative glycemic variability as another promising marker. METHODS A total of 850 patients were stratified into tertiles (low, moderate, high) based on degree of postoperative glycemic variability defined by coefficient of variation (CV). Surgical site infections were determined via chart review based on the Centers for Disease Control and Prevention definition. Demographic factors, surgical characteristics, inpatient complications, readmissions, and reoperations were determined by chart review and telephone encounters. RESULTS Overall, a statistically significant difference in 90-day adverse outcomes was observed when stratified by postoperative glycemic variability. In particular, patients with high CV had a higher odds ratio (OR) of readmission (OR = 2.19 [1.17, 4.09]; P = 0.01), experiencing a surgical site infection (OR = 3.22 [1.39, 7.45]; P = 0.01), and undergoing reoperations (OR = 2.65 [1.34, 5.23]; P = 0.01) compared with patients with low CV. No significant association was seen between low and moderate CV groups. Higher CV patients were more likely to experience longer hospital stays (β: 1.03; P = 0.01). Among the three groups, high CV group experienced the highest proportion of complications. CONCLUSION Our study establishes a significant relationship between postoperative glycemic variability and inpatient complications, length of stay, and 90-day adverse outcomes. While HbA1c has classically been used as the principal marker to assess blood glucose control, our results show CV to be a strong predictor of postoperative adverse outcomes. Future high-quality, prospective studies are necessary to explore the true effect of CV, as well as its practicality in clinical practice. Nevertheless, fluctuations in blood glucose levels during the inpatient stay should be limited to improve patient results.Level of Evidence: 4.
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30
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Fan EY, Crawford AS, Nguyen T, Judelson D, Learned A, Chan J, Schanzer A, Simons JP, Jones DW. Hemoglobin A1C Monitoring Practices Prior to Lower Extremity Bypass in Patients with Diabetes Vary Broadly and Do Not Predict Outcomes. J Vasc Surg 2022; 76:255-264. [DOI: 10.1016/j.jvs.2022.02.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
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Karathanasis D, Karathanasis CR, Karaolia A. Cardiac surgery-associated acute kidney injury: The core of etiology, treatment, and prognosis. JOURNAL OF CLINICAL AND PREVENTIVE CARDIOLOGY 2022. [DOI: 10.4103/jcpc.jcpc_5_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Bouza E, de Alarcón A, Fariñas MC, Gálvez J, Goenaga MÁ, Gutiérrez-Díez F, Hortal J, Lasso J, Mestres CA, Miró JM, Navas E, Nieto M, Parra A, Pérez de la Sota E, Rodríguez-Abella H, Rodríguez-Créixems M, Rodríguez-Roda J, Sánchez Espín G, Sousa D, Velasco García de Sierra C, Muñoz P, Kestler M. Prevention, Diagnosis and Management of Post-Surgical Mediastinitis in Adults Consensus Guidelines of the Spanish Society of Cardiovascular Infections ( SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery ( SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases ( CIBERES). J Clin Med 2021; 10:5566. [PMID: 34884268 PMCID: PMC8658224 DOI: 10.3390/jcm10235566] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/19/2021] [Accepted: 11/23/2021] [Indexed: 01/04/2023] Open
Abstract
This is a consensus document of the Spanish Society of Cardiovascular Infections (SEICAV), the Spanish Society of Thoracic and Cardiovascular Surgery (SECTCV) and the Biomedical Research Centre Network for Respiratory Diseases (CIBERES). These three entities have brought together a multidisciplinary group of experts that includes anaesthesiologists, cardiac and cardiothoracic surgeons, clinical microbiologists, infectious diseases and intensive care specialists, internal medicine doctors and radiologists. Despite the clinical and economic consequences of sternal wound infections, to date, there are no specific guidelines for the prevention, diagnosis and management of mediastinitis based on a multidisciplinary consensus. The purpose of the present document is to provide evidence-based guidance on the most effective diagnosis and management of patients who have experienced or are at risk of developing a post-surgical mediastinitis infection in order to optimise patient outcomes and the process of care. The intended users of the document are health care providers who help patients make decisions regarding their treatment, aiming to optimise the benefits and minimise any harm as well as the workload.
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Affiliation(s)
- Emilio Bouza
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | | | - Juan Gálvez
- Virgen Macarena University Hospital, 41009 Seville, Spain;
| | | | - Francisco Gutiérrez-Díez
- Cardiovascular Surgery Department, Marques de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | - Javier Hortal
- Anesthesia and Intensive Care Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - José Lasso
- Plastic Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Carlos A. Mestres
- Department of Cardiac Surgery, University Hospital Zurich, 8091 Zurich, Switzerland;
| | - José M. Miró
- Infectious Diseases Services, Hospital Clinic-IDIBAPS, University of Barcelona, 08036 Barcelona, Spain;
| | - Enrique Navas
- Infectious Diseases Department, Ramón y Cajal University Hospital, 28034 Madrid, Spain;
| | - Mercedes Nieto
- Cardiovascular Unit, Intensive Care Department, San Carlos Clinical Hospital, 28040 Madrid, Spain;
| | - Antonio Parra
- Department of Radiology, Marquez de Valdecilla University Hospital, 39008 Santander, Cantabria, Spain;
| | | | - Hugo Rodríguez-Abella
- Cardiac Surgery Department, Gregorio Marañon University Hospital, 28007 Madrid, Spain;
| | - Marta Rodríguez-Créixems
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | | | - Gemma Sánchez Espín
- Heart Clinical Management Unit, Virgen de la Victoria University Hospital, 29006 Malaga, Spain;
| | - Dolores Sousa
- Infectious Diseases Department, A Coruña Hospital Complex, 15006 A Coruña, Spain;
| | | | - Patricia Muñoz
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
| | - Martha Kestler
- Clinical Microbiology and Infectious Diseases Department, Gregorio Marañon University Hospital, Gregorio Marañon Health Research Institute, Complutense University of Madrid, CIBER of Respiratory Diseases—CIBERES, 28007 Madrid, Spain; (E.B.); (M.R.-C.); (P.M.)
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Tanaka T, Bradford T, Litofsky NS. Severity of Preoperative HbA1c and Predicting Postoperative Complications in Spine Surgery. World Neurosurg 2021; 155:e770-e777. [PMID: 34520868 DOI: 10.1016/j.wneu.2021.08.133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 08/27/2021] [Accepted: 08/28/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Diabetes mellitus (DM) is associated with a greater incidence of perioperative complications. The measurement of hemoglobin A1c (HbA1c) has not been routinely used in the preoperative assessment for spine surgeries. METHODS In the present single-institution, prospective study, HbA1c testing was included in the preoperative laboratory examination of patients undergoing spinal surgery from 2016 through 2018. The HbA1c levels were categorized using the American Diabetes Association guidelines as normal (HbA1c <5.7%), pre-DM (HbA1c 5.7%-6.4%), and diabetes (HbA1c >6.5%). Those with a HbA1c of ≥8% were separated as having poorly controlled DM for analysis. Perioperative complication and comorbidity data were collected to assess for associations with DM using logistic regression models. Odds ratios (ORs) and 95% confidence intervals were computed. RESULTS A total of 440 patients (238 men, mean age, 56.43 ± 13.28 years; mean body mass index, 30.80 ± 6.65 kg/m2) met the study criteria. The HbA1c was <5.7% in 206 patients (46.8%), 5.7%-6.4% in 148 (33.6%), 6.5%-7.9% in 64 (14.5%), and ≥8.0% in 23 patients (5.22%). Bivariate logistic modeling showed that patients with poorly controlled DM had a higher risk of complications (OR, 2.92) than did the patients with DM (OR, 2.13). Malignancy (OR, 2.62) and hypertension (OR, 1.86) were also significant risk factors for complications. However, smoking (OR, 0.83) was not significant. Poorly controlled DM remained associated with complications in multivariable logistic regression modeling (OR, 2.72). CONCLUSIONS Poorly control DM defined by the preoperative HbA1c was significantly associated with postoperative complications. Smoking, however, was not so associated. Preoperative HbA1c can be used to assess the risk of postoperative spine surgery complications.
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Affiliation(s)
- Tomoko Tanaka
- Department of Neurosurgery, University of Arkansas for Medical Science, Little Rock, Arkansas, USA; Division of Pediatric Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas, USA; Division of Neurosurgery, University of Missouri School of Medicine, Columbia, Missouri, USA.
| | - Toby Bradford
- Department of Internal Medicine, Alameda Health System, Oakland, California, USA; Medical School, University of Missouri School of Medicine, Columbia, Missouri, USA
| | - N Scott Litofsky
- Division of Neurosurgery, University of Missouri School of Medicine, Columbia, Missouri, USA
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Amabile A, Torregrossa G, Balkhy HH. Robotic-assisted coronary artery bypass grafting: current knowledge and future perspectives. Minerva Cardioangiol 2021; 68:497-510. [PMID: 33155785 DOI: 10.23736/s0026-4725.20.05302-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Minimally invasive direct coronary artery bypass grafting (MIDCAB) and totally endoscopic coronary artery bypass grafting (TECAB) are the two existing strategies for robotic-assisted, surgical myocardial revascularization. In this review, we summarize the wide evidence available in the literature regarding the benefits of these two procedures, and detail the technical skills required to master robotic coronary surgery techniques.
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Affiliation(s)
- Andrea Amabile
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA -
| | - Gianluca Torregrossa
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Husam H Balkhy
- Division of Cardiac Surgery, Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
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Kehler DS. Commentary: Addressing glycemic load in the precardiac surgical period: Does one size fit all? J Thorac Cardiovasc Surg 2021; 164:1963-1964. [PMID: 34274142 DOI: 10.1016/j.jtcvs.2021.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 06/18/2021] [Accepted: 06/21/2021] [Indexed: 11/30/2022]
Affiliation(s)
- D Scott Kehler
- Faculty of Health, School of Physiotherapy, Dalhousie University, Halifax, Nova Scotia, Canada; Division of Geriatric Medicine, Department of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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Abu Tailakh M, Ishay SY, Awesat J, Poupko L, Sahar G, Novack V. Hemoglobin A1c in Patients with Diabetes Predict Long-Term Mortality Following Coronary Artery Surgery. J Clin Med 2021; 10:jcm10122739. [PMID: 34205794 PMCID: PMC8235402 DOI: 10.3390/jcm10122739] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/13/2021] [Accepted: 06/17/2021] [Indexed: 11/16/2022] Open
Abstract
Objective: to estimate the association between preoperative hemoglobin A1c (HbA1c) levels below and above 7%, and the rate of all-cause mortality (ACM) in diabetes mellitus (DM) patients after coronary artery bypass grafting (CABG) within a ten-year follow-up period. Methods: we collected data on patient HbA1c levels that were measured up to 3 months prior to isolated CABG in consecutive patients with DM, and analyzed the rates of ACM over a median of a 5.9-year post-operative period. Results: preoperative HbA1c levels were collected in 579 DM patients. The mean HbA1c was 8.0 ± 1.7%, where 206 (35.6%) patients had an HbA1c ≤ 7% and 373 (64.4%) had an HbA1c > 7%. During the follow-up period, mortality rates were 20.4% and 28.7% in the HbA1c ≤ 7% and HbA1c > 7% groups, respectively (Kaplan-Meier estimates, log-rank p = 0.01). Multivariable Cox proportional hazards regression, adjusted for age, gender, smoking status, chronic obstructive pulmonary disease, hypertension, chronic renal failure, old myocardial infarction, number of coronary artery bypass surgeries, and post-operative glycemic control, showed a hazard ratio of 2.67 for long-term ACM (p = 0.001) in patients with HbA1c > 7%. Conclusions: DM patients with high HbA1c levels prior to CABG are at higher risk for long-term complications, especially late ACM.
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Affiliation(s)
- Muhammad Abu Tailakh
- Department of Nursing, Recanati School for Community Health Professions, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
- Nursing Research Unit, Soroka University Medical Center, Beer-Sheva 84101, Israel
- Correspondence:
| | - Shlomo-yaron Ishay
- Department of Cardiothoracic Surgery, Division of Surgical Medicine, Soroka University Medical Center, Beer-Sheva 84101, Israel; (S.-y.I.); (G.S.)
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel; (J.A.); (L.P.); (V.N.)
| | - Jenan Awesat
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel; (J.A.); (L.P.); (V.N.)
- Division of Internal Medicine, Soroka University Medical Center, Beer-Sheva 84101, Israel
| | - Liat Poupko
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel; (J.A.); (L.P.); (V.N.)
- Medical School for International Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel
| | - Gidon Sahar
- Department of Cardiothoracic Surgery, Division of Surgical Medicine, Soroka University Medical Center, Beer-Sheva 84101, Israel; (S.-y.I.); (G.S.)
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel; (J.A.); (L.P.); (V.N.)
| | - Victor Novack
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel; (J.A.); (L.P.); (V.N.)
- Division of Internal Medicine, Soroka University Medical Center, Beer-Sheva 84101, Israel
- Clinical Research Center, Soroka University Medical Center, Beer-Sheva 84101, Israel
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Corazzari C, Matteucci M, Kołodziejczak M, Kowalewski M, Formenti AM, Giustina A, Beghi C, Barili F, Lorusso R. Impact of preoperative glycometabolic status on outcomes in cardiac surgery: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2021; 164:1950-1960.e10. [PMID: 34176617 DOI: 10.1016/j.jtcvs.2021.05.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 04/21/2021] [Accepted: 05/13/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Historically, impaired glucose metabolism has been associated with early and late complicated clinical outcomes after cardiac surgery; however, such a condition is not specific to subjects with diabetes mellitus and involves a larger patient population. METHODS Databases were screened (January 2000 to December 2020) to identify eligible articles; studies that evaluated the association between preoperative metabolic status, as assessed by glycosylated hemoglobin levels and clinical outcomes, were considered. The studies were stratified in thresholds by baseline glycosylated hemoglobin level (lower vs higher). RESULTS Thirty studies, involving 34,650 patients, were included in the review. In a meta-analysis stratified by glycosylated hemoglobin levels, early mortality was numerically reduced in each threshold comparison and yielded the highest reductions when less than 5.5% versus greater than 5.5% glycosylated hemoglobin levels were compared (risk ratio, 0.39; 95% confidence interval, 0.18-0.84; P = .02). Comparing higher glycosylated hemoglobin threshold values yielded comparable results. Late mortality was reduced with lower levels of glycosylated hemoglobin. Low preoperative glycosylated hemoglobin was associated with the lowest risk of sternal wound infections (risk ratio, 0.50; 95% confidence interval, 0.32-0.80; P = .003 and risk ratio, 0.53; 95% confidence interval, 0.39-0.70; P < .0001) for comparisons of less than 7.5% versus greater than 7.5% and less than 7.0% versus greater than 7.0% glycosylated hemoglobin thresholds, respectively. Additionally, levels of glycosylated hemoglobin lower than 7% were associated with reduced hospital stay, lower risk of stroke/transient ischemic attack (risk ratio 0.53; 95% confidence interval, 0.39-0.70; P < .0001), and acute kidney injury (risk ratio, 0.65; 95% confidence interval, 0.54-0.79; P < .0001). CONCLUSIONS Lower levels of glycosylated hemoglobin in patients undergoing cardiac surgery are associated with a lower risk of early and late mortality, as well as in the incidence of postoperative acute kidney injury, neurologic complications, and wound infection, compared with higher levels.
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Affiliation(s)
- Claudio Corazzari
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Surgical and Morphological Sciences, Circolo Hospital, University of Insubria, Varese, Italy
| | - Matteo Matteucci
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Surgical and Morphological Sciences, Circolo Hospital, University of Insubria, Varese, Italy.
| | - Michalina Kołodziejczak
- Department of Anaesthesiology and Intensive Care, Collegium Medicum Nicolaus Copernicus University, Antoni Jurasz University Hospital No. 1, Bydgoszcz, Poland; Yale Cardiovascular Research Group, Yale School of Medicine, New Haven, Conn
| | - Mariusz Kowalewski
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands; Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior, Centre of Postgraduate Medical Education, Warsaw, Poland; Thoracic Research Centre, Collegium Medicum Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland
| | - Anna Maria Formenti
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Andrea Giustina
- Institute of Endocrine and Metabolic Sciences, San Raffaele Vita-Salute University, IRCCS San Raffaele Hospital, Milan, Italy
| | - Cesare Beghi
- Department of Surgical and Morphological Sciences, Circolo Hospital, University of Insubria, Varese, Italy
| | - Fabio Barili
- Cardiac Surgery Unit, S. Croce Hospital, Cuneo, Italy
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Suggested Canadian Standards for Perioperative/Periprocedure Glycemic Management in Patients With Type 1 and Type 2 Diabetes. Can J Diabetes 2021; 46:99-107.e5. [PMID: 34210609 DOI: 10.1016/j.jcjd.2021.04.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 03/25/2021] [Accepted: 04/26/2021] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The goal of this quality initiative was to develop consensus standards for glycemic management of patients with diabetes who undergo surgical procedures in Canada. METHODS A modified Delphi method was used to gather broad stakeholder input and arrive at a consensus for perioperative/periprocedure diabetes management. RESULTS Glycemic management standards were developed for the following categories: Organization of Care; Preoperative Assessment; Immediate Preoperative and Intraoperative; Postanesthesia Care Unit or Recovery Room; Postoperative Period; and Transition to Outpatient Care. CONCLUSIONS It is anticipated these standards will serve as a basis to develop clinical tools to support the recommendations.
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Narayan P, Mandal CK, Das R, Das D, Ghorai PA, Chowdhury SR, Das M. Atrial fibrillation - Can HbA1c levels really predict the risk? Asian Cardiovasc Thorac Ann 2021; 30:141-146. [PMID: 33653152 DOI: 10.1177/0218492321998933] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diabetes is associated with higher mortality and worse post-operative outcomes in patients undergoing coronary artery bypass grafting and HbA1c levels have consistently been reported to be associated with adverse post-operative outcomes. However, the role of HbA1c still remains unclear with regards to the occurrence of atrial fibrillation. METHOD Data for the patients undergoing off-pump coronary artery bypass grafting was analysed in a retrospective fashion. Patients were divided into-those with HbA1c < 6.5% and those with HbA1c ≥ 6.5% and the incidence of atrial fibrillation observed in these two groups. We also compared patient who developed atrial fibrillation in the post-operative period and compared them with those who did not. RESULTS Of the 5259 patients included in the study HbA1c was <6.5 in 2808 (53.4%) patients and was ≥6.5 in 2451 (46.6%) patients; 623 (11.8%) patients in our study developed atrial fibrillation. Onset of atrial fibrillation in the post-operative period was seen most commonly 235 (38.3%) on between 24 and 48 h after the operation with more than half of them 338 (54.2%) occurring within the first 48 h. On multivariate analysis, HbA1c was not a risk factor for atrial fibrillation (odd's ratio 1.144, 95% confidence interval 0.967-1.354). Only increased age (odd's ratio 1.08; 95% confidence interval 1.069-1.091); EuroSCORE (odd's ratio 1.073; 95% confidence interval 1.048-1.099); history of recent MI (odd's ratio 0.768; 95% confidence interval 0.606-0.971) and peripheral vascular disease (odd's ratio 1.667; 95% confidence interval 1.091-2.517) were found to be independently associated with increased risk of atrial fibrillation in the post-operative period. CONCLUSIONS After adjusting for confounders HbA1c levels do not independently predict risk of atrial fibrillation after off-pump coronary artery bypass grafting.
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Affiliation(s)
- Pradeep Narayan
- Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Chandan Kumar Mandal
- Department of Anesthesia and Critical Care, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Rajlakshmi Das
- Department of Anesthesia and Critical Care, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Debasis Das
- Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Paramita Auddya Ghorai
- Department of Bio-Statistics, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Saibal Roy Chowdhury
- Department of Anesthesia and Critical Care, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
| | - Mrinalendu Das
- Department of Cardiac Surgery, NH Rabindranath Tagore International Institute of Cardiac Sciences, Kolkata, India
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Perdue JM, Ortiz AC, Parsikia A, Ortiz J. Kidney-Pancreas Transplant Recipients Experience Higher Risk of Complications Compared to the General Population after Undergoing Coronary Artery Bypass Grafting. Int J Angiol 2021; 30:107-116. [PMID: 34054268 DOI: 10.1055/s-0040-1721680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
This retrospective analysis aims to identify differences in surgical outcomes between pancreas and/or kidney transplant recipients compared with the general population undergoing coronary artery bypass grafting (CABG). Using Nationwide Inpatient Sample (NIS) data from 2005 to 2014, patients who underwent CABG were stratified by either no history of transplant, or history of pancreas and/or kidney transplant. Multivariate analysis was used to calculate odds ratio (OR) to evaluate in-hospital mortality, morbidity, length of stay (LOS), and total hospital charge in all centers. The analysis was performed for both nonemergency and emergency CABG. Overall, 2,678 KTx (kidney transplant alone), 184 PTx (pancreas transplant alone), 254 KPTx (kidney-pancreas transplant recipients), and 1,796,186 Non-Tx (nontransplant) met inclusion criteria. KPTx experienced higher complication rates compared with Non-Tx (78.3 vs. 47.8%, p < 0.01). Those with PTx incurred greater total hospital charge and LOS. On weighted multivariate analysis, KPTx was associated with an increased risk for developing any complication following CABG (OR 3.512, p < 0.01) and emergency CABG (3.707, p < 0.01). This risk was even higher at transplant centers (CABG OR 4.302, p < 0.01; emergency CABG OR 10.072, p < 0.001). KTx was associated with increased in-hospital mortality following emergency CABG, while PTx and KPTx had no mortality to analyze. KPTx experienced a significantly higher risk of complications compared with the general population after undergoing CABG, in both transplant and nontransplant centers. These outcomes should be considered when providing perioperative care.
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Affiliation(s)
- Jordyn M Perdue
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
| | | | - Afshin Parsikia
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
| | - Jorge Ortiz
- Department of Surgery, University of Toledo College of Medicine, Toledo, Ohio
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Ke Y, Shannon NB, Yek J, Sim E, Abdullah HR. A Newly Proposed HbA1C-Hemoglobin Ratio - A Better Predictor of Outcomes in Cardiac Surgery When Compared to HbA1C and Anemia Alone. Semin Thorac Cardiovasc Surg 2021; 33:750-759. [DOI: 10.1053/j.semtcvs.2020.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 11/05/2020] [Indexed: 12/20/2022]
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Relationship between Perioperative Cardiovascular Events and Glycated Hemoglobin in Diabetic Patients Undergoing Noncardiac Surgery. BIOMED RESEARCH INTERNATIONAL 2020; 2020:3645374. [PMID: 33381551 PMCID: PMC7762655 DOI: 10.1155/2020/3645374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/24/2020] [Accepted: 12/08/2020] [Indexed: 11/24/2022]
Abstract
This retrospective nested case-control study is aimed at investigating the relationship between HbAlc and perioperative cardiovascular events (PCE) in patients with diabetes who underwent complex or moderately complex noncardiac surgery at the Second Affiliated Hospital of Xinjiang Medical University in 2013-2018. The patients were divided into four groups according to HbA1c ≤7%, 7.1%-7.9%, 8.0%-8.9%, and ≥9%. The occurrence of PCE among the groups was compared using univariable and multivariable analyses. Finally, 318 patients were included. There were 90 cases of PCE among the 318 patients; the occurrence rate of PCE was 28.3%. No death occurred. The occurrence rates of PCE in the HbA1c ≥ 8.0% − 8.9% and HbA1c ≥ 9.0% groups were 30.8% and 35.4%, respectively (P < 0.001 vs. the HbA1c 7.1%-7.9% group). The occurrence rate of PCE in the HbA1c ≤ 7% group was 25.9% (P > 0.05 vs. the HbA1c 7.1%-7.9% group). The multivariable logistic regression analysis showed that the course of diabetes (HbA1c stratification ≤7%, 7.1%-7.9%, 8.0%-8.9%, ≥9%, OR = 3.672, 95% CI: 1.552-8.687), HbA1c (OR = 1.895, 95% CI: 1.227-4.830), SBP (OR = 1.194, 95% CI: 1.015-2.023), and microalbuminuria (OR = 1.098, 95% CI: 1.005-1.023) was independently associated with PCE in diabetic patients. In conclusion, HbA1c levels are related to the incidence of PCE in diabetic patients undergoing complex or moderately complex noncardiac surgery.
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Mufti HN, Jarad M, Haider MM, Azzhary L, Namnqani S, Husain I, Albugami S, Elamin W. Impact of Pre-operative Hemoglobin A1C Level and Microbiological Pattern on Surgical Site Infection After Cardiac Surgery. Cureus 2020; 12:e11851. [PMID: 33282606 PMCID: PMC7714741 DOI: 10.7759/cureus.11851] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2020] [Indexed: 01/19/2023] Open
Abstract
Background Surgical site infection (SSI) after cardiac surgery is a major concern. A limited number of studies have addressed the relationship of preoperative glycemic control on the risk of developing SSI after cardiac surgery. We aim to determine the incidence, microbiological pattern, and impact of preoperative hemoglobin A1C (Hgb A1C) on the development of SSI after cardiac surgery. Methods This is a single-center retrospective chart review that was performed on adult patients undergoing cardiac surgery from January 2017 to December 2018. Results Two hundred and twenty-nine patients underwent 233 procedures. The median age was 60 years; 71% males, 64% were diabetic, and 67% had a Hb A1C above 7% preoperatively. Around 7% of patients developed deep SSI. For patients that developed SSI, 63% had gram-negative bacteria. Hb A1C >7% was not found to be associated with an increased incidence of SSI. Conclusion Our results show that there is no apparent relationship between pre-operative Hgb A1C levels and SSI after cardiac surgery. Although we follow a comprehensive SSI perioperative bundle based on international guidelines that advocates using antibiotics to cover gram-positive organisms, it is interesting that the rate of gram-negative organisms in our patients' cohort is unexpectedly high. We believe that adjusting the perioperative antibiotic regimen based on local microbiological patterns seems to be a reasonable and easily achievable target to decrease the incidence of SSI.
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Affiliation(s)
- Hani N Mufti
- Cardiac Surgery, King Faisal Cardiac Center, King Abdullah Medical City, Jeddah, SAU
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Medicine, King Abdullah International Medical Research Center, Jeddah, SAU
| | - Mayar Jarad
- Medicine, Ibn Sina National College, Jeddah, SAU
| | | | | | | | - Imran Husain
- Cardiothoracic Surgery, The Golden Jubilee National Hospital, Glasgow, GBR
| | - Saad Albugami
- Cardiolgy, King Faisal Cardiac Center, King Abdullah Medical City, Jeddah, SAU
| | - Wael Elamin
- Cardiac Surgery, King Faisal Cardiac Center, King Abdulaziz Medical City, Jeddah, SAU
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Chancellor WZ, Mehaffey JH, Hawkins RB, Charles EJ, Tribble C, Yarboro LT, Ailawadi G, Kirby JL. Electronic Glycemic Management System and Endocrinology Service Improve Value in Cardiac Surgery. Am Surg 2020; 87:568-575. [PMID: 33118411 DOI: 10.1177/0003134820950685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Postoperative glycemic control improves cardiac surgery outcomes but insulin protocols are limited by complexity and inflexibility. We sought to evaluate the effect of implementing an electronic glycemic management system (eGMS) in conjunction with a cardiac surgery endocrinology consult service on glycemic control and outcomes after cardiac surgery. METHODS All patients with a calculated preoperative risk of mortality who underwent cardiac surgery before and after implementation of an eGMS and an endocrinology consult service were identified. Glycemic control and surgical outcomes were compared using univariate analysis, and multivariate regression was used to model the risk-adjusted effects of the interventions on glycemic control, surgical outcomes, and resource utilization. The health care-related value added by the interventions was calculated by dividing risk-adjusted outcomes by total hospital costs. RESULTS A total of 2612 patients were identified, with 1263 patients in the preimplementation cohort and 1349 in the postimplementation cohort. Multivariate regression demonstrated fewer postoperative hyperglycemic events (odds ratio [OR] 0.8, 95% CI, 0.65-0.99) after protocol implementation without an increase in hypoglycemic events (OR 0.96, 95% CI, 0.71-1.3). Average day-weighted mean glucose decreased from 144 to 138 mg/dL (P < .001). The improved glycemic control correlated with a risk-adjusted decrease in composite morbidity or mortality (OR 0.61, 95% CI, 0.47-0.79). Although hospital costs increased after implementation, the protocol increased health care-related value by 38%. CONCLUSION Implementation of a protocol consisting of an eGMS paired with a cardiac surgery-specific endocrinology consult service was associated with improved glycemic control and reduced morbidity. Despite higher costs health care-related value increased as a result of eGMS implementation.
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Affiliation(s)
- William Z Chancellor
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - James H Mehaffey
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Robert B Hawkins
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Eric J Charles
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Curt Tribble
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Leora T Yarboro
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Gorav Ailawadi
- 2358 Division of Thoracic and Cardiovascular Surgery, Department of Surgery, University of Virginia, Virginia, USA
| | - Jennifer L Kirby
- 2358 Division of Endocrinology and Metabolism, Department of Medicine, University of Virginia, Virginia, USA
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Izumi C, Eishi K, Ashihara K, Arita T, Otsuji Y, Kunihara T, Komiya T, Shibata T, Seo Y, Daimon M, Takanashi S, Tanaka H, Nakatani S, Ninami H, Nishi H, Hayashida K, Yaku H, Yamaguchi J, Yamamoto K, Watanabe H, Abe Y, Amaki M, Amano M, Obase K, Tabata M, Miura T, Miyake M, Murata M, Watanabe N, Akasaka T, Okita Y, Kimura T, Sawa Y, Yoshida K. JCS/JSCS/JATS/JSVS 2020 Guidelines on the Management of Valvular Heart Disease. Circ J 2020; 84:2037-2119. [DOI: 10.1253/circj.cj-20-0135] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Chisato Izumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kiyoyuki Eishi
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Kyomi Ashihara
- Department of Cardiology, Tokyo Women’s Medical University Hospital
| | - Takeshi Arita
- Division of Cardiovascular Medicine Heart & Neuro-Vascular Center, Fukuoka Wajiro
| | - Yutaka Otsuji
- Department of Cardiology, Hospital of University of Occupational and Environmental Health
| | - Takashi Kunihara
- Department of Cardiac Surgery, The Jikei University School of Medicine
| | - Tatsuhiko Komiya
- Department of Cardiovascular Surgery, Kurashiki Central Hospital
| | - Toshihiko Shibata
- Department of Cardiovascular Surgery, Osaka City University Postgraduate of Medicine
| | - Yoshihiro Seo
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences
| | - Masao Daimon
- Department of Clinical Laboratory/Cardiology, The University of Tokyo Hospital
| | | | | | - Satoshi Nakatani
- Division of Health Sciences, Osaka University Graduate School of Medicine
| | - Hiroshi Ninami
- Department of Cardiac Surgery, Tokyo Women’s Medical University
| | - Hiroyuki Nishi
- Department of Cardiovascular Surgery, Osaka General Medical Center
| | | | - Hitoshi Yaku
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine
| | | | - Kazuhiro Yamamoto
- Division of Cardiovascular Medicine, Endocrinology and Metabolism, Faculty of Medicine, Tottori University
| | | | - Yukio Abe
- Department of Cardiology, Osaka City General Hospital
| | - Makoto Amaki
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Masashi Amano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center
| | - Kikuko Obase
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center
| | - Takashi Miura
- Division of Cardiovascular Surgery, Nagasaki University Graduate School of Biomedical Sciences
| | | | - Mitsushige Murata
- Department of Laboratory Medicine, Tokai University Hachioji Hospital
| | - Nozomi Watanabe
- Department of Cardiology, Miyazaki Medical Association Hospital
| | - Takashi Akasaka
- Department of Cardiovascular Medicine, Wakayama Medical University
| | - Yutaka Okita
- Department of Cardiovascular Surgery, Takatsuki Hospital
| | - Takeshi Kimura
- Department of Cardiology, Kyoto University Graduate School of Medicine
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine
| | - Kiyoshi Yoshida
- Department of Cardiology, Sakakibara Heart Institute of Okayama
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Kotfis K, Jamioł-Milc D, Skonieczna-Żydecka K, Folwarski M, Stachowska E. The Effect of Preoperative Carbohydrate Loading on Clinical and Biochemical Outcomes after Cardiac Surgery: A Systematic Review and Meta-Analysis of Randomized Trials. Nutrients 2020; 12:nu12103105. [PMID: 33053694 PMCID: PMC7600335 DOI: 10.3390/nu12103105] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/04/2020] [Accepted: 10/06/2020] [Indexed: 12/11/2022] Open
Abstract
Background and aim: Preoperative fasting leads to metabolic stress and causes insulin resistance in patients undergoing cardiac surgery. The aim of this study was to assess the effect of preoperative oral carbohydrate loading (OCH) on outcome in patients undergoing planned cardiac surgery by systematically reviewing the literature and synthesizing evidence from randomized controlled trials (RCTs). Methods: Systematic search of PubMed/MEDLINE/Embase/Cinahl/Web of Science/ClinicalTrials databases was performed to identify relevant RCTs from databased inception until 05/03/2020. We included studies that compared outcome measures between OCH with control (placebo or standard starvation). We conducted a random-effect meta-analysis of clinical and biochemical parameters. Results: Nine studies (N = 9) were included with a total of 507 patients. OCH significantly decreased aortic clamping duration (n = 151, standardized mean difference (SMD) = −0.28, 95% confidence interval (CI) = −0.521 to −0.038, p = 0.023 and differences in means (DM) = −6.388, 95%CI = −11.246 to −1.529, p = 0.010). Patients from treatment groups had shorter intensive care unit (ICU) stay (n = 202, SMD = −0.542, 95%CI = −0.789 to −0.295, p < 0.001 and DM = −25.925, 95%CI = −44.568 to −7.283, p = 0.006) and required fewer units of insulin postoperatively (n = 85, SMD = −0.349, 95%CI = −0.653 to −0.044, p = 0.025 and DM = −4.523, 95%CI = −8.417 to −0.630, p = 0.023). The necessity to use inotropic drugs was significantly lower in the OCH group (risk ratio (RR) = 0.795, 95%CI = 0.689 to 0.919, p = 0.002). All other primary outcomes did not reveal a significant effect. Conclusions: Preoperative OCH in patients undergoing cardiac surgery demonstrated a 20% reduction in the use of inotropic drugs, a 50% reduction of the length of ICU stay, a 28% decrease in aortic clamping duration and a 35% decrease of postoperative insulin requirement.
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Affiliation(s)
- Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, 70-111 Szczecin, Poland;
| | - Dominika Jamioł-Milc
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; (K.S.-Ż.); (E.S.)
- Correspondence: ; Tel.: +48-91-441-48-06; Fax: +48-91-441-48-07
| | - Karolina Skonieczna-Żydecka
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; (K.S.-Ż.); (E.S.)
| | - Marcin Folwarski
- Department of Clinical Nutrition and Dietetics, Medical University of Gdansk, 80-210 Gdansk, Poland;
- Home Enteral and Parenteral Nutrition Unit, General Surgery, Nicolaus Copernicus Hospital, 80-210 Gdansk, Poland
| | - Ewa Stachowska
- Department of Human Nutrition and Metabolomics, Pomeranian Medical University in Szczecin, 71-460 Szczecin, Poland; (K.S.-Ż.); (E.S.)
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Kazui T, Lick SD, Hsu CH, Bull DA. Short-Term Risk of Bilateral Internal Mammary Artery Grafting in Diabetic Patients. Semin Thorac Cardiovasc Surg 2020; 33:382-392. [PMID: 32977011 DOI: 10.1053/j.semtcvs.2020.09.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 09/08/2020] [Indexed: 01/04/2023]
Abstract
This study compares the morbidity and mortality at 30 days following the use of bilateral internal mammary arteries (BIMA) vs a single internal mammary artery (SIMA) at the time of coronary artery bypass grafting (CABG) in patients with a preoperative HbA1c. Patients undergoing CABG from January 2008 to December 2016 reported to the Society of Thoracic Surgeons database were retrospectively reviewed. The patients were divided into 2 groups: use of BIMA or use of SIMA and propensity matched. To assess the effect of preoperative HbA1c, both groups were further divided into 5 subgroups: patients without diabetes mellitus (DM), or patients with DM and a preoperative HbA1c level in one of four groups (< 7%, 7-9%, 9-11%, or >11%). The postoperative outcomes in both the BIMA and SIMA groups were compared. There were 700,504 and 28,115 patients with measured preoperative HbA1c levels in the SIMA and BIMA groups, respectively. Propensity score matching identified 23,635 comparable patients in each group for analysis. There was no difference in postoperative mortality between the BIMA and SIMA groups (1.3% vs 1.2%). The incidences of sternal wound infection (SWI) in patients undergoing placement of BIMA vs SIMA were: 0.8% vs 0.4% with no DM (P < 0.0001), 1.9% vs 1.0% with HbA1c < 7% (P < 0.001), 2.4% vs 1.2% with HbA1c 7-9% (P < 0.001), 2.8% vs 1.4% with HbA1c 9-11% (P = 0.02), 4.1% vs 1.5% with HbA1c > 11% (P = 0.01). Based on the incidence of SWI, BIMA is a reasonable approach with an HbA1c<7%.
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Affiliation(s)
- Toshinobu Kazui
- Division of Cardiothoracic Surgery, The University of Arizona, College of Medicine/Banner University Medical Center Tucson, Tucson, Arizona.
| | - Scott D Lick
- Division of Cardiothoracic Surgery, The University of Arizona, College of Medicine/Banner University Medical Center Tucson, Tucson, Arizona
| | - Chiu-Hsieh Hsu
- Department of Epidemiology and Biostatistics, The University of Arizona Mel and Enid Zuckerman College of Public Health, Tucson, Arizona
| | - David A Bull
- Division of Cardiothoracic Surgery, The University of Arizona, College of Medicine/Banner University Medical Center Tucson, Tucson, Arizona
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Optimizing Bariatric Surgery outcomes: the impact of preoperative elevated hemoglobin A1c levels on composite perioperative outcome measures. Surg Endosc 2020; 35:4618-4623. [PMID: 32789589 PMCID: PMC8823948 DOI: 10.1007/s00464-020-07887-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/05/2020] [Indexed: 12/22/2022]
Abstract
Introduction The use of bariatric surgery in the management of obesity and its related morbidity has significantly increased in the US over the past decade. There is a lack of data on the impact of optimal preoperative glycemic control on the morbidity and mortality following bariatric surgery. The aim of this study was to analyze the impact of hemoglobin (Hb) A1c > 7 on outcomes among patients undergoing Roux-en-Y gastric bypass (RYGB) or sleeve gastrectomy (SG). Methods Data were extracted from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (2017) and limited to patients undergoing an elective laparoscopic RYGB or SG. Multivariable logistic regression was conducted to adjust for other preoperative variables. Results A total number of 31,060 (69.3%) patients underwent SG, while 13,754 (30.7%) received RYGB. Patients who were older, male, non-Hispanic, smokers, and those with a higher American Society of Anesthesiologist Classification (ASA) score were more likely to have elevated HbA1c levels. Compared to individuals with normal HbA1c levels, patients with elevated levels had no significant difference in mortality (p = 0.902) but did have a difference in composite morbidity and mortality (p < 0.001). On multivariable analysis, elevated HbA1c, older age, increasing body mass index (BMI), elevated creatinine, longer operations, African American race, receiving RYGB, and having a trainee as surgical assistant were found to increase the odds of having an adverse outcome. No significant difference was found within smoking status, sex, ASA Classification, robotic vs laparoscopic, or if a second attending surgeon was assisting. Conclusions HbA1c levels and presence of trainees in the OR are modifiable preoperative risk factors for adverse events following bariatric surgery. Improving preoperative glycemic control may be an effective and achievable quality improvement measure.
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Vogt AP, Bally L. Perioperative glucose management: Current status and future directions. Best Pract Res Clin Anaesthesiol 2020; 34:213-224. [DOI: 10.1016/j.bpa.2020.04.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 04/22/2020] [Accepted: 04/28/2020] [Indexed: 02/08/2023]
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Regnier SM, Khatibi B, Gabriel RA. Association of diabetes mellitus with postoperative opioid consumption in patients undergoing primary unilateral hip arthroplasty. J Perioper Pract 2020; 31:96-101. [PMID: 32096444 DOI: 10.1177/1750458920903647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Opioids are an indispensable component of perioperative pain management; however, the burgeoning opioid epidemic necessitates research into the risk factors for the development of opioid dependence and abuse following surgery. Diabetes has been identified as a risk factor for prolonged opioid utilisation following non-orthopaedic surgery; however, this association has not been investigated following orthopaedic surgery. To bridge this gap in the literature, we performed a retrospective propensity-matched cohort study in patients undergoing primary unilateral total hip arthroplasty. Propensity-matched cohorts were created to compare patients with and without preexisting diabetes mellitus. Outcomes of interest were opioid utilisation and subjective pain on postoperative day 1. Our results did not identify an association between preexisting diabetes and postoperative pain or opioid utilisation. While this study did not identify an association between diabetes and opioid utilisation following total hip arthroplasty, future studies should pursue a prospective, longitudinal approach and investigate other common orthopaedic procedures.
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Affiliation(s)
- Shane M Regnier
- Department of Anesthesiology, 8784University of California San Diego, San Diego, USA
| | - Bahareh Khatibi
- Department of Anesthesiology, 8784University of California San Diego, San Diego, USA
| | - Rodney A Gabriel
- Department of Anesthesiology, 8784University of California San Diego, San Diego, USA.,Department of Medicine, Division of Biomedical Informatics, 8784University of California San Diego, San Diego, USA
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