Donihi, Amy C, PharmD, BCPS

Eder, Raymond A, PharmD

Jampana, Srinivasa, MD

Johnston, Jann M, MD

Korytkowski, Mary T, MD

Magaji, Vasudev, MD, MS

Nayak, Shriddha, MD

Nivedita, Parachur, MD

Willard, Lauren, DO

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health Network LVHN Scholarly Works Department of Medicine Efficacy and Safety of Continuous Insulin Infusion Protocols With Glycemic Targets of 110-140 mg/dL in Patients With and Without Diabetes Following Cardiac Surgery Shriddha Nayak MD Vasudev Magaji MD, MS Lehigh Valley Health Network, vasudev_g.magaji@lvhn.org Amy C. Donihi PharmD, BCPS Lauren Willard DO Srinivasa Jampana MD See next page for additional authors Follow this and additional works at: https://scholarlyworks.lvhn.org/medicine  Part of the Cardiology Commons, Endocrinology, Diabetes, and Metabolism Commons, Medical Sciences Commons, and the Surgery Commons Published In/Presented At Nayak, S., Magaji, V., Donihi, A., Willard, L., Jampana, S., Nivedita, P., Eder, R., Johnston, J., & Korytkowski, M. (2014). Efficacy and safety of continuous insulin infusion protocols with glycemic targets of 110-140 mg/dL in patients with and without diabetes following cardiac surgery. Journal of Diabetes Science and Technology, 8(2), 425-426. doi:10.1177/1932296814522747 [epub ahead of print] This Article is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by an authorized administrator. For more information, please contact LibraryServices@lvhn.org. Authors Shriddha Nayak MD; Vasudev Magaji MD, MS; Amy C. Donihi PharmD, BCPS; Lauren Willard DO; Srinivasa Jampana MD; Parachur Nivedita MD; Raymond A. Eder PharmD; Jann M. Johnston MD; and Mary T. Korytkowski MD This article is available at LVHN Scholarly Works: https://scholarlyworks.lvhn.org/medicine/401 Journal of Diabetes Science and Technology2014, Vol. 8(2) 425 –426© 2014 Diabetes Technology SocietyReprints and permissions: sagepub.com/journalsPermissions.navDOI: 10.1177/1932296814522747dst.sagepub.comLetter to the EditorContinuous insulin infusion (CII) protocols with glycemic targets 110-140 mg/dl are suggested following cardiac sur-gery in patients with and without diabetes provided that these targets can be achieved with low risk for moderate (MH) and severe (SH) hypoglycemia.1-4 The purpose of this investiga-tion was to investigate differences in efficacy and safety of these targets according to diabetes status.Glycemic data were collected from 247 consecutive patients treated with 1 of 2 published CII protocols (P1 and P2) targeting blood glucose (BG) 110-140 mg/dl for ≤48 hours following cardiac surgery.5 Diabetes status was defined by medical record documentation or preoperative A1c ≥ 6.5%.6 Protocol efficacy was measured by time to BG target; percentage of BG 70-109, 110-140, 141-180, and >180 mg/dl; and percentage of patients with BG in target after goal achieved. Glycemic variability was determined as the BG coefficient of variation (CV). Protocol safety was defined as percentage of BG 40-69 mg/dl (MH) and <40 mg/dl (SH) and percentage of patients experiencing MH or SH. Statistical analysis was performed using SPSS version 17 software (SPSS Inc, Chicago, IL).With the exception of older age in P1 subjects without diabetes, and higher A1c in P1 patients with and without dia-betes, no differences were observed in clinical characteristics (Table 1). Glycemic outcomes were similar for patients with and without diabetes treated with P1, but not P2, where dia-betes patients were less likely to have BG within goal, with higher mean BG and more glycemic variability than P2 patients without diabetes. P2 diabetes patients were older, were more obese, required more pressors, and took longer to achieve goal than those without diabetes. When comparing P1 and P2 diabetes groups, there were no differences in the percentage of patients treated with insulin (31% vs 42%) or oral agents (39% vs 49%) prior to admission. P1 diabetes patients had fewer valve procedures, received less pressor therapy, had lower baseline and mean BG, and had more BG within and below goal (Table 1). When comparing nondiabe-tes groups, P1 patients had more coronary artery bypass grafting (CABG) and fewer valve procedures. P1 versus P2 patients had lower mean BG and more BG below goal. The frequency of both MH and SH was low in all patients, expressed as percentage of BG measures, or as the number of patients experiencing hypoglycemia (Table 1). There were no differences in hospital LOS between the P1 and P2 diabe-tes (11.6 ± 5.5 vs 13.2 ± 7.4 days, P = .25) and nondiabetes (10.5 ± 4.5 vs 10.8 ± 8.7 days, P = .85) groups.In summary, this study demonstrates the efficacy and safety of 2 CII protocols with glycemic targets of 110-140 mg/dl in patients with and without diabetes following car-diac surgery.1,2,4 Despite noted differences in glycemic out-comes between protocols, mean BG was well within the desired range in all subgroups. The ability to achieve desired BG targets with low incidence of MH and SH in patients with and without diabetes supports suggested glycemic 522747 DSTXXX10.1177/1932296814522747Journal of Diabetes Science and TechnologyNayak et alresearch-article20141School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA2Lehigh Valley Hospital, Allentown, PA, USA3Department of Pharmacy, University of Pittsburgh School of Pharmacy, Pittsburgh, PA, USA4Department of Medicine University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA, USA5Duquesne University School of Pharmacy, Pittsburgh, PA, USA6Division of Endocrinology, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, PA, USA7Division of Endocrinology and Metabolism, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USACorresponding Author:Mary T. Korytkowski, MD, University of Pittsburgh Medical Center, Falk, Ste 560, 3601 Fifth Ave, Pittsburgh, PA 15213, USA. Email: mtk7@pitt.eduEfficacy and Safety of Continuous Insulin Infusion Protocols With Glycemic Targets of 110-140 mg/dL in Patients With and Without Diabetes Following Cardiac SurgeryShriddha Nayak, MD1, Vasudev Magaji, MD2, Amy C. Donihi, PharmD, BCPS3, Lauren Willard, DO4, Srinivasa Jampana, MD4, Parachur Nivedita, MD4, Raymond Eder, PharmD5, Jann Johnston, MD6, and Mary T. Korytkowski, MD7Keywordscardiac surgical procedures, clinical protocols, diabetes, hyperglycemia, insulin, intensive care426 Journal of Diabetes Science and Technology 8(2)targets of 110-140 mg/dL following cardiac surgery, meeting the criterion that these goals be safely achieved.5AbbreviationsBG, blood glucose; BMI, body mass index; CABG, coronary artery bypass grafting; CII, continuous insulin infusion; CV, coefficient of variation; GFR, glomerular filtration rate; MH, moderate hypogly-cemia; SH, severe hypoglycemia; P1, protocol 1; P2, protocol 2.Authors’ NoteThis study was presented as an abstract at the 2012 meeting of the American Diabetes Association.Declaration of Conflicting InterestsThe author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: MTK receives grant support from Sanofi-Aventis. JJ is on the speaker’s bureau for Sanofi, Lilly, and Medtronic.FundingThe author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was supported in part by NIDDK—T35DK065521, Training in Renal, GI, Endocrine and Epithelial Biology.References 1. Moghissi ES, Korytkowski MT, DiNardo M, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glyce-mic control. Endocr Pract. 2009;15:353-369. 2. Moghissi ES, Korytkowski MT, DiNardo MM, et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glyce-mic control. Diabetes Care. 2009;32:1119-1131. 3. Umpierrez GE, Hellman R, Korytkowski MT, et al. Management of hyperglycemia in hospitalized patients in non-critical care setting: an endocrine society clinical practice guideline. J Clin Endocrinol Metab. 2012;97:16-38. 4. Finfer S, Liu B, Chittock DR, et al. Hypoglycemia and risk of death in critically ill patients. N Engl J Med. 2012;367:1108-1118. 5. Magaji V, Nayak S, Donihi AC, et al. Comparison of insulin infusion protocols targeting 110-140 mg/dl in patients after cardiac surgery. Diabetes Technol Ther. 2012;14:1013-1017. 6. American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care. 2013;36:S11-S66.Table 1. Clinical Characteristics of the Study Population.Diabetes group Nondiabetes groupP value Protocol 1 (n = 49) Protocol 2 (n = 43) P value Protocol 1 (n = 57) Protocol 2 (n = 79)Age (years) 63 [33-92] 62 [37-83]* .76 66 [33-89] 59 [26-85]* .003Male (%) 63.2 72 .36 63.1 64.5 .86BMI 30.2 [18.9-47] 32 [21-50]* .263 29.3 [19.8-50] 28.6 [18-50]* .309A1c (%) preoperative 7.0 [4.6-11.8]‡ 6.5 [4.3-11.1]† .008 5.8 [4.9-6.4]‡ 5.6 [4.3-6.4]† .004GFR (ml/min/1.73 m2) 76 [12-162] 74 [6-147] .515 81 [15-138] 81.7 [8-167] .875Type of procedureCABG 74% 58.1% .076 68.4% 40.5% .001CABG + valve 12.0% 9.3% .651 17.5% 12.6% .42Valve 8.0% 23.2% .044 14.0% 45.5% <.001Other 4.0% 9.3% .312 0.0% 1.2% .39Surgery duration 5 [2-7] 5 [2-9] .096 4 [3-8] 5 [1-11] .17Hematocrit (%) 28 [21-42] 27 [19-39] .130 27 [20-38] 28 [21-39] .09Pressor use (%) 55.1 79* .015 61.4 58.2* .710Glycemic outcomesBaseline BG (mg/dl) 141 ± 37 159 ± 36 .02 155 ± 42 147 ± 39 .245Time to goal (hours) 5.2 [0.8-19.4] 6.6 [1.8-12.7]† .09 2.8 [0.2-9.85] 4.1 [0.9-19.8]† .03% BG 110-140 mg/dL 42 36 .03 46 48 .21% BG 141-180 mg/dL 23 30 .006 20 26 .015% BG > 180 mg/dL 7 13 .02 5 5 .85% BG 70-109 mg/dL 26 20 .04 28 20 .001% BG 40-69 mg/dl 1.3 0.8 .27 0.7 0.9 .45% BG < 40 mg/dl 0.07 0.00 .35 0.00 0.00 —% patients with MH 29 16 .17 18 18 .98% patients with SH 1 0 1.00 0 0 —Mean BG after goal achieved 123 ± 11 133 ± 14 <.001 121 ± 10 126 ± 9 .003% patients with mean BG in target after goal achieved 76 74 .90 86 89 .65CV 21 ± 4 24 ± 7 .08 21 ± 8 20 ± 5 .22Duration CII (hrs) 44 [18-136] 44 [21-166] .66 43 [11-115] 43 [16-123] .77*P < .05 for diabetes versus no diabetes with protocol 2. †P < .01 for diabetes versus no diabetes with protocol 2. ‡P < .01 for diabetes versus no diabetes with protocol 1.

Efficacy and Safety of Continuous Insulin Infusion Protocols With Glycemic Targets of 110-140 mg/dL in Patients With and Without Diabetes Following Cardiac Surgery

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Efficacy and Safety of Continuous Insulin Infusion Protocols With Glycemic Targets of 110-140 mg/dL in Patients With and Without Diabetes Following Cardiac Surgery

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