Çağlar ÖDEK, Tanıl KENDİRLİ, Nihan YILDIRIM YILDIZ, Ayhan YAMAN, Tayfun UÇAR, Zeynep EYİLETEN, CAN ATEŞ, Adnan UYSALEL, Ercan TUTAR, Semra ATALAY

Perioperative factors associated with hyperglycemia after pediatric cardiac surgery and impact of hyperglycemia on morbidity and mortality

This retrospective, observational, single-center study aimed to determinethe perioperative factors associated with postoperative hyperglycemia (bloodglucose level ≥126 mg/dl) and the impact of hyperglycemia on morbidity andmortality in a cohort of children undergoing cardiac surgery. Non-diabeticchildren aged between 1 month to 18 years who were consecutively admittedto pediatric intensive care unit (PICU) after cardiac surgery for congenitalheart disease between January 2008 and December 2013 were included.One hundred and twenty-six patients were qualified for inclusion during thestudy period. Seventy-four (57.8%) of the patients had at least one glucosemeasurement ≥ 126 mg/dl. Higher PRISM III-24 (OR 1.1, 95% CI 1.02-1.18, p= 0.004) and PELOD (p=0.006) scores, higher Wernovsky inotropicscore (p=0.027) and vasoactive-inotropic score (p=0.029) were associatedwith hyperglycemia. Postoperative hyperglycemia was not associated withduration of mechanical ventilation), length of PICU stay, healthcare associatedinfections, or mortality. Our study establishes that hyperglycemia is commonafter pediatric cardiac surgery but not associated with short-term morbidityand mortality. Insulin therapy can be accomplished without hypoglycemiawhen a permissive glycemic target is used. A large prospective multipleinstitution trial is necessary to facilitate defined guidelines for postoperativehyperglycemia after pediatric cardiac surgery.

PDF

___

1. Ulate KP, Zimmerman JJ. Common endocrinopathies in the pediatric intensive care unit. In: Fuhrman BP, Zimmerman J, Carcillo JA, Clark RS, Rotta AT, Tobias JD, Relvas MS, Thompson AE (eds). Pediatric Critical Care (4th ed). Philadelphia: Elsevier, 2011: 1105-1123.

2. Ulate KP, Falcao GC, Bielefeld MR, Morales JM, Rotta AT. Strict glycemic targets need not to be so strict: a more permissive glycemic range for critically ill children. Pediatrics 2008; 122: e898-e904.

3. Moga MA, Manlhiot C, Marwali EM, McCrindle BW, Van Arsdell GS, Schwartz SM. Hyperglycemia after pediatric cardiac surgery: Impact of age and residual lesions. Crit Care Med 2011; 39: 266-272.

4. Falcao G, Ulate K, Kouzekanani K, Bielefeld MR, Morales JM, Rotta AT. Impact of postoperative hyperglycemia following surgical repair of congenital cardiac defects. Pediatr Cardiol 2008; 29: 628-636.

5. Yates AR, Dyke PC 2nd, Taeed R, et al. Hyperglycemia is a marker for poor outcome in the postoperative pediatric cardiac patient. Pediatr Crit Care Med 2006; 7: 351-355.

6. Lou S, Ding F, Long C, Jinping Liu, Ju Zhao, Zhengyi Feng. Effects of peri-operative glucose levels on adverse outcomes in infants receiving open-heart surgery for congenital heart disease with cardiopulmonary bypass. Perfusion 2011; 26: 133-139.

7. Rossano JW, Taylor MD, Smith EO, et al. Glycemic profile in infants who have undergone the arterial switch operation: Hyperglycemia is not associated with adverse events. J Thorac Cardiovasc Surg 2008; 135: 739-745.

8. Krueger JJ, Brotschi B, Balmer C, Bernet V, Latal B. Postoperative hyperglycemia and 4-year neurodevelopmental outcome in children operated for congenital heart disease. J Pediatr 2015; 167: 1253- 1258.

9. Agus MS, Steil GM, Wypij D, et al.; SPECS Study Investigators. Tight glycemic control versus standard care after pediatric cardiac surgery. N Engl J Med 2012; 367: 1208-1219.

10. Macrae D, Grieve R, Allen E, et al.; CHiP Investigators. A randomized trial of hyperglycemic control in pediatric intensive care. N Engl J Med 2014; 370: 107-118.

11. Jenkins KJ. Risk adjustment for congenital heart surgery: the RACHS-1 method. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2004; 7: 180-184.

12. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2005; 28(Suppl 1): S37-S42.

13. Langdon DR, Stanley CA, Sperling MA. Hypoglycemia in the toddler and child. In: Sperling MA (ed). Pediatric Endocrinology (4th ed). Philadelphia: Elsevier, 2014: 920-955.

14. Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6: 2-8.

15. Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24: 743-752.

16. Leteurtre S, Martinot A, Duhamel A, et al. Validation of the Paediatric Logistic Organ Dysfunction (PELOD) score: prospective, observational, multicenter study. Lancet 2003; 362: 192-197.

17. Wernovsky G, Wypij D, Jonas RA, et al. Postoperative course and hemodynamic profile after the arterial switch operation in neonates and infants: A comparison of low-flow cardiopulmonary bypass and circulatory arrest. Circulation 1995; 92: 2226-2235.

18. Gaies MG, Gurney JG, Yen AH, et al. Vasoactiveinotropic score as a predictor of morbidity and mortality in infants after cardiopulmonary bypass. Pediatr Crit Care Med 2010; 11: 234-238.

19. Alaei F, Davari PN, Alaei M, Azarfarin R, Soleymani E. Postoperative outcome for hyperglycemic pediatric cardiac surgery patients. Pediatr Cardiol 2012; 33: 21-26.

20. Ulate KP, Raj S, Rotta AT. Critical illness hyperglycemia in pediatric cardiac surgery. J Diabetes Sci Technol 2012; 6: 29-36.

21. Gaynor JW, Berkowitz DH. Cardiac bypass for repair of congenital heart disease in infants and children. In: Fuhrman BP, Zimmerman J, Carcillo JA, Clark RS, Rotta AT, Tobias JD, Relvas MS, Thompson AE (eds). Pediatric Critical Care (4th ed). Philadelphia: Elsevier, 2011: 379-400.

22. Floh AA, Manlhiot C, Redington AN, et al. Insulin resistance and inflammation are a cause of hyperglycemia after pediatric cardiopulmonary bypass surgery. J Thorac Cardiovasc Surg 2015; 150: 498-504.e1.

23. de Betue CT, Verbruggen S, Schierbeek H, et al. Does a reduced glucose intake prevent hyperglycemia in children early after cardiac surgery? A randomized controlled crossover study. Critical Care 2012; 16: R176.

24. Güvener M, Korun O, Demirtürk OS. Risk factors for systemic inflammatory response after congenital cardiac surgery. J Card Surg 2015; 30: 92-96.

25. Boehne M, Sasse M, Karch A, et al. Systemic inflammatory response syndrome after pediatric congenital heart surgery: Incidence, risk factors, and clinical outcome. J Card Surg 2017; 32: 116-125.

26. Verhoeven JJ, Hokken-Koelega AC, den Brinker M, et al. Disturbance of glucose homeostasis after pediatric cardiac surgery. Pediatr Cardiol 2011; 32: 131-138.

27. Polito A, Thiagarajan RR, Laussen PC, et al. Association between intraoperative and early postoperative glucose levels and adverse outcomes after complex congenital heart surgery. Circulation 2008; 118: 2235-2242.

28. Vlasselaers D, Milants I, Desmet L, et al. Intensive insulin therapy for patients in paediatric intensive care: A prospective, randomised controlled study. Lancet 2009; 373: 547-556.

29. Mahle WT. A little sugar never hurt anyone: Hyperglycemia after infant heart surgery. J Pediatr 2015; 167: 1185-1186.