Effects of cardiopulmonary bypass on glucose homeostasis after coronary artery bypass surgery
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Published on: March 23, 2018
Russell E Anderson1, Kerstin Brismar, Gunilla Barr
1Department of Cardiothoracic Surgery and Anaesthesiology, Karolinska University Hospital, S-171 76 Stockholm, Sweden. russell.anderson@kirurgi.ki.se
Insights
Cardiopulmonary bypass significantly worsens hyperglycemia and catabolism after coronary artery bypass surgery, requiring more insulin. This exacerbates glucose homeostasis disturbances already present from the surgery itself.
Area of Science:
- Cardiology
- Endocrinology
- Metabolic Surgery
Background:
- Hyperglycemia is a known complication of cardiac surgery, linked to increased mortality and morbidity.
- Surgical stress generally causes hyperglycemia, but cardiopulmonary bypass (CPB) is suspected as a primary driver in cardiac procedures.
Purpose of the Study:
- To investigate the specific contribution of cardiopulmonary bypass to hyperglycemia following coronary artery bypass (CAB) surgery.
- To compare glucose homeostasis and catabolism in patients undergoing CAB with and without CPB.
Main Methods:
- Randomized controlled trial comparing primary coronary artery bypass grafting with and without cardiopulmonary bypass.
- All patients received continuous insulin infusions and postoperative glucose infusions.
- Blood glucose, serum insulin, insulin-like growth factor-1 (IGF-1), and IGF binding protein-1 (IGFBP-1) were monitored for three days post-surgery.
Main Results:
- Patients undergoing CPB required 30% more insulin and exhibited higher post-meal blood glucose levels for three days.
- CPB led to a greater decrease in IGF-1 and increase in IGFBP-1, indicating heightened catabolism.
- The ratio of IGF-1 to IGFBP-1 and IGF-1 standard deviation score confirmed increased catabolism with CPB.
Conclusions:
- Glucose homeostasis is often disturbed preoperatively in non-diabetic patients undergoing coronary bypass surgery.
- Cardiopulmonary bypass significantly exacerbates postoperative hyperglycemia and catabolism compared to surgery without CPB.
Objective:
Hyperglycaemia is associated with increased mortality and morbidity after cardiac surgery. While surgical stress results in hyperglycaemia after all operations, it has been suggested that cardiopulmonary bypass is the dominating contributor after cardiac surgery. This study aimed to determine the contribution of cardiopulmonary bypass to hyperglycaemia after coronary artery bypass.
Methods:
Patients scheduled for primary coronary artery bypass grafting were randomised to surgery with or without cardiopulmonary bypass. All patients received continuous insulin infusions during the initial 24-h period. Glucose was infused (100mg/kg per h) postoperatively in the intensive care unit but not during surgery. Blood glucose was measured 4 times daily until the third postoperative day. Serum insulin, insulin-like growth factor-1 and its binding protein were determined.
Results:
Average blood glucose during the day of surgery did not differ between groups, but 30% more insulin (P=0.003) was required when cardiopulmonary bypass was used. Blood glucose 2-3h after meals was higher in patients using cardiopulmonary bypass during the first 3 postoperative days. Fasting blood glucose was still equally elevated 20-30% in both groups on the third postoperative day. Insulin-like growth factor-1 decreased more (P=0.01) and insulin-like growth factor binding protein-1 increased more (P<0.001) with cardiopulmonary bypass than without. The ratio of insulin-like growth factor-1 concentration to the concentration of its binding protein-1 was more negative (indicating greater catabolism) with cardiopulmonary bypass than without both postoperatively (P=0.002) and on the third postoperative day (P=0.02). Insulin-like growth factor-1 standard deviation score, also a measure of catabolism, was greater after surgery with cardiopulmonary bypass than without (P=0.02).
Conclusions:
Glucose homeostasis is disturbed preoperatively for many non-diabetic patients undergoing coronary bypass surgery. Cardiopulmonary bypass exacerbates the catabolism and disturbed glucose homeostasis that is induced also to a lesser degree by surgery without cardiopulmonary bypass.
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