title: Association of fast-track cardiac management and low-dose to moderate-dose glucocorticoid administration with perioperative hyperglycemia.
abstract: OBJECTIVE
  To delineate associations between preoperative risk factors and clinical processes of care and perioperative glucose tolerance in patients managed on a fast-track cardiac surgery clinical pathway with prebypass methylprednisolone administration.
  
  
  METHODS
  Retrospective sequential cohort study.
  
  
  METHODS
  University-affiliated Department of Veterans Affairs medical center.
  
  
  METHODS
  Fast-track patients (n = 293; n = 72 low-dose methylprednisolone [100-125 mg]; n = 221 moderate-dose methylprednisolone [500 mg]) plus pre-fast-track patients (n = 258; no methylprednisolone) undergoing cardiac surgery with cardiopulmonary bypass.
  
  
  METHODS
  None.
  
  
  RESULTS
  Multivariate linear regression was used to model the association of 17 preoperative risk and intraoperative process-of-care variables with serum glucose concentration on arrival in the intensive care unit. Preoperative serum glucose concentrations were not significantly different among the pre-fast-track, fast-track with low-dose methylprednisolone, and fast-track with moderate-dose methylprednisolone cohorts (129 +/- 54, 137 +/- 55, 127 +/- 46 mg/dL [mean +/- SD]). Postoperative serum glucose concentrations were significantly different (171 +/- 58, 223 +/- 56, 250 +/- 75 mg/dL; p < 0.03, for all pairwise comparisons). Using backward elimination from the full 17-variable multivariate model (R-square = 0.63), 4 variables remained significant (all p < 0.0001; R-square = 0.60): (1) Preoperative diabetes status (adjusted mean post-operative glucose level, mg/dL; [95% confidence interval (CI)]): no treatment, 193 (188-199); oral agent, 276 (262-291); insulin requiring, 301 (283-320); (2) steroid group: pre-fast-track, 201 (195-209), fast-track with low-dose methylprednisolone, 271 (256-287); fast-track with moderate-dose methylprednisolone, 295 (284-306); (3) volume of glucose-containing cardioplegia (beta coefficient, 95% CI): 2.22% (1.37-3.10) increase per 100 mL; and (4) intraoperative epinephrine infusion: none, 231 (224-239); yes, 276 (264-288). No significant interactions were identified. No significant effect of opioid dose was observed.
  
  
  CONCLUSIONS
  At this institution, implementation of the fast-track pathway was associated with a deterioration of glucose tolerance. Preoperative diabetes, pre-cardiopulmonary bypass administration of steroids, volume of glucose-containing cardioplegia solution administered, and use of epinephrine infusions were significantly associated multivariate factors.
authors.affiliation: Department of Anesthesia and Perioperative Medicine, University of California, San Francisco, San Francisco Veterans Affairs Medical Center, 94121, USA.
authors.forename: M J
authors.initials: MJ
authors.lastname: London
authors.forename: G K
authors.initials: GK
authors.lastname: Grunwald
authors.forename: A L
authors.initials: AL
authors.lastname: Shroyer
authors.forename: F L
authors.initials: FL
authors.lastname: Grover
mesh_terms: D000368:Aged; D001786:Blood Glucose / Q000378:metabolism; D006348:Cardiac Surgical Procedures / Q000009:adverse effects*; D015331:Cohort Studies; D005260:Female; D005938:Glucocorticoids / Q000008:administration & dosage / Q000009:adverse effects*; D005951:Glucose Tolerance Test; D006801:Humans; D006943:Hyperglycemia / Q000139:chemically induced*; D007431:Intraoperative Complications / Q000139:chemically induced*; D016014:Linear Models; D008297:Male; D008775:Methylprednisolone / Q000008:administration & dosage / Q000009:adverse effects*; D008875:Middle Aged; D011184:Postoperative Period; D012189:Retrospective Studies; D012307:Risk Factors
chemical_list: D001786:Blood Glucose; D005938:Glucocorticoids; D008775:Methylprednisolone