title: Perioperative hyperglycemia is associated with postoperative neurocognitive disorders after cardiac surgery.
abstract: OBJECTIVE
  Neurocognitive disorders commonly occur following cardiac surgery. However, the underlying etiology of these disorders is not well understood. The current study examined the association between perioperative glucose levels and other risk factors and the onset of neurocognitive disorders in adult patients following coronary artery bypass and/or valvular surgery.
  
  
  METHODS
  Adult patients who underwent their first cardiac surgery at a large tertiary care medical center were identified and those with neurocognitive disorders prior to surgery were excluded. Demographic, perioperative, and postoperative neurocognitive outcome data were extracted from the Society for Thoracic Surgery database, and from electronic medical records, between January 2004 and June 2009. Multiple clinical risk factors and measures associated with insulin resistance, such as hyperglycemia, were assessed. Multivariable Cox competing risk survival models were used to assess hyperglycemia and postoperative neurocognitive disorders at follow up, adjusting for other risk factors and confounding variables.
  
  
  RESULTS
  Of the 855 patients included in the study, 271 (31.7%) had new onset neurocognitive disorders at follow-up. Age, sex, New York Heart Failure (NYHF) Class, length of postoperative intensive care unit stay, perioperative blood product transfusion, and other key factors were identified and assessed as potential risk factors (or confounders) for neurocognitive disorders at follow-up. Bivariate analyses suggested that new onset neurocognitive disorders were associated with NYHF Class, cardiopulmonary bypass, history of diabetes, intraoperative blood product use, and number of diseased coronary vessels, which are commonly-accepted risk factors in cardiac surgery. In addition, higher first glucose level (median =116 mg/dL) and higher peak glucose >169 mg/dL were identified as risk factors. Male sex and nonuse of intra-operative blood products appeared to be protective. Controlling for potential risk factors and confounders, multivariable Cox survival models suggested that increased perioperative first glucose measured in 20 unit increments, was significantly associated with the onset of postoperative neurocognitive disorders at follow-up (hazard ratio [HR] =1.16, P<0.001) and that women had an elevated risk for this outcome (HR =4.18, P=0.01).
  
  
  CONCLUSIONS
  Our study suggests that perioperative hyperglycemia was associated with new onset of postoperative neurocognitive disorders in adult patients after cardiac surgery, and that men tended to be protected from these outcomes. These findings may suggest a need for the revision of clinical protocols for perioperative insulin therapy to prevent long-term neurocognitive complications.
authors.affiliation: Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA.
authors.forename: Xiaopeng
authors.initials: X
authors.lastname: Zhang
authors.affiliation: Center for Health Research, Geisinger Clinic, Danville, PA, USA.
authors.forename: Xiaowei
authors.initials: X
authors.lastname: Yan
authors.affiliation: Center for Health Research, Geisinger Clinic, Danville, PA, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Gorman
authors.affiliation: Department of Neurology, Geisinger Medical Center, Danville, PA, USA.
authors.forename: Stuart N
authors.initials: SN
authors.lastname: Hoffman
authors.affiliation: Department of Anesthesiology, Geisinger Medical Center, Danville, PA, USA.
authors.forename: Li
authors.initials: L
authors.lastname: Zhang
authors.affiliation: Center for Health Research, Geisinger Clinic, Danville, PA, USA.
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Boscarino
keywords: gender; insulin resistance; intensive care; neurocognitive disorders