title: Intraoperative tight glucose control using hyperinsulinemic normoglycemia increases delirium after cardiac surgery.
abstract: BACKGROUND
  Postoperative delirium is common in patients recovering from cardiac surgery. Tight glucose control has been shown to reduce mortality and morbidity. Therefore, the authors sought to determine the effect of tight intraoperative glucose control using a hyperinsulinemic-normoglycemic clamp approach on postoperative delirium in patients undergoing cardiac surgery.
  
  
  METHODS
  The authors enrolled 198 adult patients having cardiac surgery in this randomized, double-blind, single-center trial. Patients were randomly assigned to either tight intraoperative glucose control with a hyperinsulinemic-normoglycemic clamp (target blood glucose, 80 to 110 mg/dl) or standard therapy (conventional insulin administration with blood glucose target, <150 mg/dl). Delirium was assessed using a comprehensive delirium battery. The authors considered patients to have experienced postoperative delirium when Confusion Assessment Method testing was positive at any assessment. A positive Confusion Assessment Method was defined by the presence of features 1 (acute onset and fluctuating course) and 2 (inattention) and either 3 (disorganized thinking) or 4 (altered consciousness).
  
  
  RESULTS
  Patients randomized to tight glucose control were more likely to be diagnosed as being delirious than those assigned to routine glucose control (26 of 93 vs. 15 of 105; relative risk, 1.89; 95% CI, 1.06 to 3.37; P = 0.03), after adjusting for preoperative usage of calcium channel blocker and American Society of Anesthesiologist physical status. Delirium severity, among patients with delirium, was comparable with each glucose management strategy.
  
  
  CONCLUSIONS
  Intraoperative hyperinsulinemic-normoglycemia augments the risk of delirium after cardiac surgery, but not its severity.
authors.affiliation: From the Departments of Outcomes Research (L.S., A.E.D., J.-P.Y., B.D.H., J.Y., D.I.S., A.K.), Cardiothoracic Anesthesia (A.E.D., J.-P.Y.), Quantitative Health Sciences (J.Y.), Regional Practice Anesthesiology (A.D.), and General Anesthesiology (A.K.), Cleveland Clinic, Cleveland, Ohio.
authors.forename: Leif
authors.initials: L
authors.lastname: Saager
authors.forename: Andra E
authors.initials: AE
authors.lastname: Duncan
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Yared
authors.forename: Brian D
authors.initials: BD
authors.lastname: Hesler
authors.forename: Jing
authors.initials: J
authors.lastname: You
authors.forename: Anupa
authors.initials: A
authors.lastname: Deogaonkar
authors.forename: Daniel I
authors.initials: DI
authors.lastname: Sessler
authors.forename: Andrea
authors.initials: A
authors.lastname: Kurz
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001786:Blood Glucose / Q000032:analysis*; D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000523:psychology; D003221:Confusion / Q000523:psychology; D003693:Delirium / Q000139:chemically induced* / Q000523:psychology*; D004311:Double-Blind Method; D005260:Female; D015309:Glucose Clamp Technique; D006801:Humans; D006946:Hyperinsulinism / Q000097:blood* / Q000523:psychology*; D007430:Intraoperative Care / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009483:Neuropsychological Tests; D011183:Postoperative Complications / Q000139:chemically induced* / Q000523:psychology*
chemical_list: D001786:Blood Glucose