Association of fast-track cardiac management and low-dose to moderate-doseglucocorticoid administration with perioperative hyperglycemia

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 met hylprednisolone administration. Design: Retrospective sequential cohort study, Setting: University-affiliate Department of Veterans Affairs medical center . Participants: Fast-track patients (n = 293; n = 72 low-dose methylprednisol one [100-125 mg]; n = 221 moderate-dose methylprednisolone [500 mg]) plus p re-fast-track patients (n = 258; no methylprednisolone) undergoing cardiac surgery with cardiopulmonary bypass. Interventions: None. Measurements and Main Results: Multivariate linear regression was used to m odel 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 significantl y different among the pre-fast-track, fast-track with low-dose methylpredni solone, and fast-track with moderate-dose methylprednisolone cohorts (129 /- 54, 137 +/- 55, 127 +/- 46 mg/dL [mean +/- SD]). Postoperative serum glu cose concentrations were significantly different (171 +/- 58, 223 +/- 56, 2 50 +/- 75 mg/dL; p < 0.03, for all pairwise comparisons). Using backward el imination from the full 17-variable multivariate model (R-square = 0.63), 4 variables remained significant (all p < 0.0001; R-square = 0.60): (1) Preo perative diabetes status (adjusted mean postoperative glucose level, mg/dL; (95% confidence interval (CI)1): no treatment, 193 (188-199); oral agent, 276 (262-291); insulin requiring, 301 (283-320); (2) steroid group: pre-fas t-track, 201 (195-209), fast-track with low-dose methylprednisolone, 271 (2 56-287); 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 mt; and (4) intraoperative epinephrine inf usion: none, 231 (224-239); yes, 276 (264-288). No significant interactions were identified. No significant effect of opioid dose was observed. Conclusion:At this institution, implementation of the fast-track pathway wa s associated with a deterioration of glucose tolerance. Preoperative diabet es, pre-cardiopulmonary bypass administration of steroids, volume of glucos e-containing cardioplegia solution administered, and use of epinephrine inf usions were significantly associated multivariate factors. Copyright (C) 20 00 by W.B. Saunders Company.