Percentage of adult patients, undergoing open cardiac surgery with any intraoperative blood glucose value < 70 mg/dL.

The chosen threshold of <70mg/dL is consistent with the Society of Thoracic Surgeons (STS) Practice Guidelines which recommends maintaining serum glucose levels ≤ 180 mg/dL for at least 24 hours after cardiac surgery.¹ This is also consistent with the 2020 Updates from the Adult Cardiac Anesthesiology Section of STS,² guidelines for perioperative care in cardiac surgery: enhanced recovery after surgery,^3,4 as well as other supporting literature emphasizing the impact of glucose managements on outcomes in cardiac surgery.^5-11

The American Diabetes Association also uses an outpatient hypoglycemia definition of <70 mg/dL.^12,13 Severe hypoglycemia in inpatients is considered <40mg/dL.¹³ Acute hypoglycemia in the perioperative period can lead to inadequate supply of glucose to the brain, resulting in seizures, permanent brain damage, and death. In hospitalized diabetic patients, hypoglycemia has been associated with increased length of stay and mortality.¹⁴ The risk of negative sequelae related to hypoglycemia is reduced with early recognition and treatment of mild to moderate hypoglycemia (40-69mg/dL).^12,15,16 The common signs/symptoms of hypoglycemia are masked by general anesthesia, making vigilance and quick treatment especially important.¹⁷ Fasting patients with or without diabetes and diabetic patients treated with oral glycemic agents or insulin are at increased risk of perioperative hypoglycemia.^18-19

Perioperative hypoglycemia is a rare event typically caused by the following: ²⁰

• Insulin overdose, either by patient taking higher than normal doses on the morning of surgery or by providers giving more insulin than necessary
• Septic or circulatory shock
• Failure to monitor

Anesthesia Start to 15 minutes after Anesthesia End

Adult patients undergoing open cardiac surgical procedures (determined by Procedure Type: Cardiac value code: 1).

• Age < 18 years
• ASA 6 (Organ Procurement - CPT: 01990)
• Non-cardiac, Transcatheter/Endovascular, EP/Cath, and Other Cardiac cases (determined by Procedure Type: Cardiac value codes: 0, 2, 3, and 4)

• The lowest blood glucose was maintained at >/=70 mg/dL, or
• Glucose <70mg/dL that was rechecked within 15 minutes and found to be >/=70mg/dL.

• Evaluate each low glucose between anesthesia start and end. If *none* of the conditions are true for a given low glucose, the case is marked as passed.
  • Blood glucose <70mg/dL is rechecked within 15 minutes and found to be <70mg/dL = flagged.
  • Blood glucose <70 mg/dL is not rechecked within 15 minutes = flagged.
• Any case with a glucose <70mg/dL that was rechecked within 15 minutes and found to be >/=70mg/dL = pass.
• If no low glucose values <70 mg/dL are documented between anesthesia start and end, case is passed.
• If two blood glucose levels are documented in the same minute, the higher blood glucose will be considered for this measure (in the case of spurious values that were rechecked)
• If no blood glucose values are documented for a case, then the case will be flagged, as blood glucose values should be checked multiple times throughout the case to ensure adequate blood glucose control.
• All values mapped to glucose MPOG concepts with SI units (mmol/L) will be converted to mg/dL (mmol/L * 18.018 = mg/dL)

*This measure will include valid MPOG cases defined by the Is Valid Case phenotype.

Not applicable.

Provider(s) signed in at the first blood glucose of <70mg/dL that was not rechecked and found to be >/=70 will be attributed. In the event that two or more providers in the same role are signed in, both will be attributed.

1. Lazar HL, McDonnell M, Chipkin SR, Furnary AP, Engelman RM, Sadhu AR, Bridges CR, Haan CK, Svedjeholm R, Taegtmeyer H, Shemin RJ, Society of Thoracic Surgeons Blood Glucose Guideline Task Force: The Society of Thoracic Surgeons practice guideline series: Blood glucose management during adult cardiac surgery. Ann Thorac Surg 2009; 87:663–9

2. Del Rio JM, Abernathy JJ 3rd, Taylor MA, Habib RH, Fernandez FG, Bollen BA, Lauer RE, Nussmeier NA, Glance LG, Petty JV 3rd, Mackensen GB, Vener DF, Kertai MD: The Adult Cardiac Anesthesiology Section of STS Adult Cardiac Surgery Database: 2020 Update on Quality and Outcomes. Anesth Analg 2020 doi:10.1213/ANE.0000000000005093

3. Engelman DT, Ben Ali W, Williams JB, Perrault LP, Reddy VS, Arora RC, Roselli EE, Khoynezhad A, Gerdisch M, Levy JH, Lobdell K, Fletcher N, Kirsch M, Nelson G, Engelman RM, Gregory AJ, Boyle EM: Guidelines for Perioperative Care in Cardiac Surgery: Enhanced Recovery After Surgery Society Recommendations. JAMA Surg 2019 doi:10.1001/jamasurg.2019.1153

4. Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH: Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39–47

5. Gumus F, Polat A, Sinikoglu SN, Yektas A, Erkalp K, Alagol A: Use of a lower cut-off value for HbA1c to predict postoperative renal complication risk in patients undergoing coronary artery bypass grafting. J Cardiothorac Vasc Anesth 2013; 27:1167–73

6. Bansal B, Carvalho P, Mehta Y, Yadav J, Sharma P, Mithal A, Trehan N: Prognostic significance of glycemic variability after cardiac surgery. J Diabetes Complications 2016; 30:613–7

7. Hruska LA, Smith JM, Hendy MP, Fritz VL, McAdams S. Continuous insulin infusion reduces infectious complications in diabetics following coronary surgery. Journal of cardiac surgery. 2005;20(5):403-407

8. Bhamidipati CM, LaPar DJ, Stukenborg GJ, Morrison CC, Kern JA, Kron IL, Ailawadi G: Superiority of moderate control of hyperglycemia to tight control in patients undergoing coronary artery bypass grafting. J Thorac Cardiovasc Surg 2011; 141:543–51

9. Song JW, Shim JK, Yoo KJ, Oh SY, Kwak YL: Impact of intraoperative hyperglycaemia on renal dysfunction after off-pump coronary artery bypass. Interact Cardiovasc Thorac Surg 2013; 17:473–8 

10. KDIGO. 2012. “KDIGO 2012 Clinical Practice Guideline for the Evaluation and Management of Chronic Kidney Disease.” https://kdigo.org/wp-content/uploads/2017/02/KDIGO_2012_CKD_GL.pdf

11. NICE-SUGAR Study Investigators, Finfer S, Chittock DR, Su SY-S, Blair D, Foster D, Dhingra V, Bellomo R, Cook D, Dodek P, Henderson WR, Hébert PC, Heritier S, Heyland DK, McArthur C, McDonald E, Mitchell I, Myburgh JA, Norton R, Potter J, Robinson BG, Ronco JJ: Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009; 360:1283–97

12. Moghissi, Etie S., Mary T. Korytkowski, Monica DiNardo, Daniel Einhorn, Richard Hellman, Irl B. Hirsch, Silvio E. Inzucchi, et al. 2009. “American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control.” Diabetes Care 32 (6): 1119–31.

13. Cryer, Philip E., Stephen N. Davis, and Harry Shamoon. 2003. “Hypoglycemia in Diabetes.” Diabetes Care 26 (6): 1902–12.

14. Turchin, Alexander, Michael E. Matheny, Maria Shubina, James V. Scanlon, Bonnie Greenwood, and Merri L. Pendergrass. 2009. “Hypoglycemia and Clinical Outcomes in Patients with Diabetes Hospitalized in the General Ward.” Diabetes Care 32 (7): 1153–57.

15. DiNardo, Monica, Michelle Noschese, Mary Korytkowski, and Stephanie Freeman. 2006. “The Medical Emergency Team and Rapid Response System: Finding, Treating, and Preventing Hypoglycemia.” Joint Commission Journal on Quality and Patient Safety / Joint Commission Resources 32 (10): 591–95.

16. DiNardo, M., A. C. Donihi, M. DeVita, L. Siminerio, H. Rao, and M. T. Korytkowski. 2005. “A Nurse Directed Protocol for Recognition and Treatment of Hypoglycemia in Hospitalized Patients.” Pract Diabetol 22: 37–40.

17. Akhtar, Shamsuddin, Paul G. Barash, and Silvio E. Inzucchi. 2010. “Scientific Principles and Clinical Implications of Perioperative Glucose Regulation and Control.” Anesthesia and Analgesia 110 (2): 478–97.

18. Falconer, R., C. Skouras, T. Carter, L. Greenway, and A. M. Paisley. 2014. “Preoperative Fasting: Current Practice and Areas for Improvement.” Updates in Surgery 66 (1): 31–39.

19. Leung, Vivien, and Kristal Ragbir-Toolsie. 2017. “Perioperative Management of Patients with Diabetes.” Health Services Insights 10 (November): 1178632917735075.

20. Schwenk, Eric S., Boris Mraovic, Ryan P. Maxwell, Gina S. Kim, Jesse M. Ehrenfeld, and Richard H. Epstein. 2012. “Root Causes of Intraoperative Hypoglycemia: A Case Series.” Journal of Clinical Anesthesia 24 (8): 625–30.