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Tight glycemic control reduced infection risk in some infants after cardiac surgery
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Postoperative tight glycemic control after cardiac surgery reduced the risk for infection compared with standard care among children older than 60 days at the time of surgery, according to recent findings.
Conversely, children aged 60 days or younger at the time of surgery were at increased risk for infection with tight glycemic control compared with standard care.
In a secondary post-hoc analysis of the two-center, randomized SPECS study, researchers evaluated 980 children who underwent cardiopulmonary bypass at an age of up to 36 months. The patients enrolled in the study underwent surgery and received postoperative treatment at the cardiac ICU of either Boston Children’s Hospital or the University of Michigan C.S. Mott Children’s Hospital.
During recovery, patients were randomly assigned to tight glycemic control with a goal of normoglycemia (80-110 mg/dL) or standard care. Blood glucose levels were maintained in the tight control group via insulin infusions.
The primary outcome was incidence of 30-day health care-related infections, including pneumonia and infections of the bloodstream, surgical site or urinary tract. Mortality, cardiac index, duration of vasoactive support and mechanical ventilation were secondary outcomes, along with length of stay in the cardiac ICU.
Researchers observed significant interplay between treatment and aged 30 days or younger at surgery and intraoperative glucocorticoid exposure on infection risk (P=.03 for both). In patients aged 60 days or younger, there was a significant increase in the rate and incidence of health care-related infections in the tight glycemic control group compared with the standard group (13.5 vs. 3.7 infections per 1,000 cardiac ICU days, P=.01 for rate; 13% vs. 4%, P=.02 for incidence). Among those older than 60 days at surgery, infections were significantly decreased in the tight control group vs. standard care recipients (5 vs. 14.1 infections per 1,000 cardiac ICU days, P=.02 for rate; 2% vs. 5%, P=.03 for incidence). The interaction between treatment group and age was highly statistically significant (P=.001).
Secondary outcomes occurred at similar rates regardless of patient age or treatment group, except for a 26% increase in cardiac index in the glycemic control group (2.4 L/min/m2 compared with 1.9 L/min/m2; P=.03) in patients older than 60 days, and significantly more red blood cell transfusions among those aged 60 days or younger in the glycemic control group (76% vs. 63% with standard care; P=.04).
After multivariable logistic regression adjusting for treatment, age and their interaction, prior cardiac surgery (OR=3.08; 95% CI, 1.41-6.72), chromosomal abnormalities (OR=3.05; 95% CI, 1.39-6.51) and delayed closure of the sternum (OR=4.32; 95% CI, 1.83-10.19) were independently correlated with increased infection risk.
“To our knowledge, there are no other data suggesting a 60-day age cutoff for differential response to [tight glycemic control],” the researchers wrote. “It is conceivable that [tight glycemic control] confers benefits that have more relevance to the older child whose maternally acquired, antibody-mediated immunity has waned, as opposed to the infant who also may be more susceptible to protocol-associated hypoglycemia and anemia.”
Disclosure: One researcher reported having acted as a paid consultant to Medtronic Diabetes and to Roche Diagnostics, but no ongoing professional relationships.
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