Blood glucose monitoring in pediatric patients on cardio-pulmonary bypass


  • Manish Sonkusale AVBRH Sawangi Meghe Wardha, Maharashtra, India
  • Yogesh N. Zanwar Department of Anaethesiology, GMC & SSH, Nagpur, Maharashtra, India
  • Deepa Kane Department of Anaethesiology, Seth G. S. Medical College, Parel, Mumbai, Maharashtra, India
  • Anil M. Patwardhan Department of CVTS Surgery, AVBRH Sawangi Meghe Wardha, Maharashtra, India



Acyanotic heart disease, Hemo-cue glucometer, Insulin


Background: Meticulous blood glucose control during cardio-pulmonary bypass has received a lot of attention recently. Children are more vulnerable to adverse effects of cardio-pulmonary bypass (CPB) on glucose homeostasis. Objectives of the study were to find out changes in blood glucose due to cardio-pulmonary bypass and the Insulin requirements intra - operatively.

Methods: A single centre, prospective trial in 130 children undergoing cardiac surgery for congenital cyanotic/ acyanotic heart disease, requiring cardio-pulmonary bypass. We administered dextrose IV 0.5g/kg/hr in pre bypass period to avoid hypoglycemia. Blood glucose levels were measured at various point of time [baseline, after 10 min and then every half hourly during bypass, 30 minutes after bypass and next during the immediate post-operative using a Hemo-cue glucometer]. To control blood glucose on cardio-pulmonary bypass pump, we used inj. Insulin as per study protocol. The statistical analysis was done using paired and unpaired t test & chi square test.

Results: We had examined 130 pediatric patients going on CPB for cardiac surgery. Blood glucose was monitored in patients who did not required inj. Insulin (Group II) on bypass for hyperglycemia (n=33) while 97 patients required insulin (Group I) on bypass because of hyperglycemia. 74% of patient required insulin on pump shows that cardio-pulmonary bypass significantly affects glucose homeostasis in children; most of the children (43%) required insulin 30 min after starting cardio-pulmonary bypass.

Conclusions: Blood glucose rise in children of congenital cardiac disease was significant after induction of anesthesia; on hypothermic CPB children of congenital cardiac disease may had rising blood glucose trend and the pre-operative blood glucose significantly affects the trend of blood glucose on CPB. The duration of CPB might not significantly affect insulin requirement of pediatric patients. CPB significantly affected glucose homeostasis in children. Hence it seems prudent to administer small amount of IV dextrose in prebypass period to avoid hypoglycemia but rate and dose of insulin should be adjusted as it may affect blood glucose level on CPB.


Allison SP. Changes in insulin secretion during open heart surgery. British Journal of Anaesthesia. 197l;43:138-43.

Carvalho G. Maintenance of Normoglycemia During Cardiac Surgery. Anesthesia Analgesia. 2004;99:319-24.

Verma S, Maitland A, Weisel RD. Hyperglycemia exaggerates ischemia-reperfusion-induced cardiomyocyte injury: Reversal with endothelin antagonism. Journal of Thoracic Cardiovascular surgery. 2002;123:1120-4.

Mescheryakov AV. Glucose Metabolism and Insulin Activity during Cardiac Surgery. Journal of Cardiothoracic Anesthesia. 1989;3(5):536-43.

Sieber FE, Traystman RJ. Glucose and the brain. Critical Care Medicine. 1992;20:104-14.

Bell C, Hughes CW, Oh TH. The effect of intravenous dextrose infusion on post bypasses hyperglycemia in pediatric patients undergoing cardiac operations. Journal Clinical Anesthesia. 1993;5:381-5.

Nicolson SC, Jobes DR, Zucker HA. The effect of administering or withholding dextrose in pre bypasses intravenous fluids on intraoperative blood glucose concentrations in infants undergoing hypothermic circulatory arrest. Journal of Cardiothoracic Vascular Anesthesia. 1992;6:316-8.

Auer RN. Hypoglycemic brain damage. Stroke. 1986;7:699-708.

Wagner KR, Kleinholz M, Courten-Myers GM. Hyperglycemic versus normoglycemic stroke: Topography of brain metaholites, intracellular pH, and infarct size. Journal of Cerebral Blood Flow Metabolism. 1992;12:213-22.

Lee KU, Lee HK, Koh CS, Min HK. Artificial induction of intravascular lipolysis by lipid-heparin infusion leads to insulin resistance in man. Diabetologia. 1988;31:285-90.

Lehot JJ, Piriz H, Villard J. Glucose homeostasis: comparison between hypothermic and normothermic cardiopulmonary bypass. Chest. 1992;102:106-11.

Kuntschen FR, Galletti PM, Hahn C. Glucose-insulin interactions during cardiopulmonary bypass. Journal of Thoracic & Cardiovascular Surgery. 1986;91:451-9.

Replogle R, Levy M, De Wall RA. Catecholamine and serotonin response to cardiopulmonary bypass. Journal of Thoracic and Cardiovascular Surgery. 1962;44:638-48.

Stanley TH, Berman L, Green O, Robertson D. Plasma catecholamine and cortisol responses to fentanyl oxygen anesthesia for coronary artery operations. Anesthesiology. 1980;53:250-3.

Tsubo T, Kudo T, Matsuki A, Oyama T. Decreased glucose utilization during prolonged anaesthesia and surgery. Canadian Journal of Anaesthesia. 1990;37:645-9.

Braden H, Cheema-Dhadli S, Mazer D. Hyperglycemia during normothermic cardiopulmonary bypass: the role of the kidney. Annals of Thoracic Surgery. 1998;65:1588-93.

Kuntschen FR, Galletti PM, Hahn C. Alterations of insulin and glucose metabolism during cardiopulmonary bypass under normothermia. Journal of Thoracic and Cardiovascular Surgery. 1985;89:97-106.

Bovill JG, Sebel PS, Fiolet JW. The intluence of sufentanil on endocrine and metabolic responses to cardiac surgery. Anesthesia Analgesia. 1983;62:391-7.

LS Nuutinen, P Mononen, M Kairaluoma, S Tuononen. Effects of open-heart surgery on carbohydrate and lipid metabolism. The Journal of Thoracic and Cardiovascular Surgery. 1977;73:680-3.

Bandali KS, Belanger MP, Wittnich C. Is hyperglycemia seen in children during cardiopulmonary bypass a result of hyperoxia? Journal of Thoracic Cardiovascular surgery. 2001;122:753-8.

De Ferranti, Sarah G, Kimberlee H. Intraoperative Hyperglycemia during Infant Cardiac Surgery Is Not Associated with Adverse Neurodevelopmental Outcomes at 1, 4, and 8 Year. Anesthesiology. 2004;100:1339-41.

Chaney MA. Nikolov MP, Blakeman. Attempting to Maintain Normoglycemia During Cardiopulmonary Bypass with Insulin May Initiate Postoperative Hypoglycemia Anesthesia Analgesia. 1999;89:1091.

Kersten JR, Toller WG, Gross ER, Pagel PS, Warltier DC. Diabetes abolishes ischemic preconditioning: Role of glucose, insulin and osmolality. American Journal of Physiology. 2000;278:H1218-24.

Anand KJS, Hansen DD, HJckey PR. Hormonal-metabolic stress responses in neonates undergoing cardiac surgery. Anesthesiology. 1990;73:661-70.

Nishina K, Mikawa K, Maekewa N. Effects of exogenous intravenous glucose on plasma glucose and lipid homeostasis in anesthetized infants. Anesthesiology. 1995;83:258-63.

Aono J, Ueda W, Hirakawa M. Masui. Perioperative blood glucose levels in children. 1992;41(12):1900-4.

Weale NK, Rogers CA, Cooper R, Nolan J, Wolf AR. Effect of remifentanil infusion rate on stress response to the pre-bypass phase of paediatric cardiac surgery. British Journal of Anaesthesia. 2004;92(2):187-94.

Anand KJS, Phil D, Hickey PR. Halothane-morphine compared with high-dose sufentanil for anesthesia and postoperative analgesia in neonatal cardiac surgery. New England Journal of Medicine. 1992;326:1-9.

Keidan I, Aabriel A. The metabolic effects of fresh versus old stored blood in the priming of cardiopulmonary bypass solution for pediatric patients. Journal of Thoracic and Cardiovascular Surgery. 2004;127(4):949-52.

Mcknight CK, Elliott M. Continuous monitoring of blood glucose concentration during open-heart surgery. British Journal of Anaesthesia. 1985;57(6):595-601.

Doenst T, Wijeysundera D. Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery. Journal of Thoracic Cardiovascular Surgery. 2005;130:1144.

Gandhi GY. Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery A Randomized Trial. Annals of Internal Medicine. 2007;146:233-43.

Ouattara, Lecomte A, Patrick Le M, Yannick. Poor Intraoperative Blood Glucose Control Is Associated with a Worsened Hospital Outcome after Cardiac Surgery in Diabetic Patients. Anesthesiology. 2005;103:677-8.

Ellger B, Debaveye Y, Vanhorebeek I, Langouche L. Survival benefits of intensive insulin therapy in critical illness: impact of maintaining normoglycemia versus glycemia-independent actions of insulin. Diabetes. 2006;55:1096.

Vanhorebeek I, De Vos R, Mesotten D, Wouters PJ, De Wolf-Peeters C. Protection of hepatocyte mitochondrial ultrastructure and function by strict blood glucose control with insulin in critically ill patients. Lancet. 2005;365:53-9.

Gandhi GY, Nuttall GA, Abel MD. Intraoperative Hyperglycemia and Perioperative Outcomes in Cardiac Surgery Patients. Mayo Clin Proc. 2005;80(7):862-6.






Original Research Articles