Intensive Intraoperative Insulin Therapy versus Conventional Glucose Management during Cardiac Surgery The association of preoperative glycemic control, intraoperative insulin sensitivity, and outcomes after cardiac surgery. The Role of Chronic and Perioperative Glucose Management in High-Risk Surgical Closures: A Case for Tighter Glycemic Control Effects of moderate intensity glycemic control after cardiac surgery. Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes. Multidisciplinary intervention for control of diabetes in patients undergoing coronary artery bypass graft (CABG). Effects of intensive glycemic control on outcomes of cardiac surgery. The Clinical Significance of an Elevated Postoperative Glucose Value in Nondiabetic Patients after Colorectal Surgery: Evidence for the Need for Tight Glucose Control? Perioperative management with glucose solution and insulin. Insulin subcutaneous application vs. continuous infusion for postoperative blood glucose control in patients with non-insulin-dependent diabetes mellitus. Randomized Controlled Trial of Intensive Versus Conservative Glucose Control in Patients Undergoing Coronary Artery Bypass Graft Surgery: GLUCO-CABG Trial Effect of hyperglycemia and continuous intravenous insulin infusions on outcomes of cardiac surgical procedures: the Portland Diabetic Project. Attempting to maintain normoglycemia during cardiopulmonary bypass with insulin may initiate postoperative hypoglycemia. An observational cohort study to assess glycosylated hemoglobin screening for elective surgical patients A prospective randomized controlled study of a virtual clinic integrating primary and specialist care for patients with Type 2 diabetes mellitus. The association of diabetes and glucose control with surgical-site infections among cardiothoracic surgery patients. Gastric Bypass Leads to Improvement of Diabetic Neuropathy Independent of Glucose Normalization—Results of a Prospective Cohort Study (DiaSurg 1 Study)
Context Intensive insulin therapy used to maintain normoglycemia during intensive care after cardiac surgery improves perioperative outcomes . Its effect during cardiac surgery is unknown . Contributions The authors r and omly assigned 400 cardiac surgical patients to tight glycemic control ( blood glucose level , 4.4 to 5.6 mmol/L [ 80 to 100 mg/dL ] ) during surgery or usual intraoperative care . All patients received tight glycemic control in the cardiac intensive care unit . The groups had the same risk for perioperative adverse events ( risk ratio , 1.0 [ 95 % CI , 0.8 to 1.2 ] ) . The intensive treatment group had more strokes ( 8 vs. 1 ) and more deaths ( 4 vs. 0 ) than the conventional treatment group . Caution The authors performed the study at a single center . Implication s Maintaining normoglycemia during cardiac surgery does not improve outcomes and might worsen them . The Editors Hyperglycemia occurs frequently in patients with and without diabetes during cardiac surgery , especially during cardiopulmonary bypass surgery ( 1 , 2 ) . In a study by Van den Berghe and colleagues ( 3 ) , intensive insulin therapy after surgery reduced morbidity and death in critically ill patients , most of whom underwent cardiac surgery . As a result , professional organizations have recommended rigorous glycemic control in hospitalized patients ( 4 ) and strict glycemic control is now routine practice during the postoperative period in cardiac surgical patients . However , no consensus exists on the optimal management of intraoperative hyperglycemia in cardiac surgical patients because of the lack of evidence from r and omized trials . Research ers are increasingly extrapolating evidence from studies that assess the role of strict postoperative glycemic control in critically ill patients to advocate for intravenous insulin therapy for patients in the operating room ( 3 , 57 ) . Evidence , strictly from observational studies , suggests that tight intraoperative glycemic control may reduce postoperative complications ( 810 ) . We recently reported , in a retrospective , observational study of 409 cardiac surgical patients , that intraoperative hyperglycemia was an independent risk factor for perioperative complications , including death , after adjustment for postoperative glucose concentrations . Each 1.1-mmol/L ( 20 mg/dL ) increase in glucose concentration greater than 5.6 mmol/L ( > 100 mg/dL ) during surgery was associated with a 34 % increase in the likelihood of postoperative complications ( 8) . An association between intraoperative hyperglycemia and adverse outcomes based on observational studies does not prove causality . Because hyperglycemia can adversely affect immunity , wound healing , and vascular function , the concept that normoglycemia be maintained during the relatively brief duration of cardiac surgery seems plausible ( 1116 ) . On the other h and , the degree of intraoperative hyperglycemia may merely reflect the severity of underlying stress . If so , prevention of hyperglycemia might not reduce perioperative complications , and the risks and costs of intensive intraoperative glycemic management may outweigh the benefits . Simple , safe , and effective insulin infusion algorithms that achieve rigorous intraoperative glycemic control are lacking . To address these questions , we conducted a r and omized , controlled trial at 1 center to determine whether maintenance of near normoglycemia during cardiac surgery by using intraoperative intravenous insulin infusion reduced perioperative death and morbidity when added to rigorous postoperative glycemic control . Methods Design Overview This was a r and omized , open-label , controlled trial with blinded assessment . We r and omly assigned patients to receive intensive insulin therapy to maintain intraoperative glucose levels between 4.4 ( 80 mg/dL ) and 5.6 mmol/L ( 100 mg/dL ) or conventional treatment . By design , both groups were postoperatively treated with strict glycemic control to ensure that the observed difference in outcome could be attributed to the effects of intraoperative glycemic control . Setting We performed the study at St. Marys Hospital , Rochester , Minnesota , which is a tertiary care teaching hospital with 1157 beds and an average of more than 41000 admissions per year . Participants Adults undergoing elective cardiac surgery between July 2004 and April 2005 were eligible for enrollment in our study . We excluded patients who had off-pump cardiopulmonary bypass procedures . The Mayo Foundation Institutional Review Board , Rochester , Minnesota , approved the protocol . R and omization and Interventions Before we enrolled patients in our r and omized trial , we enrolled 20 patients in a 2-week pilot trial to ensure that the anesthesiologists in the operating room and the nursing staff in the intensive care units ( ICUs ) had adequate experience with the study insulin infusion algorithm . The 20 patients received intensive insulin therapy during surgery and for 24 hours after surgery . The pilot period data allowed us to modify the grade d insulin infusion to achieve desired glucose concentration goals . We built safety features into our infusion protocol to minimize hypoglycemia . We discontinued the infusion when glucose levels were less than 4.4 mmol/L ( < 80 mg/dL ) and initiated dextrose infusion . When glucose levels decreased to less than 3.3 mmol/L ( < 60 mg/dL ) , we treated hypoglycemia according to a st and ardized hypoglycemia protocol . Per protocol , patients treated in the pilot phase were not included in the analyzed cohort . Study coordinators obtained written informed consent from all patients who met eligibility criteria . We r and omly assigned patients to receive intensive or conventional intraoperative insulin therapy . R and omization was computer-generated with permuted blocks of 4 , with stratification according to surgeon , surgical procedure ( coronary artery bypass grafting [ CABG ] with or without other procedures and no CABG ) , and diabetes . The r and omization assignments were concealed in opaque , sealed , tamper-proof envelopes that were opened sequentially by study personnel after participants signed the patient consent form . We could not possibly know , before obtaining consent , the few patients who would not have intraoperative hyperglycemia ( glucose concentration of 5.6 mmol/L or more [ 100 mg/dL ] ) . Therefore , per protocol , patients who gave consent were r and omly assigned , and those whose glucose levels were less than 5.6 mmol/L ( < 100 mg/dL ) during surgery were not included in the final analyses . Intraoperative Period Intensive Treatment Patients in the intensive treatment group received a continuous intravenous insulin infusion , 250 units of NovoLin R ( Novo Nordisk , Princeton , New Jersey ) in 250 mL of 0.45 % sodium chloride , when their blood glucose levels exceeded 5.6 mmol/L ( > 100 mg/dL ) . We adjusted the infusions to maintain blood glucose levels between 4.4 ( 80 mg/dL ) and 5.6 mmol/L ( 100 mg/dL ) . We adjusted the dose according to a st and ardized algorithm used by anesthesiologists ( Appendix Table 1 ) . Appendix Table 1 . Insulin Infusion Protocol * Conventional Treatment Patients in the conventional treatment group did not receive insulin during surgery unless their glucose levels exceeded 11.1 mmol/L ( 200 mg/dL ) . If glucose concentration was between 11.1 ( 200 mg/dL ) and 13.9 mmol/L ( 250 mg/dL ) , patients received an intravenous bolus of 4 units insulin every hour until the glucose concentration was less than 11.1 mmol/L ( < 200 mg/dL ) . If the intraoperative glucose concentration was greater than 13.9 mmol/L ( > 250 mg/dL ) , patients received an intravenous infusion of insulin that was continued until the glucose level was less than 8.3 mmol/L ( < 150 mg/dL ) . In both study groups , we measured arterial plasma glucose concentration every 30 minutes , starting just before anesthetic induction by using hexokinase method on a Double P Modular System ( Roche Diagnostics , Indianapolis , Indiana ) . Intraoperative procedures , including cardiopulmonary bypass , monitoring , laboratory testing , and treatment , were left to the discretion of anesthesiologists and cardiac surgeons . There was no st and ard protocol for monitoring and managing intraoperative potassium levels . Postoperative Period Intravenous insulin infusion was started in patients in the conventional treatment group on their arrival in the ICU . Thereafter , both study groups were treated identically , with the intravenous insulin infusion rates adjusted by a nursing staff that was not involved with the study according to a st and ard protocol . The target blood glucose range was 4.4 ( 80 mg/dL ) to 5.6 mmol/L ( 100 mg/dL ) ( Appendix Table 1 ) . Arterial blood glucose levels were measured every 1 to 2 hours by using the Accu-Check Inform blood glucose monitoring system ( glucometer ) ( Roche Diagnostics ) . During the first 24 hours after surgery , patients were given only clear liquids by mouth ; we did not administer subcutaneous insulin or oral diabetic medications during this time . Thereafter , the hospital diabetes consulting service saw all patients and provided individualized recommendations for ongoing care . Outcomes and Measurements The primary outcome variable was a composite of death , sternal wound infections , prolonged pulmonary ventilation , cardiac arrhythmias ( new-onset atrial fibrillation , heart block requiring permanent pacemaker , or cardiac arrest ) , stroke , and acute renal failure within 30 days after surgery . Secondary outcome measures were length of stay in the ICU and hospital . Trained study personnel identified the occurrence of a complication through chart abstract ion by using confirmable , objective criteria in accordance with st and ardized definitions from the Society of Thoracic Surgeons ( STS ) data base committee ( 17 ) . Personnel who assessed outcomes were not aware of patient treatment assignment or of the study hypothesis . Follow-up Procedures We contacted patients by telephone and used a st and ardized telephone survey at 30 days after surgery to assess outcomes that occurred after discharge . We considered CONTEXT The impairment of insulin sensitivity , a marker of surgical stress , is important for outcomes . OBJECTIVE The aim was to assess the association between the quality of preoperative glycemic control , intraoperative insulin sensitivity , and adverse events after cardiac surgery . DESIGN AND SETTING We conducted a prospect i ve cohort study at a tertiary care hospital . SUBJECTS Nondiabetic and diabetic patients scheduled for elective cardiac surgery were included in the study . Based on their glycosylated hemoglobin A ( HbA(1c ) ) , diabetic patients were allocated to a group with good ( HbA(1c ) < 6.5 % ) or poor ( HbA(1c ) > 6.5 % ) glycemic control . INTERVENTION We used the hyperinsulinemic-normoglycemic clamp technique . MAIN OUTCOME MEASURES The primary outcome was insulin sensitivity measurement . Secondary outcomes were major complications within 30 d after surgery including mortality , myocardial failure , stroke , dialysis , and severe infection ( severe sepsis , pneumonia , deep sternal wound infection ) . Other outcomes included minor infections , blood product transfusions , and the length of intensive care unit and hospital stay . RESULTS A total of 143 nondiabetic and 130 diabetic patients were studied . In diabetic patients , a negative correlation ( r = -0.527 ; P < 0.001 ) was observed between HbA(1c ) and intraoperative insulin sensitivity .  Diabetic patients with poor glycemic control had a greater incidence of major complications ( P = 0.010 ) and minor infections ( P = 0.006 ) . They received more blood products and spent more time in the intensive care unit ( P = 0.030 ) and the hospital ( P < 0.001 ) than nondiabetic patients . For each 1 mg x kg(-1 ) x min(-1 ) decrease in insulin sensitivity , the incidence of major complications increased ( P = 0.004 ) . CONCLUSIONS In diabetic patients , HbA(1c ) levels predict insulin sensitivity during surgery and possibly outcome . Intraoperative insulin resistance is associated with an increased risk of complications , independent of the patient 's diabetic state Background : The exact risk that poor glucose control introduces to patients undergoing surgical closure has yet to be fully defined . Methods : The authors retrospectively analyzed a prospect ively collected data base of patients seen at their wound care center to evaluate the effects of chronic and perioperative glucose control in high-risk patients undergoing surgical wound closure .  Hemoglobin A1c and blood glucose levels for the 5 days before and after surgical closure were recorded and compared with the primary endpoints of dehiscence , infection , and reoperation . Univariate and multivariate analyses were performed . Results : Seventy-nine patients had perioperative glucose levels and 64 had hemoglobin A1C levels available for analysis . Preoperative and postoperative hyperglycemia ( defined as any blood glucose measurement above 200 mg/dl ) as well as elevated A1C levels ( above 6.5 percent or 48 mmol/ml ) were significantly associated with increased rates of dehiscence ( odds ratio , 3.2 , p = 0.048 ; odds ratio , 3.46 , p = 0.028 ; and odds ratio , 3.54 , p = 0.040 , respectively ) . Variability in preoperative glucose ( defined as a range of glucose levels exceeding 200 points ) was significantly associated with increased rates of reoperation ( odds ratio , 4.14 , p = 0.025 ) and trended toward significance with increased rates of dehiscence ( p = 0.15 ) . In multivariate regression , only perioperative hyperglycemia and elevated A1c were significantly associated with increased rates of dehiscence . Conclusions : In primary closure of surgical wounds in high-risk patients , poor glycemic control is significantly associated with worse outcomes . Every effort should be made to ensure tight control in both the chronic and subacute perioperative periods . CLINICAL QUESTION /LEVEL OF EVIDENCE : Risk , II BACKGROUND The impact of intensive insulin therapy on the clinical outcomes of hospitalized patients is highly controversial . We used a protocol based on dynamic insulin administration targeted to achieve moderately tight glycemic control and tested its impact on clinical outcomes after cardiac surgery . METHODS Patients with diabetes mellitus or r and om blood glucose greater than 150 mg/dL were treated in the intensive care unit with intravenous insulin , followed by a multi-injection protocol consisting of 4 glargine/aspart insulin injections in the ward , with a glycemic target of 110 to 150 mg/dL. The study cohort ( n = 410 ) consisted of consecutive patients undergoing cardiothoracic surgery . Control patients ( n = 207 ) were admitted during the first 8 months and treated according to st and ard of care . The intervention group of patients ( n = 203 ) were operated on during the following 8 months . The main outcome measures were glycemic control and the rate of postsurgery infections . RESULTS During the intervention , mean blood glucose ± SD was 151 ± 19 mg/dL and 157 ± 32 mg/dL in the intensive care unit and ward , respectively , versus 166 ± 27 mg/dL and 184 ± 46 mg/dL during the control period ( p < 0.0001 ) . The incidence of hypoglycemia ( blood glucose less than 60 mg/dL ) was low and similar in the two groups ( 2.5 % control versus 3 % intervention ) . Intensive insulin treatment  decreased the risk for infection from 11 % to 5 % ( 56 % risk reduction , p = 0.018 ) , mainly by reducing the incidence of graft harvest site infection ( 6.9 % versus 2.5 % , p = 0.034 ) . The incidence of atrial fibrillation after coronary artery bypass graft surgery decreased from 30 % to 18 % ( 39 % risk reduction ; p = 0.042 ) . CONCLUSIONS Moderate-intensity dynamic blood glucose control after cardiac surgery is effective and safe , and is associated with improved clinical outcomes OBJECTIVE Although hyperglycemia is hypothesized to increase the short-term risk of infection , this hypothesis has not been well tested in a clinical setting . This study was design ed to assess the relationship of perioperative glycemic control to the subsequent risk of infectious complications . RESEARCH DESIGN AND METHODS A total of 411 adults with diabetes who underwent coronary artery surgery from 1990 to 1995 in the cardiac surgery service of an urban university hospital were included in a nonconcurrent prospect i ve cohort study based on chart review . Perioperative glycemic control was characterized by the mean of six capillary glucose measurements taken during the 36-h interval following surgery . The major outcomes studied were infections of leg and chest wounds , pneumonia , and urinary tract infections . RESULTS Mean postoperative glucose levels ranged from 121 to 352 mg/dl and were divided into quartiles : quartile 1 ( 121 - 206 mg/dl ) , quartile 2 ( 207 - 229 mg/dl ) , quartile 3 ( 230 - 252 mg/dl ) , and quartile 4 ( 253352 mg/dl ) . After simultaneous adjustment for age , sex , race , underlying comorbidity , acute severity of illness , and the length of the stay in the surgical intensive care unit , patients with higher mean capillary glucose readings were at increased risk of developing infections . Compared with people in the lowest quartile of postoperative glucose , those in quartiles 2 ( relative odds of infection [ 95 % CI ] = 1.17 [ 0.57 - 2.40 ] ) , 3 ( 1.86 [ 0.94 - 3.68 ] ) , and 4 ( 1.78 [ 0.86 - 3.47 ] ) were at progressively higher risk for infection ( P = 0.05 for trend ) . CONCLUSIONS In patients with diabetes who undergo coronary artery surgery , postoperative hyperglycemia is an independent predictor of short-term infectious complications . Physicians should consider a glucose concentration target of < or = 200 mg/dl to reduce the risk of infection In Israel , as elsewhere , diabetes mellitus is highly prevalent among patients undergoing coronary artery bypass graft ( CABG ) .  The bulk of evidence , derived retrospectively , suggests that poor control of diabetes predisposes to complications of CABG and increases mortality ; but the findings in a number of studies fail to support that impression . Anticipating a prospect i ve investigation design ed to resolve this issue , we have carried out a preliminary study of 147 consecutive patients with diabetes who were hospitalized for elective CABG during 1998 . Our objective was to determine how well and how often diabetes could be controlled in accordance with selected metabolic goals in the brief interval between hospital admission and surgery and during the operation itself and in the postoperative period . The task was undertaken by a multidisciplinary team , in cooperation with the Department of Cardiac Surgery . The metabolic goals were : fasting blood glucose consistently between 65 - 140 mg/dl before and after surgery and 120 - 180 mg/dl at the time of surgery ; and postpr and ial blood glucose consistently < 180 mg/dl . These goals were achieved in 18.1 % of fasting blood glucose measurements before and after surgery , 22.1 % of prepr and ial and 14.6 % of postpr and ial blood glucose levels consistently < 180 mg/dl . There were no clinical episodes of hypoglycemia . Due to the low incidence of major infection related complications ( deep sternal wound infection in only 3 patients ( 2.0 % ) ) no significant statistical conclusions on the relations between glucose control and these complications could be drawn . The means of all values of FBG and of hemoglobin A1c were significantly higher among patients with complications ( n=49 ) than in those without ( P=0.01 ) OBJECTIVES To investigate the effects of postoperative intensive glycemic control on patient outcomes . BACKGROUND Ineffective perioperative glycemic control has been associated with high mortality and morbidity rates among cardiac surgery patients . METHODS 212 cardiac surgery patients were allocated by a quasi-experimental design to : a ) a  control group ( n = 107 ) with targeted blood glucose levels 161 - 200 mg/dl or b ) a therapy group ( n = 105 ) with blood glucose target 120 - 160 mg/dl  . We compared the two groups on their mortality , length of stay , duration of intubation , incidence of severe hypoglycemia and frequency of postoperative infections . RESULTS The mean postoperative blood glucose levels were significantly lower for the therapy group compared with the control group ( 153.9 mg/dl vs. 173.9 md/dl , p < 0.001 ) . The intensive glycemic control was strongly associated with decreased in-hospital mortality ( 7 deaths/105 patients for the control group vs. 1 death/105 patients for the therapy group ; p = 0.033 ) . We did not identify any statistically significant associations regarding the other patient outcomes . CONCLUSIONS This r and omized quasi-experimental trial found lower in-hospital mortality with more intense blood glucose control . Effective postoperative glycemic control did not affect the other studied patient outcomes Objectives : To evaluate the significance of hyperglycemia in patients without a preoperative diagnosis of diabetes undergoing elective colorectal surgery . Methods : Preoperative and all postoperative blood glucose measurements were retrieved for 2628 consecutive patients undergoing elective colorectal resection within 2 years at 1 center . Nondiabetic patients were identified as those without a preoperative diagnosis of diabetes and /or based on HbA1C levels . The association between any elevated postoperative r and om glucose value ( hyperglycemia : > 125 mg/dL ) and level of elevation ( > 125 mg/dL or > 200 mg/dL ) within 72 hours of surgery in nondiabetic patients with 30-day mortality and infectious and noninfectious complications was assessed . Results : Evaluation of 16,404 postoperative glucose measurements for all 2447 nondiabetic patients who underwent surgery in 2010 and 2011 revealed that 66.7 % patients experienced hyperglycemia . Degree of hyperglycemia correlated with increasing American Society of Anesthesiologists class and surgical severity ( blood loss ) . Hyperglycemia was associated with infectious and noninfectious complications and mortality , the rates of these complications increasing parallel to the degree of hyperglycemia . Hyperglycemia was independently associated with septic complications ( P = 0.024 ) . Conclusions : Postoperative hyperglycemia is frequent after elective colorectal surgery in nondiabetic patients . Even a single postoperative elevated glucose value is adversely associated with morbidity and mortality ; this risk is related to the degree of glucose elevation . These findings strongly support monitoring of glucose values and early consideration of management strategies for glycemic control after surgery even in nondiabetic patients The objective of this study was to analyze how preoperative glucose treatment influences the blood glucose level as a measured exponent of surgical stress and to establish the best postoperative replacement considering glucose solutions and insulin . This prospect i ve clinical trial involved 208 non-diabetic patients with normal glucose tolerance , who underwent major surgical procedures and needed 24 hours ICU monitoring postoperatively . Patients were r and omly given 5 % glucose solution ( 1000 mL ) one day before surgery or after overnight fasting . Group A and group B were r and omized to be given 5 different kinds of postoperative replacement with cristalloids and insulin . None of the patients from group A or group B were given glucose solutions during surgical procedures . Blood glucose levels were measured 14 times from the preoperative period until 24 hours after admission to the ICU and the main outcome measure was blood glucose level . All patients had a statistically significant increase in blood glucose levels in comparison to basal levels ( p < 0.05 ) in all measurements . All data were processed with descriptive statistics , chi-square test , parametric ANOVA test and ANOVA test with repeated measure , non parametric Kruskal-Wallis test and Mann-Whitney U-test . Statistically significant change was accepted with p < 0.05 . Preoperative glucose infusion decreased metabolic and endocrine response only during surgery ; the smallest increase of postoperative blood glucose level was noticed after administering postoperative non-glucose crystalloid solutions ; there is no clinical evidence that one specific postoperative replacement is better than the other ; there is no clinical evidence that postoperative use of insulin can decrease or attenuate surgical induced insulin resistance BACKGROUND Frequently , the use of insulin is considered for metabolic control in postoperative patients with non-insulin-dependent diabetes mellitus ( NIDDM ) . We sought to determine the best method for control of glucose in NIDDM non-insulin patients during postoperative care . METHODS Two algorithms were developed : subcutaneous administration of insulin ( SC ) , and continuous intravenous infusion ( IV ) . A r and omized , controlled clinical trial was design ed . In addition , both experimental groups were compared with a non-concurrent routinely managed group ( RM ) with insulin administration under no predetermined algorithm .  Eligible patients were those subjected to major surgery under general anesthesia or spinal blockade . They were followed for 48 h after surgery . Target variables were capillary and central blood glucose , insulin dose administered , urine glucose and ketone strip determination , and development of hyper- or hypoglycemia . RESULTS A total of 62 patients were studied ( RM = 25 , SC = 19 , IV = 18 ) . Results for both experimental algorithms were similar except for the IV group that required less insulin per hour compared to SC ( 0.64 vs. 0.34 U/h ; p = 0.0003 ) . The RM control group showed poor control in all capillary glucose measurements ( 194.9 + /- 26.8 mg/dL ) compared with the two experimental algorithms ( SC = 129.9 + /- 21 ; IV = 131.6 + /- 20.4 ) ( p < 0.05 ) . More hyperglycemia events appeared in the RM group ( p = 0.016 ) . Only one hypoglycemia event occurred in the IV group . CONCLUSIONS Postoperative control of NIDDM is similar with both tested methods . The use of any of the algorithms studied improves metabolic control substantially because it st and ardizes postoperative management of the diabetic patient with timely determination of capillary blood glucose and insulin administration . However , IV administration has the advantage of accomplishing adequate control with a smaller insulin dose OBJECTIVE The optimal level of glycemic control needed to improve outcomes in cardiac surgery patients remains controversial . RESEARCH DESIGN AND METHODS We r and omized patients with diabetes ( n = 152 ) and without diabetes ( n = 150 ) with hyperglycemia to an intensive glucose target of 100–140 mg/dL ( n = 151 ) or to a conservative target of 141–180 mg/dL ( n = 151 ) after coronary artery bypass surgery ( CABG ) surgery .  After the intensive care unit ( ICU ) , patients received a single treatment regimen in the hospital and 90 days postdischarge . Primary outcome was differences in a composite of complications , including mortality , wound infection , pneumonia , bacteremia , respiratory failure , acute kidney injury , and major cardiovascular events . RESULTS Mean glucose in the ICU was 132 ± 14 mg/dL ( interquartile range [ IQR ] 124–139 ) in the intensive and 154 ± 17 mg/dL ( IQR 142–164 ) in the conservative group ( P < 0.001 ) . There were no significant differences in the composite of complications between intensive and conservative groups ( 42 vs. 52 % , P = 0.08 ) . We observed heterogeneity in treatment effect according to diabetes status , with no differences in complications among patients with diabetes treated with intensive or conservative regimens ( 49 vs. 48 % , P = 0.87 ) , but a significant lower rate of complications in patients without diabetes treated with intensive compared with conservative treatment regimen ( 34 vs. 55 % , P = 0.008 ) . CONCLUSIONS Intensive insulin therapy to target glucose of 100 and 140 mg/dL in the ICU did not significantly reduce perioperative complications compared with target glucose of 141 and 180 mg/dL after CABG surgery . Subgroup analysis showed a lower number of complications in patients without diabetes , but not in patients with diabetes treated with the intensive regimen . Large prospect i ve r and omized studies are needed to confirm these findings OBJECTIVE To describe the main findings of the Portl and Diabetic Project , which eluci date s the adverse relationship between hyperglycemia and outcomes of cardiac surgical procedures in patients with diabetes and delineates the protective effects of intravenous insulin therapy in reducing those adverse outcomes . RESULTS In this ongoing 17-year prospect i ve , nonr and omized , interventional study of 4,864 patients with diabetes who underwent an open-heart surgical procedure , we investigated the effects of hyperglycemia , and its subsequent reduction by continuous intravenous insulin ( CII ) therapy , on in-hospital outcomes . Increasing blood glucose levels were found to be directly associated with increasing rates of death , deep sternal wound infections ( DSWI ) , length of hospital stay ( LOS ) , and hospital cost . In separate multivariate analyses , increasing hyperglycemia was found to be independently predictive of increasing mortality ( P<0.0001 ) , DSWI ( P = 0.017 ) , and LOS ( P<0.002 ) . Conversely , CII therapy , design ed to achieve predetermined target blood glucose levels , independently reduced the risks of death and DSWI by 57 % and 66 % , respectively ( P<0.0001 for both ) . Target blood glucose levels of less than 150 mg/dL and a 3-day postoperative duration of CII therapy are both important variables that determine the effect of the CII therapy on improved outcomes . Coronary artery bypass grafting-related mortality ( 2.5 % ) and DSWI rates ( 0.8 % ) in patients with diabetes were normalized to those of the nondiabetic population by the use of the Portl and CII Protocol . CONCLUSION Perioperative hyperglycemia in patients undergoing a cardiac surgical procedure affects biochemical and physiologic functions , which , in turn , adversely alter mortality , LOS , and infection rates . The Portl and CII Protocol is a cost-efficient method that effectively eliminates hyperglycemia and reduces postoperative morbidity and mortality in patients with diabetes undergoing an open-heart operation . CII protocol s should be the st and ard care for glycometabolic control in all patients undergoing cardiac surgical procedures UNLABELLED We attempted to develop an insulin administration protocol that maintains normoglycemia in patients undergoing cardiac surgery and to study the effects of intraoperative blood glucose management on serum levels of creatine phosphokinase isoenzyme BB ( CK-BB ) and S-100 protein .  Twenty nondiabetic patients were r and omly allocated to receive either " tight control " of blood glucose with a st and ardized IV insulin infusion intraoperatively ( Group TC ) or " no control " of blood glucose intraoperatively ( Group NC ) . Perioperative serum levels of glucose , CK-BB , and S-100 protein were determined in all patients . Group TC patients received 90.0 + /- 49.2 units of insulin , whereas Group NC patients received none . Despite insulin , both Group TC ( P = 0.00026 ) and Group NC ( P = 0.00003 ) experienced similar significant increases in blood glucose levels during hypothermic cardiopulmonary bypass . However , mean blood glucose level upon intensive care unit arrival was significantly decreased in Group TC , compared with Group NC ( 84.7 + /- 41.0 mg/dL , range 32 - 137 mg/dL vs 201.4 + /- 67.5 mg/dL , range 82 - 277 mg/dL , respectively ; P = 0.0002 ) . Forty percent of Group TC patients required treatment for postoperative hypoglycemia ( blood glucose level < 60 mg/dL ) . Substantial interindividual variability existed in regard to insulin resistance . The investigation was terminated after we realized that normoglycemia was unattainable with the study protocol and that postoperative hypoglycemia was unpredictable . All patients in both groups experienced similar significant increases in postoperative serum levels of CK-BB and S-100 protein . These results indicate that " tight control " of intraoperative blood glucose in nondiabetic patients undergoing cardiac surgery was unattainable with the study protocol and may initiate postoperative hypoglycemia . IMPLICATION S The appropriate intraoperative management of hyperglycemia and whether it adversely affects neurologic outcome in patients after cardiac surgery remains controversial . This investigation reveals that attempting to maintain normoglycemia in this setting with insulin may initiate postoperative hypoglycemia Introduction Uncontrolled blood glucose is associated with a higher incidence of surgical site infections , greater utilization of re sources , and increased mortality . Preoperative screening for diabetes in elective surgical patients is not routinely performed . The purpose of this study was to examine blood glucose control in a preoperative surgical population . Methods Following ethics approval , adults presenting to the pre-surgical screening clinic in preparation for elective surgery were recruited . Data collection included a self-administered question naire on diabetic risk factors and blood glucose testing , including glycosylated hemoglobin ( HbA1c ) . Descriptive analyses were conducted . Results Seventy of the 402 participants ( 17.4 % ) had a previous diagnosis of diabetes ( diabetics ) . Among those without a history of diabetes ( n = 332 non-diabetics ) , 23.2 % ( n = 77 ) were considered very high risk for diabetes ( HbA1c = 6.0 - 6.4 % ) , and 3.9 % ( n = 13 ) had a provisional diagnosis of diabetes ( HbA1c ≥ 6.5 % ) . Fifty-six percent ( n = 39/70 ) of diabetics had suboptimal glycemic control ( HbA1c > 7.0 % ) , and 51.3 % ( n = 20/39 ) of this subgroup presumed their blood sugars were reasonably or very well controlled . Fifteen percent ( n = 2/13 ) of patients with a provisional diagnosis of diabetes ( HbA1c ≥ 6.5 % ) had an elevated r and om blood sugar ( RBS ) ( ≥ 11.1 mmol·L−1 ) , while 67 % ( n = 8/12 ) had an elevated fasting blood sugar ( FBS ) ( ≥ 7.0 mmol·L−1 ) . Forty-two percent ( n = 16/38 ) of suboptimally controlled diabetics ( HbA1c > 7.0 % ) had an elevated RBS ( ≥ 11.1 mmol·L−1 ) , and 86 % ( n = 31/36 ) had an elevated FBS ( ≥ 7.0 mmol·L−1 ) . Discussion Many elective surgical patients are at risk for unrecognized postoperative hyperglycemia and associated adverse outcomes . R and om blood sugar testing has limited value and HbA1c may be a more appropriate test for the preoperative assessment of diabetic patients .Résumé Introduction La glycémie non contrôlée est associée à une incidence plus élevée d’infections du site chirurgical , à une utilisation plus importante des res sources et à une augmentation de la mortalité . Le dépistage préopératoire du diabète chez les patients de chirurgie non urgente n’est pas systématique . L’objectif de cette étude était d’examiner le  contrôle glycémique  chez une population chirurgicale en période préopératoire . MéthodeAprès avoir obtenu l’accord du comité d’éthique , des adultes se rendant à la clinique de dépistage préchirurgical en préparation d’une chirurgie non urgente ont été recrutés . La collecte des données incluait un question naire auto-administré sur les facteurs de risque de diabète et un test de glycémie , y compris de l’hémoglobine glyquée ( HbA1c ) . Des analyses descriptives ont été réalisées . RésultatsUn diagnostic de diabète avait déjà été posé pour soixante-dix des 402 participants ( 17,4 % ) ( diabétiques ) . Parmi les patients sans antécédents de diabète ( n = 332 , non-diabétiques ) , 23,2 % ( n = 77 ) ont été évalués comme présentant un risque très élevé de diabète ( HbA1c = 6,0 - 6,4 % ) , et un diagnostic provisoire de diabète ( HbA1c ≥ 6,5 % ) a été posé pour 3,9 % ( n = 13 ) de ces patients . Le contrôle glycémique était sous-optimal chez 56 % ( n = 39/70 ) des diabétiques ( HbA1c > 7,0 % ) , et 51,3 % ( n = 20/39 ) de ce sous-groupe prenait pour acquis que leur glycémie était raisonnablement ou très bien contrôlée . Quinze pour cent ( n = 2/13 ) des patients ayant reçu un diagnostic provisoire de diabète ( HbA1c ≥ 6,5 % ) avaient une glycémie aléatoire élevée ( ≥ 11,1 mmol·L−1 ) , alors que 67 % ( n = 8/12 ) avaient une glycémie à jeun élevée ( ≥ 7,0 mmol·L−1 ) . Quarante-deux pour cent ( n = 16/38 ) des diabétiques mal contrôlés ( HbA1c > 7,0 % ) présentaient une glycémie aléatoire élevée ( ≥ 11,1 mmol·L−1 ) , et 86 % ( n = 31/36 ) une glycémie à jeun élevée ( ≥ 7,0 mmol·L−1 ) . Discussion De nombreux patients devant subir une chirurgie non urgente courent un risque d’hyperglycémie postopératoire non identifiée et de complications associées . Les tests de glycémie aléatoire ont une valeur limitée et le test de la HbA1c pourrait être mieux adapté pour évaluer les patients diabétiques en période préopératoire AIMS To investigate the effectiveness of a diabetes virtual clinic to enhance diabetes in primary care by developing clinical management plans for patients with suboptimal metabolic control and /or case complexity . METHODS A prospect i ve study with r and omized allocation to virtual clinic or usual care .  Patients with Type 2 diabetes ( n = 208 ) were recruited from six general practice s in South London . The primary outcome for the study was glycaemic control , secondary outcomes included : lipids , blood pressure , weight ( kg and BMI ) and renal function ( eGFR ) . Data were collected from participants ' records at baseline and 12 months . We also considered process measures including therapy optimization . RESULTS The 12-month data show equivalence between the virtual clinic and control groups for glycaemic control with both achieving clinical ly significant reductions in HbA1c of 8 mmol/mol ( 0.6 ± 1.7 % ) and 10 mmol/mol ( 0.8 ± 1.9 % ) , respectively ( P = 0.4 ) . The virtual clinic group showed superiority over the intervention group for blood pressure control with a mean reduction in systolic blood pressure of 6 ± 16 mmHg compared with an increased of 2 ± 18 mmHg in the control group ( P = 0.008 ) . There were no significant differences between the groups in terms of cholesterol , weight and renal function . Process measures showed an increased level of therapy adjustment in the virtual clinic group . CONCLUSION The virtual clinic model explored in this study showed a clinical ly important improvement in glycaemic control . Although this improvement was not superior to that observed in the control participants , this might be attributable to the systemic impact of the virtual clinic on the practice as a whole OBJECTIVE To assess the importance of diabetes , diabetes control , hyperglycemia , and previously undiagnosed diabetes in the development of surgical-site infections ( SSIs ) among cardiothoracic surgery patients . SETTING A 540-bed tertiary-care university-affiliated hospital . DESIGN Prospect i ve cohort and case-control studies . PATIENTS All patients having cardiothoracic surgery between November 1998 and September 1999 were eligible for participation . One thous and patients had preoperative hemoglobin A1c determinations . Seventy-four patients with SSIs were identified . RESULTS Diabetes ( odd ratio [ OR ] , 2.76 ; P<.001 ) and postoperative hyperglycemia ( OR , 2.02 ; P=.007 ) were independently associated with development of SSIs . Among known diabetics , elevated hemoglobin A1c values were not associated with a statistically significantly increased risk of infection ; the mean A1c value was 8.44 % among those with infections compared with 7.80 % for those without ( P=.09 ) . Forty-two ( 6 % ) of 700 patients without prior diabetes history had evidence of undiagnosed diabetes ; their infection rate was comparable to that of known diabetics ( 3/42 [ 7 % ] vs 17/300 [ 6 % ] ; P=.72 ) . An additional 30 % of nondiabetics had elevated hemoglobin A1c determinations or perioperative hyperglycemia . CONCLUSIONS Postoperative hyperglycemia and previously undiagnosed diabetes are associated with development of SSIs among cardiothoracic surgery patients . Screening for diabetes and hyperglycemia among patients having cardiothoracic surgery may be warranted to prevent postoperative and chronic complications of this metabolic abnormality Objective : Surprisingly , 40 % to 95 % of patients with type 2 diabetes mellitus ( T2DM ) show early remission of hyperglycemia after obesity surgery . It is unknown to what extent other diabetes-associated comorbidities such as distal peripheral neuropathy ( DPN ) might be influenced by obesity surgery . This pilot study aim ed at providing further evidence for the impact of Roux-en-Y gastric bypass ( RYGB ) on both glycemic control and DPN in nonseverely obese patients with insulin-dependent T2DM . Methods : In the present prospect i ve cohort study , 20 patients with long-st and ing , insulin-dependent T2DM and a body mass index ( BMI ) between 25 and 35 kg/m2 underwent laparoscopic RYGB .  Body mass index , glycosylated hemoglobin ( HbA1c ) , and DPN [ quantified by the Neuropathy Symptom Score ( NSS ) and the Neuropathy Deficit Score ( NDS ) ] were investigated . Results : Six months after surgery , the preoperative BMI of 32.8 ± 2.1 kg/m2 ( mean ± st and ard deviation ) dropped to 25.6 ± 2.5 kg/m2 ( P < 0.001 ) . Preoperative HbA1c levels decreased from 8.5 ± 1.2 % to 7.1 ± 1.2 % ( P < 0.001 ) , with 15 % of patients having a normalized HbA1c level lower than 6.2 % . Of 12 patients with documented DPN , the median NSS was 8 ( range , 0–10 ) preoperatively and 0 ( range , 0–9 ) postoperatively ( P = 0.004 ) , with 8 patients scoring an NSS of 0 . The median NDS was 6 ( range , 2–8 ) preoperatively and 4 ( range , 0–8 ) postoperatively ( P = 0.027 ) , with 1 patient scoring an NDS of 0 . All patients had an improvement or normalization in either 1 or both scores . Conclusions : As expected , BMI and HbA1c levels improved significantly after RYGB . More interestingly , neuropathy scores , such as NSS and NDS , improved significantly early after surgery . Symptomatic neuropathy was completely reversible in 67 % of the patients . These findings add further evidence to the fact that RYGB might be a valuable treatment option not only for improving glycemic control but also for reducing diabetes-associated comorbidities , such as DPN . This points to a complex metabolic effect of RYGB that exceeds glucose normalization . However , the results still need to be confirmed in controlled trials
None of the trials examined the effects of the interventions in terms of costs .
AUTHORS ' CONCLUSIONS The included trials did not demonstrate significant differences for most of the outcomes when targeting intensive perioperative glycaemic control compared with conventional glycaemic control in patients with diabetes mellitus .
However , posthoc analysis indicated that intensive glycaemic control was associated with an increased number of patients experiencing hypoglycaemic episodes .
BACKGROUND Patients with diabetes mellitus are at increased risk of postoperative complications .
Data from r and omised clinical trials and meta-analyses point to a potential benefit of intensive glycaemic control , targeting near-normal blood glucose , in patients with hyperglycaemia ( with and without diabetes mellitus ) being su bmi tted to surgical procedures .
However , there is limited evidence concerning this question in patients with diabetes mellitus undergoing surgery .
OBJECTIVES To assess the effects of perioperative glycaemic control for diabetic patients undergoing surgery .