Tight Glycemic Control in Diabetic Coronary Artery Bypass Graft Patients Improves Perioperative Outcomes and Decreases Recurrent Ischemic Events

Abstract

Background-This study sought to determine whether tight glycemic control with a modified glucose-insulin-potassium (GIK) solution in diabetic coronary artery bypass graft (CABG) patients would improve perioperative outcomes. Methods and Results-One hundred forty-one diabetic patients undergoing CABG were prospectively randomized to tight glycemic control (serum glucose, 125 to 200 mg/dL) with GIK or standard therapy (serum glucose Ͻ250 mg/dL) using intermittent subcutaneous insulin beginning before anesthesia and continuing for 12 hours after surgery. GIK patients had lower serum glucose levels (138Ϯ4 versus 260Ϯ6 mg/dL; PϽ0.0001), a lower incidence of atrial fibrillation (16.6% versus 42%; Pϭ0.0017), and a shorter postoperative length of stay (6.5Ϯ0.1 versus 9.2Ϯ0.3 days; Pϭ0.003). GIK patients also showed a survival advantage over the initial 2 years after surgery (Pϭ0.04) and decreased episodes of recurrent ischemia (5% versus 19%; Pϭ0.01) and developed fewer recurrent wound infections (1% versus 10%, Pϭ0.03). Conclusions-Tight glycemic control with GIK in diabetic CABG patients improves perioperative outcomes, enhances survival, and decreases the incidence of ischemic events and wound complications.

Secondary Prevention After Coronary Artery Bypass Graft Surgery

“…This may facilitate optimal diabetes mellitus management in the perioperative and postoperative periods. As detailed elsewhere, 272 the perioperative control of serum glucose (glucose goal, 125-200 mg/dL) has been shown to improve both shortterm 273 and long-term 274 outcomes after CABG in most studies. However, an overly aggressive lowering of serum glucose during and after CABG surgery (glucose goal, 90-120 mg/ dL) may fail to improve clinical outcomes, mainly because of the adverse effects of hypoglycemic episodes, compared with more moderate glycemic control (glucose goal, 120-180 mg/dL).…”

Blood glucose management in the patient undergoing cardiac surgery: A review

“…Some clinicians argue that elective coronary artery bypass surgery should be delayed when elevated HbA1c levels are detected to reduce the likelihood of perioperative complications. In a prospective study conducted by Lazar et al [42] , preoperative HbA1c levels were not predictive of 30 d morbidity, length of stay, or mortality following coronary artery surgery if glycemic control was achieved. However, this was a small study (n = 167) and a larger cohort would be needed to establish a definite conclusion regarding negative outcome associations with an elevated preoperative HbA1c measurement [42] .…”

“…In a prospective study conducted by Lazar et al [42] , preoperative HbA1c levels were not predictive of 30 d morbidity, length of stay, or mortality following coronary artery surgery if glycemic control was achieved. However, this was a small study (n = 167) and a larger cohort would be needed to establish a definite conclusion regarding negative outcome associations with an elevated preoperative HbA1c measurement [42] . The current recommendation from the Society of Thoracic Surgeons practice guideline is that oral hypoglycemics should be withheld for at least 24 h prior to surgery.…”

Factors Associated with Increases in Glucose Levels in the Perioperative Period in Non-Diabetic Patients

“…Various target glucose levels have been used in previous studies to titrate insulin administration. Van den Bergh et al [3] targeted a blood glucose level (BG) of 80 -110 mg/dl, Krinsley et al [4] targeted a BG < 140 mg/dl and the NICE-SUGAR study [5] had a range of 81 -108 mg/dl, in ICU patients while Lazar et al [1] targeted a BG 125 -200 mg/dl in patients undergoing coronary artery bypass graft. Different levels of glucose (mean and maximum) have also been used to compare patient outcomes, Frisch et al [6] used a cutoff of >150 mg/dl before and after surgery, and McGirt et al [14] used >200 mg/dl before surgery.…”

“…The majority of investigations have focused on diabetic patients undergoing cardiac surgery [1,2] and/or on critically ill patients in intensive care units [3][4][5]. Blood glucose levels are not routinely monitored for nondiabetic patients during the perioperative period.…”