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J Thorac Cardiovasc Surg 2003;125:1007-1021
© 2003 The American Association for Thoracic Surgery
Cardiopulmonary Support and Physiology |
From the Department of Cardiothoracic Surgery, Providence St Vincent Medical Center,a the Medical Data Research Center, Providence Health Systems,b the Department of Endocrinology,c and the Department of Surgery,d Oregon Health and Science University, Portland, Ore.
Read at the Eighty-second Annual Meeting of The American Association for Thoracic Surgery, Washington, DC, May 5-8, 2002.
Received for publication May 15, 2002. Revisions requested July 22, 2002; revisions received Aug 23, 2002. Accepted for publication Sept 30, 2002. Address for reprints: Anthony P. Furnary, MD, 9155 SW Barnes Rd, No. 240, Portland, OR 97225 (E-mail: tfurnary{at}starrwood.com).
Objective: Diabetes mellitus is a risk factor for death after coronary artery bypass grafting. Its relative risk may be related to the level of perioperative hyperglycemia. We hypothesized that strict glucose control with a continuous insulin infusion in the perioperative period would reduce hospital mortality.
Methods: All patients with diabetes undergoing coronary artery bypass grafting (n = 3554) were treated aggressively with either subcutaneous insulin (1987-1991) or with continuous insulin infusion (1992-2001) for hyperglycemia. Predicted and observed hospital mortalities were compared with both internal and external (Society of Thoracic Surgeons 1996) multivariable risk models.
Results: Observed mortality with continuous insulin infusion (2.5%, n = 65/2612) was significantly lower than with subcutaneous insulin (5.3%, n = 50/942, P < .0001). Likewise, glucose control was significantly better with continuous insulin infusion (177 ± 30 mg/dL vs 213 ± 41 mg/dL, P < .0001). For internal comparison, multivariable analysis showed that continuous insulin infusion was independently protective against death (odds ratio 0.43, P = .001). Conversely, cardiogenic shock, renal failure, reoperation, nonelective operative status, older age, concomitant peripheral or cerebral vascular disease, decreasing ejection fraction, unstable angina, and history of atrial fibrillation increased the risk of death. For external comparison, observed mortality with continuous insulin infusion was significantly less than that predicted by the model (observed/expected ratio 0.63, P < .001). Multivariable analysis revealed that continuous insulin infusion added an independently protective effect against death (odds ratio 0.50, P = .005) to the constellation of risk factors in the Society of Thoracic Surgeons risk model.
Conclusion: Continuous insulin infusion eliminates the incremental increase in in-hospital mortality after coronary artery bypass grafting associated with diabetes. The protective effect of continuous insulin infusion may stem from the effective metabolic use of excess glucose to favorably alter pathways of myocardial adenosine triphosphate production. Continuous insulin infusion should become the standard of care for glycometabolic control in patients with diabetes undergoing coronary artery bypass grafting.
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J. Thorac. Cardiovasc. Surg. 2003 125: 985-987.
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 C. Ingels, Y. Debaveye, I. Milants, E. Buelens, A. Peeraer, Y. Devriendt, T. Vanhoutte, A. Van Damme, M. Schetz, P. J. Wouters, et al. Strict blood glucose control with insulin during intensive care after cardiac surgery: impact on 4-years survival, dependency on medical care, and quality-of-life Eur. Heart J., November 2, 2006; 27(22): 2716 - 2724. [Abstract] [Full Text] [PDF]
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 S. Donaldson, G. Villanuueva, L. Rondinelli, and D. Baldwin Rush University Guidelines and Protocols for the Management of Hyperglycemia in Hospitalized Patients: Elimination of the Sliding Scale and Improvement of Glycemic Control Throughout the Hospital The Diabetes Educator, November 1, 2006; 32(6): 954 - 962. [Abstract] [Full Text] [PDF]
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 H. G. Piper, J. L. Alexander, A. Shukla, F. Pigula, J. M. Costello, P. C. Laussen, T. Jaksic, and M. S.D. Agus Real-Time Continuous Glucose Monitoring in Pediatric Patients During and After Cardiac Surgery Pediatrics, September 1, 2006; 118(3): 1176 - 1184. [Abstract] [Full Text] [PDF]
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K. G. Shann, D. S. Likosky, J. M. Murkin, R. A. Baker, Y. R. Baribeau, G. R. DeFoe, T. A. Dickinson, T. J. Gardner, H. P. Grocott, G. T. O'Connor, et al. An evidence-based review of the practice of cardiopulmonary bypass in adults: A focus on neurologic injury, glycemic control, hemodilution, and the inflammatory response. J. Thorac. Cardiovasc. Surg., August 1, 2006; 132(2): 283 - 290.e3. [Full Text] [PDF]
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C. De Block, B. Manuel-y-Keenoy, L. Van Gaal, and P. Rogiers Intensive Insulin Therapy in the Intensive Care Unit: Assessment by continuous glucose monitoring Diabetes Care, August 1, 2006; 29(8): 1750 - 1756. [Abstract] [Full Text] [PDF]
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The ACE/ADA Task Force on Inpatient Diabetes American College of Endocrinology and American Diabetes Association Consensus Statement on Inpatient Diabetes and Glycemic Control: A call to action Diabetes Care, August 1, 2006; 29(8): 1955 - 1962. [Full Text] [PDF]
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 D. E Birnbaum and K. Lehle CPB in High-Risk Groups: CPB in Diabetics Perfusion, July 1, 2006; 21(4): 235 - 238. [PDF]
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 S. A. Nasraway Jr Hyperglycemia During Critical Illness JPEN J Parenter Enteral Nutr, May 1, 2006; 30(3): 254 - 258. [Abstract] [Full Text] [PDF]
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C. Nielson, T. Lange, and N. Hadjokas Blood Glucose and Coronary Artery Disease in Nondiabetic Patients Diabetes Care, May 1, 2006; 29(5): 998 - 1001. [Abstract] [Full Text] [PDF]
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 A. Arimura, M. Li, V. Batuman, W.F. Clark, A.K. Stewart, G.A. Rock, M. Sternbach, D.M. Sutton, B.J. Barrett, A.P. Heidenheim, et al. Cast Nephropathy in Myeloma--Does PACAP38, a New Member of the Vasoactive Intestinal Peptide Family, Open a Therapeutic Window?: Potential Protective Action of Pituitary Adenylate Cyclase-Activiating Polypeptide (PACAP38) on In Vitro and In Vivo Models of Myeloma Kidney Injury. Blood 107: 661-668, 2006 J. Am. Soc. Nephrol., April 1, 2006; 17(4): 911 - 919. [Full Text] [PDF]
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A. G. Pittas, R. D. Siegel, and J. Lau Insulin Therapy and In-Hospital Mortality in Critically Ill Patients: Systematic Review and Meta-analysis of Randomized Controlled Trials JPEN J Parenter Enteral Nutr, March 1, 2006; 30(2): 164 - 172. [Abstract] [Full Text] [PDF]
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J. S. Krinsley and R. L. Jones Cost Analysis of Intensive Glycemic Control in Critically Ill Adult Patients Chest, March 1, 2006; 129(3): 644 - 650. [Abstract] [Full Text] [PDF]
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 M. Egi, R. Bellomo, E. Stachowski, C. J. French, G. Hart, P. Stow, W. Li, and S. Bates Intensive Insulin Therapy in Postoperative Intensive Care Unit Patients: A Decision Analysis Am. J. Respir. Crit. Care Med., February 15, 2006; 173(4): 407 - 413. [Abstract] [Full Text] [PDF]
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G. Van den Berghe, A. Wilmer, G. Hermans, W. Meersseman, P. J. Wouters, I. Milants, E. Van Wijngaerden, H. Bobbaers, and R. Bouillon Intensive Insulin Therapy in the Medical ICU N. Engl. J. Med., February 2, 2006; 354(5): 449 - 461. [Abstract] [Full Text] [PDF]
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J. Plank, J. Blaha, J. Cordingley, M. E. Wilinska, L. J. Chassin, C. Morgan, S. Squire, M. Haluzik, J. Kremen, S. Svacina, et al. Multicentric, Randomized, Controlled Trial to Evaluate Blood Glucose Control by the Model Predictive Control Algorithm Versus Routine Glucose Management Protocols in Intensive Care Unit Patients Diabetes Care, February 1, 2006; 29(2): 271 - 276. [Abstract] [Full Text] [PDF]
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 L. Langouche, I. Vanhorebeek, and G. Van den Berghe Glycaemic control in trauma patients, is there a role? Trauma, January 1, 2006; 8(1): 13 - 19. [Abstract] [PDF]
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H. L. Lazar Hyperglycemia during cardiac surgery J. Thorac. Cardiovasc. Surg., January 1, 2006; 131(1): 11 - 13. [Full Text] [PDF]
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American Diabetes Association Standards of Medical Care in Diabetes-2006 Diabetes Care, January 1, 2006; 29(suppl_1): S4 - S42. [Full Text] [PDF]
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 R. Bellomo and M. Egi Glycemic Control in the Intensive Care Unit: Why We Should Wait for NICE-SUGAR Mayo Clin. Proc., December 1, 2005; 80(12): 1546 - 1548. [PDF]
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E. D. Davis, K. Harwood, L. Midgett, M. Mabrey, and L. F. Lien Implementation of a New Intravenous Insulin Method on Intermediate-Care Units in Hospitalized Patients The Diabetes Educator, November 1, 2005; 31(6): 818 - 823. [Abstract] [Full Text] [PDF]
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J.-S. Choi, K. R. Cho, and K.-B. Kim Does Diabetes Affect the Postoperative Outcomes After Total Arterial Off-Pump Coronary Bypass Surgery in Multivessel Disease? Ann. Thorac. Surg., October 1, 2005; 80(4): 1353 - 1360. [Abstract] [Full Text] [PDF]
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T. Doenst, D. Wijeysundera, K. Karkouti, C. Zechner, M. Maganti, V. Rao, and M. A. Borger Hyperglycemia during cardiopulmonary bypass is an independent risk factor for mortality in patients undergoing cardiac surgery J. Thorac. Cardiovasc. Surg., October 1, 2005; 130(4): 1144 - 1144. [Abstract] [Full Text] [PDF]
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P. C. Davidson, R. D. Steed, and B. W. Bode Glucommander: A computer-directed intravenous insulin system shown to be safe, simple, and effective in 120,618 h of operation Diabetes Care, October 1, 2005; 28(10): 2418 - 2423. [Abstract] [Full Text] [PDF]
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J. M. Carr, F. W. Sellke, M. Fey, M. J. Doyle, J. A. Krempin, R. de la Torre, and J. R. Liddicoat Implementing Tight Glucose Control After Coronary Artery Bypass Surgery Ann. Thorac. Surg., September 1, 2005; 80(3): 902 - 909. [Abstract] [Full Text] [PDF]
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R. E. Anderson, K. Brismar, G. Barr, and T. Ivert Effects of cardiopulmonary bypass on glucose homeostasis after coronary artery bypass surgery Eur. J. Cardiothorac. Surg., September 1, 2005; 28(3): 425 - 430. [Abstract] [Full Text] [PDF]
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G. Y. Gandhi, G. A. Nuttall, M. D. Abel, C. J. Mullany, H. V. Schaff, B. A. Williams, L. M. Schrader, R. A. Rizza, and M. M. McMahon Intraoperative Hyperglycemia and Perioperative Outcomes in Cardiac Surgery Patients Mayo Clin. Proc., July 1, 2005; 80(7): 862 - 866. [Abstract] [PDF]
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M. Kosiborod, S. S. Rathore, S. E. Inzucchi, F. A. Masoudi, Y. Wang, E. P. Havranek, and H. M. Krumholz Admission Glucose and Mortality in Elderly Patients Hospitalized With Acute Myocardial Infarction: Implications for Patients With and Without Recognized Diabetes Circulation, June 14, 2005; 111(23): 3078 - 3086. [Abstract] [Full Text] [PDF]
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F. H. Edwards, V. A. Ferraris, D. M. Shahian, E. Peterson, A. P. Furnary, C. K. Haan, and C. R. Bridges Gender-Specific Practice Guidelines for Coronary Artery Bypass Surgery: Perioperative Management Ann. Thorac. Surg., June 1, 2005; 79(6): 2189 - 2194. [Abstract] [Full Text] [PDF]
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F. A. McAlister, S. R. Majumdar, S. Blitz, B. H. Rowe, J. Romney, and T. J. Marrie The Relation Between Hyperglycemia and Outcomes in 2,471 Patients Admitted to the Hospital With Community-Acquired Pneumonia Diabetes Care, April 1, 2005; 28(4): 810 - 815. [Abstract] [Full Text] [PDF]
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M. Bryer-Ash and A. J. Garber Point: Inpatient Glucose Management: The emperor finally has clothes Diabetes Care, April 1, 2005; 28(4): 973 - 975. [Full Text] [PDF]
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