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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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